TrialSite’s Founder Daniel O’Connor recently had the honor of interviewing Duke University’s Schenita D. Randolph, PhD, MPH, RN, CNE, assistant professor, and her colleague Ragan Johnson, DNP, MSN, APRN-BC, assistant professor, in an effort to learn more about an innovative effort led by Duke University School of Nursing to utilize a salon-based intervention to promote HIV prevention and awareness to Black women in the southern United States.
A Scary Situation Not Well Known
As it turns out, although the African American population as a whole accounts for just under 14 percent of the U.S. population (and Black women represent 52% of this total for about 7 percent of the total U.S. population), face a far greater probability from HIV infection than any other demographic group. The southern region of the country for some complex reasons are the epicenter of this HIV crisis.
The CDC reports that the region known as the South (see the map), although not near 52 percent of the American population, now accounts for 52 percent of all new HIV infections. A fact that few know, Black women now account for 69 percent of all new HIV infections in this large region of the country. A shocking number that certainly triggered the attention of TrialSite.
Founder and CEO Daniel O’Connor sought the interview with Dr. Randolph and Dr. Johnson to better understand what was going on in the southern parts of the United States, especially with Black women and the health systems. TrialSite believes that this information should be shared with a broader audience; that this innovative research and community engagement model is not only important but necessary for an important intervention to help an at-risk population.
Importantly the Duke University assistant professors recently submitted a proposal to American biopharmaceutical company Gilead Sciences entitled “A Salon-Based, Multi-Level Intervention to Improve PrEP Uptake Among Black Women Living in the United States South.”
PrEP is an effective way to help prevent HIV and in fact can reduce the infection rate by over 90 percent, but its usage among Black women is incredibly low. Hence, TrialSite’s founder and publisher launched the interview.
O’Connor: The fact that the PrEP therapy method can reduce HIV transmission by over 90% is amazing. But before we get into that what is going on in the American South? Other regions have large African American populations and the transmission rates of HIV are not as high with this demographic. Why such high numbers?
Dr. Randolph: This is a complex issues with a number of contributing factors. The research to date reveals that much of the education and HIV prevention initiatives are still geared toward either same-sex demographic population or heterosexual males (both White and Black). The fact is that based on all the data thus far there is very little in the form of intervention literature that reaches Black women.
O’Connor: Are socioeconomic factors a major function in the infection rates in the South? That is African American groups that are higher up the income distribution face less of a risk?
Dr. Randolph: No, its not that simple. The research and our interviews and engagement to date reveal a cross-section of Black women are at-risk. Our concern in looking too narrowly at one particular socioeconomic demographic cohort within the African American community may unduly narrow our focus for education and outreach to Black women across the South. That wouldn’t meet our ultimate aim of protecting all women at risk.
O’Connor: What are other factors that might explain why Black women in the American South are so much more at risk than, say Black women in places like the Midwest or Northeast?
Dr. Randolph: Well to get back to those possible contributing factors, as I mentioned, it’s a complex situation. We suspect there could be wider gaps in consistent access to foundational medical care in the South for example. Poverty may be a factor as well, education and perhaps even other considerations.
O’Connor: Could residual or even more persistent racial bias, even if implicit, still be at play here? Perhaps impacting in subtle or not so subtle ways not only access to care issues but also perhaps inherent in subconscious assumptions of some care providers when interacting with Black women?
Dr. Randolph: This most certainly is a factor at play here and merits ongoing strategies to address it. We are quite interested in patterns associated with patient and provider encounters in the American South. What kinds of implicit bias could be present for example and how could that be contributing to a situation where Black women aren’t informed and educated about existing medical evidence that offers great protection.
O’Connor: The fact that PrEP can reduce risk of transmission by 92% is an incredible accomplishment and it’s a tragedy that this word isn’t being spread to all communities and demographic groups. Can you break out the access to PrEP by demographic?
