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Xavier J, Ward MC, McDonald P, Kalita N, Corr P. Identifying the factors influencing culturally responsive HIV and PrEP screening for racial, ethnic, sexual, and gender-minoritized patients: A scoping review. HPHR. 2024;89. https://doi.org/10.54111/0001/KKKK6
The effect of structural barriers and screening deficits on human immunodeficiency virus (HIV) spread among historically marginalized groups is underestimated. Primary care practitioners can foster culturally responsive patient-clinician interactions that encourage effective screening conversations and reduce disparities and disease burden for marginalized populations. This scoping review identifies factors influencing culturally responsive HIV and pre-exposure prophylaxis (PrEP) screening practices for racial, ethnic, sexual, and gender-minoritized groups.
This scoping review follows Arksey and O’Malley’s framework and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR).
Forty-nine studies published between 2019-2022 were analyzed for factors influencing screening. After rigorous quality checking, factors fell into 4 categories of culturally responsive communication: culture of the patient, culture of the clinician, culture of medicine, and culture of racism. Key factors positively influencing screening included clinician competence, availability of inclusive messaging, effective service promotion, services addressing structural barriers, and clinician respect. Key factors negatively influencing screening included financial constraints, inadequate clinician competence, lack of trust in clinicians, clinician bias, and community stigma.
Culturally responsive communication is vital to reducing the HIV burden among minoritized populations. This scoping review identifies factors that promote or inhibit these screening conversations and identifies the need to support the intersectional needs of and provide social support to diverse individuals. These holistic approaches to solving structural inequities encourage patients to seek care. Further, clinicians need comprehensive, early training to actively oppose bias and oppression of minoritized patients and effectively prevent HIV. The primary study limitation was the challenge in quantifying and coding factors. Our findings have important multilevel policy implications for HIV and PrEP screening practices. Additionally, these results offer ways to tailor culturally responsive interventions to promote HIV and PrEP screening in the primary care setting.
Primary care practitioners (PCPs)- used in place of the more common term ‘primary care providers’ to avoid reinforcing existing power imbalances between patients and clinicians- are called on to establish trusting relationships with patients to provide high-quality care to the populations they serve. There has been a shift in the provision of HIV care by PCPs due to the dwindling of the HIV workforce and the routinization of HIV care. Central to this work is the concept of cultural responsiveness. In our scoping review protocol, we described culturally responsive communication as the range of ways to appreciate the unique health perspectives of their patients and acknowledge the role of intersecting oppressions on health to work intentionally, continually, and effectively to improve the health of historically marginalized communities.1
Human immunodeficiency virus (HIV) and coronavirus disease 2019 (COVID-19) are two preventable, communicable illnesses with considerable burdens of disease, both highly stigmatized and disproportionately affecting individuals from racial, ethnic, sexual, and gender-minoritized groups.1 In the landscape of existing disparities, these patients are harmed by the underutilization of culturally responsive screening practices in the primary care setting that prioritize their experiences and views.1 Further, shifts in research and funding priorities during the height of the COVID-19 pandemic worsened HIV screening deficits.2,3 This scoping review summarizes the state of recent literature to identify influences of culturally responsive HIV and pre-exposure prophylaxis (PrEP) screening.
HIV transmission, morbidity, and mortality in the United States has always disproportionately affected those of minoritized backgrounds since the start of the epidemic, in particular racial and ethnic minorities. Today, more than 1.2 million individuals in the US are living with HIV, and Black and Hispanic or Latinx individuals made up almost 70% of new diagnoses in 2020, despite making up less than 40% of the US population together. 4,5 Though racial, ethnic, sexual, and gender-minoritized groups deal with a significantly greater burden of disease, they receive significantly less screening and prophylaxis.1,4,5 Research supports that structural and systemic barriers to care influence these disparate rates more than individual risk behaviors might.2
For instance, data show that significant racial and ethnic disparities exist in coverage rates in the US for PrEP, a highly effective prescription medicine that prevents HIV transmission ,6 and that primary care settings are particularly lacking in rates of HIV testing uptake.7 Even when current standards of opt-out HIV testing are followed in the primary care setting, other investigational arms of this study have identified that testing without context makes minoritized patients feel disrespected and like their consent has been violated. Naturally, these feelings perpetuate the mistrust that marginalized groups have towards clinicians and healthcare institutions. As dedicated HIV services and specialties have been absorbed into the primary care scope to improve the continuity and reach of services in recent decades, the role of PCPs in HIV screening, or lack thereof, is of particular interest.
