Ending the HIV epidemic in the U.S. among Latinx Sexual and Gender Minorities

In 2019 it was announced the goal of ending the HIV epidemic in the U.S. within a decade. In its first phase, the Ending the HIV Epidemic (EHE) Initiative focuses on 57 geographic areas where HIV transmission occurs more frequently.¹ Often, the most vulnerable populations are not well incorporated in the activities to execute these kind of systemic plan and have therefore not evenly benefited. ² Consequently, focus on the highest burden populations will be critical for the success of the EHE initiative.

HIV continues to be a public health issue globally and disproportionally impacts vulnerable populations. Despite leading other countries in investments in HIV prevention, care, and research, the U.S. has the most serious HIV epidemic among high-income countries, and social inequalities contribute to deepening the concentration of the HIV epidemic among certain populations.³ In the U.S., adult and adolescent gay and bisexual men and other men who have sex with men (MSM) comprised most of the new HIV diagnoses,(REF)⁴ and transgender people also are disproportionately impacted by the HIV epidemic.^5,6 Among these sexual and gender minorities, significant racial and ethnic HIV disparities also exist. Recently, while new HIV diagnoses stabilized for MSM, Latinx MSM experienced an increased in new infections (Latinx is a gender-neutral term used in lieu of Latino or Latina).⁷ Latinx MSM in all parts of the country need effective HIV services, yet rising rates of HIV diagnosis are geographically concentrated⁸ and if current HIV diagnosis rates persist, about one in five Latinx MSM will be diagnosed with HIV during their lifetime.⁷ Similarly, Latinx transgender individuals have increased vulnerability to HIV due to social and structural factors.^9,10,11

Public health authorities are already planning and rolling out strategies to contribute to the EHE Initiative. However, ending the HIV epidemic in the U.S. is very unlikely without specific efforts with and for Latinx sexual and gender minority populations.² Latinx communities are not monolithic. No plan to partner with and serve diverse Latinx communities can be effective if a rigid, single approach is adopted. Rather, topline leadership can be important for demanding that state and local jurisdictions assess the epidemiological profiles of their communities recognizing the multiple cultural and social communities falling under the Latinx labels. Similarly, it is fundamental to establish metrics that enable monitoring of progress at increasing engagement in HIV care and increased viral suppression, as well as reduced HIV transmission. Program implementation should be flexible to respond to the cultural variations and the need for representation from across diverse Latinx communities.

Based on the experience working with Latinx sexual and gender minorities (LSGM) in the U.S., we recommend three pathways to ending the HIV epidemic and improve their well-being: 1) Develop targeted programming for the populations with the greatest need, 2) Use participatory research approaches, and 3) Facilitate uptake and upscale of interventions using implementation science methods.

First, we must conduct population-specific research and use the knowledge gained over the last decades to inform interventions for LSGM. An example of this is conducting socioepidemiologic research on Latinx transgender experiences in rural areas in highest burden jurisdictions. Similarly, culturally and linguistically congruent research and interventions are needed for LSGM populations with different experiences of migration. As migration from Latin America and the Caribbean continues to the U.S. and restrictive and punitive migratory laws are enforced, research must focus on the undocumented immigrant populations and those who are monolingual Spanish speakers to understand and address their challenges accessing health and social services.

Second, research must include the meaningful involvement of LSGM from its conception to the dissemination of findings and involve interdisciplinary, cross-generational, multi-site, and intersectional working teams. Community-based participatory research (CBPR)^12, is an evidenced-based participatory approach that can facilitate interventions to reduce social and behavioral HIV risks, including by increasing feelings of trust and safety among LSGM and by addressing determinants of health such as racism. Latinx scientists who are committed to their communities can leverage well-established relationships. However, systemic changes are needed to enable LSGM scientists who are committed to their communities to conduct high-impact participatory research. Federal agencies should increase the representation of Latinxs in scientific panels and in research funding decisions.^13,14

Third, implementation science frameworks and academic-community partnerships should be adopted to increase the uptake of HIV interventions that are effective among LSGM.¹⁵ Special attention should be given to facilitating academic-community partnerships as platforms for projects to reduce HIV disparities. Several interventions have been developed following these approaches.¹⁶ For example, Connecting Latinos en Parejas, a couples-based HIV biobehavioral HIV prevention and treatment intervention for Latino men and their same-sex partners is providing for healthy relationships by improving their sexual health, overall well-being, and strengthening their communication.¹⁷ Similarly, Contacto is a health education intervention aimed at improving health outcomes (i.e., HIV status or sexual orientation/gender identity disclosure, engagement in healthcare) by addressing the negative impact of social stigma among HIV-positive Spanish-speaking gay, bisexual, and other MSM.¹⁸ For those recently-arrived Latinx sexual and gender minorities, the intervention HOLA en Grupo provides for increased consistent condom use and HIV testing. Trans Equity Project is a homegrown, community-level HIV prevention and treatment intervention for transgender men and women of color, including Latinxs.¹⁴ Other interventions such as SOMOS and ChiCAS are currently being assessed in facilitating engagement in care for transgender Latina women.¹⁹ Implementation science should also guide the uptake of pre-exposure prophylaxis (PrEP) and other biomedical prevention tools and include assessment of biomarkers.^5,20

With proper research and social and political will, we can end the HIV epidemic in the U.S. We must create the conditions for culturally relevant research and foster environments where it is safe for LSGM to engage with the health system and take steps to protect their health.