Through the Innovative Community Engagement Strategies to Reduce HIV-related Stigma and Disparities Challenge, the U.S. Department of Health and Human Services (HHS) Office of Minority Health (OMH) in partnership with the OASH Office of Infectious Disease and HIV/AIDS Policy (OIDP), is seeking innovative and effective approaches (e.g., models, strategies, best practices and/or tools) for community engagement and mobilization to reduce HIV stigma and improve pre-exposure prophylaxis (PrEP) and antiretroviral therapy (ART) utilization among racial and ethnic minority individuals who are at increased risk for HIV infection or are people with HIV (PWH). The Challenge mechanism provides an opportunity for on the ground voices to participate in developing novel innovative approaches that can be successfully implemented within their local communities.
HHS OMH is dedicated to improving the health of racial and ethnic minority populations through the development of health policies and programs that help eliminate health disparities. OMH awards and other activities are intended to support the identification of effective policies, programs and practices for improving health outcomes and to promote sustainability and dissemination of these approaches. This effort aligns with other HHS activities, including: (1) HHS Ending the HIV Epidemic in the U.S. (EHE) strategies to prevent new HIV transmissions and treat people with HIV; (2) recommendations from the Advisory Committee on Minority Health (ACMH) to increase community engagement and reduce stigma to reduce HIV incidence in groups that have been marginalized; (3) National Institutes of Health (NIH) Office of AIDS Research and National Institute of Mental Health (NIMH) Division of AIDS Research workshop on HIV-related intersectional stigma research; (4) the Centers for Disease Control and Prevention’s (CDC) principles of community engagement that are cornerstones of efforts to improve public health and address health disparities1; and (5) the Health Resources and Services Administration’s Ryan White HIV/AIDS Program’s longtime commitment to implementing community engagement activities to improve care for people with HIV.2
PrEP and ART are effective prevention methods against transmission of HIV.3 PrEP is an HIV prevention method in which people who don’t have HIV take PrEP medicine daily to reduce their risk of acquiring HIV infection if they are exposed to the virus. ART is a combination of medications taken daily that help people with HIV stay healthy by reducing the amount of HIV in their blood and reducing the risk of HIV transmission to others. Persons with HIV who benefit from HIV treatment are estimated to have similar life expectancies compared to persons without HIV4. Despite the development of HIV prevention and treatment approaches, disparities exist among racial and ethnic minority populations in their utilization of these strategies.
Racial and ethnic minority populations have disproportionately higher rates of new HIV infections and HIV diagnoses, and lower rates of PrEP and ART awareness, initiation and adherence. A CDC analysis shows that nearly 80 percent of new HIV infections in the U.S. in 2016 occurred from the nearly 40 percent of PWH who either did not know they had HIV, or who had been diagnosed but were not receiving HIV care.5 Black persons accounted for 14 percent of the U.S. population but 41 percent of new HIV infections in 2019.6,7 The rate of new HIV diagnoses among Black adults is eight times that of White adults and more than twice that of Hispanic/Latino adults. The rate for Black males was four times the rate for Black females. (Hispanic/Latino persons accounted for almost 29 percent of all HIV infection cases in 2019.8 American Indian/Alaska Native persons have the highest percentage of estimated diagnoses of HIV infection attributed to injection drug use, compared with all other races/ethnicities.9 Among persons with HIV, the largest percentage of persons with undiagnosed HIV infection was that among American Indian/Alaska Native persons (20.5%), followed by Hispanic/Latino persons (16.4%), Black/African American persons (13.4%), Asian persons (13.4%), multiracial persons (11.1%), and White persons (10.8%).10 The latest estimates indicate that effective HIV prevention and treatment are not adequately reaching those who could most benefit from them.11 Although Black persons accounted for approximately 40 percent of persons with PrEP indications, nearly six times as many White persons were prescribed PrEP as were Black persons. Only 26 percent of Black men who have sex with men (MSM) and 30 percent of Hispanic MSM reported taking PrEP within the past year, compared with 42 percent of white MSM.12
Research indicates that HIV-related stigma is one of the factors that contributes to poor uptake of prevention tools and treatment. HIV-related stigma is rooted in a fear of HIV and is defined as negative attitudes and beliefs about people with HIV.13 It is the prejudice that comes with labeling an individual as part of a group that is believed to be socially unacceptable. Discrimination related to HIV status often leads to internalized stigma (development of negative self-image) and external stigma (experience of unfair treatment by others). Stigma can lead to feelings of shame, fear of disclosure, isolation, and despair which can keep people from getting tested and treated for HIV.14 Data on the effects of HIV-related stigma on treatment adherence show that those who had experienced stigma tended to report lower adherence. Lower treatment adherence leads to poor rates of undetectable viral load (amount of HIV in the body so low that a test cannot detect it) in PWH with subsequent increased HIV transmission15 and can result in drug resistant strains. The White House Office of National AIDS Policy and the EHE have both identified reduction of stigma as a critical step toward decreasing HIV disparities and reducing barriers to utilization of HIV prevention and treatments.
Community engagement and mobilization have been a priority within HIV prevention strategies and increasingly recognized as vital to expand access to quality care, prevent disease, and achieve health equity. Community-based organizations that serve racial and ethnic minority and other groups that have been marginalized are uniquely positioned to identify and reach racial and ethnic minority individuals at increased risk for HIV and PWH. Community engagement has been critical to HIV prevention and was a critical part of the development of the EHE. During the 2019 ACMH Meeting, the ACMH discussed the incorporation of new strategies to engage communities with significant numbers of new HIV infections. The ACMH also recommended the identification of mechanisms to reduce stigma and discrimination for individuals from racial and ethnic minority populations to maximize HIV prevention, diagnosis, and treatment.
Ultimately, increased knowledge and implementation of community engagement and mobilization strategies to support stigma reduction among racial and ethnic minority populations could result in increased initiation of and adherence to PrEP or ART to prevent new infections, reduce HIV transmission and incidence rates, and help PWH achieve and maintain viral load suppression.
OMH is creating a national competition to identify innovative and effective approaches to enhance community engagement and mobilization on the reduction of HIV stigma and disparities. Desired outcomes include improved utilization of PrEP and ART among racial and ethnic minority PWH or racial and ethnic minorities who are at increased risk for HIV infection. Participants will have access to subject matter experts (SMEs) for group and individual coaching throughout the Challenge phases. This Challenge seeks to achieve its desired outcomes through supporting innovative and effective approaches for racial and ethnic minority populations that:
- Identify types of stigma to be addressed (e.g., internalized, enacted, anticipated, ageism, racism)
- Incorporate validated stigma measurement tools (e.g., HIV Stigma Scale, Everyday Discrimination Scale, Intersectional Discrimination Index, Multiple Discrimination Scale, Gendered Racism Scale)
- Use community engagement and mobilization strategies
- Increase knowledge and skills in reducing HIV stigma among community-based organizations serving racial and ethnic minorities
- Evaluate scalability of developed approaches
Subject and Scope of Prize Competition
Projects must result in innovative and effective approaches that utilize community engagement and mobilization strategies to reduce stigma related to PrEP and ART within racial and ethnic minority populations. The approaches will be shared with the general public.
The competition has three phases. All eligible submissions will be evaluated, and separate prizes may be awarded for each of the three phases.