Dr. Randolph: Yes. White’s represent 69% of the total while Hispanic/Latinos account for 13% and Blacks 11% Of the 11% only 1% of Black women are aware of and prescribed to PrEP. We also share some CDC statistics with the TrialSite audience.
O’Connor: That’s really incredibly disturbing.
Dr. Randolph: Absolutely it is. And hence the importance of this study and effort to ensure that this dynamic and trend is turned around as fast as possible.
O’Connor: Can you describe PrEP in this context?
Dr. Randolph: It stands for Pre-exposure prophylaxis (PrEP) and is a term used to describe the use of select approved medicines to prevent the spread of disease in people who have not yet been exposed to a disease-causing pathogen, such as HIV. In this case it refers to the use of antiviral drugs as a strategy to block or increase the probability of infection with HIV.
O’Connor: So, if you could share with TrialSite more about this study? What is the approach?
Dr. Randolph: Yes it’s a Community Engagement Approach model to reach out to this important and at risk population.
O’Connor: Yes, we at TrialSite have experience with patient recruitment challenges from past roles and understand that certain “underrepresented” populations are hard to reach and hence at risk. This is quite an innovative approach to reach into salons in the African American community.
Dr. Randolph: Well actually for a couple decades at least now, salons and barbershops in the Black community have been channels for outreach and health education for example. They represent an important space in the community to connect with, engage and inform.
O’Connor: Can you share more about the pilot study?
Dr. Randolph: Yes this pilot study will include six salons and six stylists. They will be rigorously trained and even certified by the state cosmetology board for participation. Trained stylist will be able to include program signage at their particular salon station. The study includes a web based app and four training modules. Moreover, the study includes the use of navigators one we get going to help coordinate assistance.
Dr. Johnson: There are three levels of engagement in this effort, including 1) the stylists directly, 2) the stylist clients, and 3) the PrEP navigators. A key point here is that the study has been designed so that the interaction and engagement between the stylist and the client happens in an organic and seamless kind of way. The impact of this authentic, important and compelling message will be greater we believe.
O’Connor: Yes. That is powerful way to reach out, engage and make a difference. Where do the navigators come from? How are they trained?
Dr. Johnson: They are affiliated with the public health departments from Durham and Wake Counties in North Carolina.
O’Connor: So the study pilot will start in the Research Triangle Park area and then expand from there?
Dr. Johnson: Yes. That’s right.
O’Connor: I go back to the uncomfortable topic of perhaps residual institutional bias or even some forms of legacy institutional racial bias in healthcare institutions. It seems like this approach has enormous potential: that Black women will be engaged and educated and in the process empowered to start changing the dialogue in patient and provider encounters in the American South. Is this your assumption?
Dr. Randolph: Yes. That would most definitely be a positive direction.
O’Connor: You both of designed quite an impressive community-based study in an effort to not only connect with an engage, but impact a highly at risk population. What would be the main goal?
Dr. Randolph. Of course, the pilot is to prove the effectiveness of this approach and as we gather the preliminary data and asses and validate momentum, we need to change a fundamental problem right now: there is no evidence based interventions for HIV prevention targeting Black women—especially in the South.
This must change and we will work diligently to contribute to positive change. Moreover, we must contribute to the meaningful increase in usage of PrEP among Black women in the U.S. South. Ultimately, our study must lead to a measurable reduction in the rate of new HIV infection in this population.
O’Connor: Well, I want to thank you both for taking the time to visit with TrialSite News. I must say it’s been an honor and a pleasure, and we commend you for the work you and Duke University School of Nursing are doing to change health inequities in the United States.
Dr. Randolph and Dr. Johnson: Thank you. It’s been a pleasure to participate and share this study with TrialSite News.
Schenita D. Randolph, PhD, MPH, RN, CNE, Assistant Professor
Ragan Johnson, DNP, MSN, APRN-BC, Assistant Professor
Call to Action: African American women should follow the work of Dr. Randolph and Dr. Johnson. Sponsors and HIV/AIDS and other organizations should get behind work like this. See the study here.