How Cultural Humility Can Improve HIV Outcomes
Everyone should be screened for HIV. Some people should be screened one time, but for people who have greater exposure to HIV through sex or drug use, screening should be done at regular intervals. Not only will screening identify people who are living with HIV so they can begin highly effective treatment, but testing can also lead to very important discussions about preventing HIV in people who have elevated risk of acquiring HIV. Nearly 40% of new HIV diagnoses originate from people who are unaware of their HIV status, so screening people for HIV is critical to ending the epidemic.
Unfortunately, people who don't have a regular source of health care may miss out on routine screenings and preventive health interventions. As the popularity of on-demand healthcare solutions such as urgent and convenient care clinics rises, so too does the need for providers in those settings to screen their patients and discuss their sexual health.
In addition to barriers to healthcare access, discomfort, stigma, discrimination, and lack of knowledge are also significant barriers to improving sexual health-related outcomes. Conversations about sexual health that should begin in the clinic are often avoided by both healthcare providers and patients. Health care providers may be uncomfortable or not skilled at asking questions, and they may use language that prevents patients from feeling safe enough to be open and honest.
The solution is rooted in cultural humility, which can foster positive interactions and engagement between patients and their health care providers. Cultural humility is a continuous process of self-exploration and self-critique combined with a willingness to learn from others. People who practice cultural humility enter a relationship with another person with the intention of honoring their beliefs, customs, and values. For people who often experience stigma and discrimination in health care settings, relationships with health care providers who practice cultural humility may offer them better health outcomes.i
Groups That Can Greatly Benefit from Cultural Humility
Practicing cultural humility benefits people who have been stigmatized, including people from sexual or gender minority groups,ii who have experienced discrimination, stigma, denial or refusal of services, and verbal or physical abuse in health care settings.iii iv One in five trans persons has avoided seeking medical care because of past negative experiences and transphobia in medical settings.v
Recently, DKBmed spoke with several experts and stakeholders, including patients, healthcare providers, and community advocates and leaders, about their views on employing cultural humility in health care settings. Despite the disparate backgrounds, community aspects, and work settings of the many people we consulted, a common theme emerged: people with exposure to or living with HIV often face multiple stigmatizing and stressful identities.vi
In addition to belonging to a sexual or gender minority group, patients may have other stigmatizing or stressful identities, including:
- History of incarceration
- Poverty
- Limited education
- Language barriers
- Challenges with steady employment
- Housing instability
- Chronic health conditions
- Substance use
- Mental health disorders
- Familial dysfunction (e.g., domestic abuse, caregiving, disabilities)
Employing Cultural Humility
One study found that sexual minority men have an average of 5.7 intersecting identities or characteristics that contribute to minority stress (eg, from a racial minority group, unstable housing). The minority health theory suggests that people from minority groups experience stress stemming from their past and current experience with stigma and discrimination. Consequently, many of those who need medical care end up avoiding the services that they need because of previous hostility and negative encounters from the health care communities.
“For some of my patients, having HIV is the least of their problems.”
-Dovie Lenore Watson, MD, MSCE, AAHIVS, physician at Penn Medicine
Employing cultural humility may reduce the harmful effects of minority stress. Cultural humility is theorized to lead to greater self-awareness, reduced implicit biases, and increased sensitivity to power dynamics in cross-cultural interactions.vii The framework has been applied to educational interventions to improve sexual health services for people who are in sexual or gender minority groups. Fostering cultural humility is a recognized priority for creating inclusive and affirming health care environments for individuals from gender and sexual minority groups, who experience discrimination and other barriers when seeking health care.viii
What We’re Doing
Experts recognize the urgent need to introduce cultural humility into medical climates and used in everyday clinical practice situations. Our previous experience in related topics such as the importance of trauma-informed care demonstrates not only the low baseline knowledge of clinicians but also, the value of our education, with notable gains in knowledge and competence (chart below).ix
In July 2024, we will launch an educational activity called STOP (Screen, Treat, Overcome, Prevent) HIV: PrEP Care on Demand that will reach health care clinicians, specifically those working in urgent and convenient care settings, through a 60-minute webcast featuring clinician and patient faculty discussing the importance of cultural humility within care. The educational program will also cover HIV screening and prevention. STOP HIV: PrEP Care on Demand will place a strong focus on the importance of employing cultural humility to better engage young adults, who are least likely to use HIV preventive medications (PrEP) while representing a large portion of new HIV diagnoses. Young adults are also less likely to have a “regular” primary care provider and more likely to seek health care in urgent and convenient care settings.
For more information on this project, you can contact us.
References
- Stubbe DE. Practicing Cultural Competence and Cultural Humility in the Care of Diverse Patients. Focus (Am Psychiatr Publ). 2020 Jan;18(1):49-51. doi: 10.1176/appi.focus.20190041. Epub 2020 Jan 24. PMID: 32047398; PMCID: PMC7011228.
- Reeves, K., Job, S., Blackwell, C., Sanchez, K., Carter, S., & Taliaferro, L. (2024). Provider cultural competence and humility in healthcare interactions with transgender and nonbinary young adults. Journal of Nursing Scholarship, 56(1), 18-30. https://doi.org/10.1111/jnu.12903
- Mosher DK, McConnell JM, Hook JN, et al. Cultural humility of religious communities and well-being in sexual minority persons. J Psychol Theol. 2019;47(3):160-174
- Ayhan CHB, Bilgin H, Uluman OT, Sukut O, Yilmaz S, Buzlu S. A systematic review of the discrimination against sexual and gender minority in health care settings. Int J Health Serv. 2020;50(1):44-61.
- Data on file. DKBmed. Conversation with D Watson
- Bonett S, Mahajan A, Williams J, et al. Perspectives From Community-Based HIV Service Organization Leaders on Priorities in Serving Sexual and Gender Minority Populations. AIDS Educ Prev. 2023 Aug;35(4):277-289. doi: 10.1521/aeap.2023.35.4.277. PMID: 37535325; PMCID: PMC10461513.
- Yeager KA, Bauer-Wu S. Cultural humility: essential foundation for clinical researchers. Appl Nurs Res. 2013 Nov;26(4):251-6. doi: 10.1016/j.apnr.2013.06.008. Epub 2013 Aug 12. PMID: 23938129; PMCID: PMC3834043.
- Practicing Cultural Humility to Transform Health Care. Available at: https://aidsetc.org/blog/practicing-cultural-humility-transform-health-care
- Data on file. DKBmed.Outcomes eHIV Review V8.ECHO SAVA