Clearly, reliance on a cohort of less specialized and experienced clinicians could compound the strain of existing gaps in PrEP and HIV screening and testing practices. Both disparately harm members of marginalized groups who are already disproportionately burdened by HIV. Given the broad gaps in preventative HIV services, we use the term “screening” to indicate those counseling and communication practices that empower informed HIV testing and connection to PrEP. We also recognize that while the CDC screening guidelines for PrEP are comprehensive, there is far less awareness and adherence to the strong recommendations offered. To further understand factors influencing HIV and PrEP screening in the primary care setting, a scoping review was conducted to map the landscape of existing literature. This review has two aims: 1) to identify factors influencing HIV and PrEP screening for racial, ethnic, sexual, and gender-minoritized groups and 2) to provide opportunities for future investigation.
As detailed in our protocol, this scoping review was performed according to the five-step framework first outlined by Arksey and O’Malley.1,8 The PRISMA extension for scoping reviews (PRISMA-ScR) served as a guide.9
The primary research question was: “What factors influence culturally responsive HIV and PrEP screening for historically marginalized populations?” A subquestion was: “What themes and gaps exist in the literature regarding culturally responsive HIV and PrEP screening for historically marginalized populations?” The terms “historically marginalized populations” and “minoritized groups” were operationalized during Step 1 as including individuals from racial, ethnic, sexual, and gender-minoritized backgrounds, so we use these phrases to refer to our population of interest moving forward.
The scoping review was conducted across four databases. The full search strategy is presented in our published protocol.1 We use author initials throughout the methods section to identify research roles.
The scoping review was conducted across four databases. The full search strategy is presented in our published protocol.1 We use author initials throughout the methods section to identify research roles.
Studies were included if they were peer-reviewed articles published in English that concerned HIV and/or PrEP screening in the context of U.S. health systems. Studies were excluded if they were book chapters or study protocols, if full-text articles could not be obtained, or if they did not focus on unknown/negative HIV status among our priority populations. Our review focused on studies published between 2019-2022 to mirror the timeframe of a second investigational arm studying COVID-19. The full inclusion and exclusion criteria are in our protocol.1
Results were uploaded to Covidence and a title and abstract screening was performed, followed by a full-text screening. The primary reviewers (JX, NK) screened results against the inclusion and exclusion criteria and senior reviewers (PM and PC) resolved disagreements.
Figure 1. PRISMA 2020 Flow Diagram. Adapted from Haddaway, et al. (2022)
After full-text screening, data were extracted and charted by nine reviewers. The extraction items were developed through an iterative process creating a working definition of each item. This initial list of factors included in the extraction tool was framed as “barriers” and “facilitators” and was generated by the primary reviewer (JX), informed by interviews with PCPs and patients, and contextualized within the social-ecological model.10 A full overview of the types of data extracted is indicated in our published protocol.1
Next, the senior researchers worked with the primary reviewers to conduct a quality check to ensure that all data extracted and items marked had supporting evidence from each manuscript reviewed. This quality check included reviewing the work of student research assistants, discussing areas of disagreement, and pulling articles to find supporting evidence. Notably, within a given manuscript, extracted text could indicate both a barrier and facilitator or multiple barriers or facilitators. Because of this phenomenon, we allude below to a shift in our language to focus on “factors” and their implications rather than “facilitators” and “barriers.” The flow diagram in Figure 1 details the article selection process. The findings below follow PRISMA-ScR guidelines.
