Can ending the HIV epidemic be achieved without nurses?

Can ending the HIV epidemic be achieved without nurses?
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When the Trump administration announced its nearly $300 million proposal to end the HIV epidemic back in February, many people were shocked. Why would this administration, which has sought to roll back worker protections for LGBTQ individuals and barred transgender individuals from serving in the military, put such great effort into ending an epidemic that disproportionately affects minority populations, including gay, bisexual and other men who have sex with men and those in poverty?

Many experts agreed the plan, which includes connecting people to testing, increasing the distribution of the pre-exposure prophylaxis (PrEP) medication and using data to target high-risk hotspots, is strong. But the larger issues of stigma and social factors driving the HIV epidemic remain unaddressed.

The New York Times, for example, shared stories of African-Americans in the Deep South who face barriers of stigma and deeply held religious beliefs that often prevent access to treatment. Kaiser Health News gave the example of Native Americans with access to an Indian Health Service Clinic being fearful of being outed because a family member may work at the clinic. 

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For many people at risk for or living with HIV, the stigma can be a major barrier to testing and counseling and engagement in care. Tackling HIV stigma and other forms of discrimination is much more abstract, and complicated, than expanding access to treatment or PrEP. 

Unraveling deep-seated beliefs that lead to the marginalization of individuals living with HIV requires a much more holistic approach. It involves undoing the source of stigma surrounding HIV — the historic neglect or worse of people of color, people in poverty and LGBTQ+ people. This racism, classism, sexism and homophobia drive inequities in care that result in people not getting access to the prevention or treatment they need.

For example, while African-Americans make up 13 percent of the United States population, they account for 43 percent of all new HIV cases. And when we think about PrEP, a once-a-day medication that can prevent people from getting HIV, we have considerable work to do considering that only 14 percent of white people who could benefit from being on PrEP are actually on it. Even more alarming is the fact that only 2.5 percent of Latinxs and 1.4 perent of African-Americans who could benefit from PrEP are actually on it.

That’s where nurses can come in. The foundation of nursing education and practice is that health is holistic, determined just as much and often more by social factors than just genetics. These social factors examine the conditions where people live, learn, work and play and are powerful drivers of health of inequities.

As nurses, we’re taught to care for the “whole person.” This includes the medical and social components of a person’s health status and many nurse-led programs that primarily address social determinants have successfully improved health outcomes.

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For example, the Nurse-Family Partnership, a nurse home visit program for high-risk, low-income pregnant women, provides counseling on everything from safe pregnancy to caring for a child to building a secure future. This program has more than four decades of research documenting an improvement in a variety of health outcomes for new mothers and their babies.

As it relates to HIV treatment and prevention, one community intervention program with psychiatric nurse practitioners coordinating care improved both physical and mental health outcomes for individuals dually diagnosed as living with HIV and serious mental illness. 

Another found that nurse-led community-based interventions can reduce stigma and improve health-related quality of life among African American mothers living with HIV. Still others find that home visits by nurses can lower depressive symptoms and increase adherence to PrEP.

The type of care needed to address the HIV epidemic is the perfect model of what nursing is all about. Holistic care and addressing the social drivers of health and illness are what nurses do best. While the Trump administration’s proposal is strong, nurse-led programs to address the stigma and the social determinants related to HIV is essential to truly ending the epidemic.

Jacqueline Nikpour, BSN, RN is a Robert Wood Johnson Foundation Future of Nursing scholar and a Ph.D. student at the Duke University School of Nursing.

Michael Relf, Ph.D., RN, is the associate dean for Global and Community Health Affairs in the Duke University School of Nursing and a research professor in the Duke Global Health Institute.