Table 1. Study Characteristics.
Characteristics of the Included Studies (n = 49) | |||
Reference no. | Author, year | Study design(s) | Population(s) of Interest |
11 | Hines et al., 2019 | Qualitative | Sexual/Gender-minoritized, Transgender |
12 | Hubach et al., 2020 | Qualitative | Sexual/Gender-minoritized, MSM |
13 | Gailloud et al., 2022 | Qualitative | Black/African American, Latine/x/Hispanic |
14 | Potea et al., 2021 | Qualitative | Sexual/Gender-minoritized |
15 | Uhrig et al., 2019 | Qualitative, Literature review | Sexual/Gender-minoritized, Transgender |
16 | Warylord et al., 2022 | Qualitative | Black/African American, Latine/x/Hispanic |
17 | Nunn et al., 2020 | Qualitative | Sexual/Gender-minoritized, MSM |
18 | Rogers et al., 2022 | Qualitative | Sexual/Gender-minoritized |
19 | Jones et al., 2022 | Qualitative, Cross-sectional | Sexual/Gender-minoritized, MSM |
20 | Bauermeister et al., 2019 | Qualitative, Cross-sectional | Sexual/Gender-minoritized, MSM |
21 | Sherbuk et al., 2020 | Qualitative | Latine/x/Hispanic |
22 | James et al., 2019 | Qualitative | Physicians, trainees, and medical students |
23 | Furness et al., 2020 | Qualitative | Sexual/Gender-minoritized, MSM, Transgender |
24 | Lelutiu-Weinberger et al., 2020 | Cross-sectional | Sexual/Gender-minoritized, Transgender |
25 | Gray et al., 2020 | Cross-sectional | Sexual/Gender-minoritized, MSM |
26 | Cianelli et al., 2019 | Cross-sectional | Latine/x/Hispanic |
27 | Aurora et al., 2022 | Cross-sectional | Physicians, trainees, and medical students |
28 | Meanley et al., 2021 | Cross-sectional | Sexual/Gender-minoritized, MSM |
29 | Tordoff et al., 2022 | Cross-sectional | Sexual/Gender-minoritized, Transgender |
30 | Russ et al., 2022 | Cross-sectional | Sexual/Gender-minoritized, MSM |
31 | Griffin et al., 2020 | Cross-sectional | Sexual/Gender-minoritized, MSM |
32 | Aisner et al., 2020 | Literature review | Sexual/Gender-minoritized, MSM, Transgender |
33 | Aidoo-Frimpong et al., 2021 | Literature review, Systematic review | Immigrant |
34 | Fields et al., 2020 | Literature review | Sexual/Gender-minoritized, MSM, Black/African American |
35 | Goldhammer et al., 2022 | Literature review | Sexual/Gender-minoritized, Transgender |
36 | Ramos et al., 2021 | Literature review | Black/African American, Latine/x/Hispanic |
37 | Safer et al., 2019 | Literature review | Sexual/Gender-minoritized, Transgender |
38 | Mayer et al., 2021 | Literature review, Systematic review | Sexual/Gender-minoritized, MSM |
39 | Vaitses Fontanari et al., 2019 | Systematic review | Sexual/Gender-minoritized, Transgender |
40 | Lee et al., 2019 | Systematic review | AAPI |
41 | Gunn et al., 2022 | Systematic review | Sexual/Gender-minoritized, MSM |
42 | Dang et al., 2022 | Systematic review | Sexual/Gender-minoritized, Transgender |
43 | He et al., 2020 | Cohort | Sexual/Gender-minoritized, Black/African American |
44 | Scott et al., 2020 | Cohort | Sexual/Gender-minoritized, MSM, Black/African American, Latine/x/Hispanic |
45 | Connolly et al., 2020 | Cohort | Sexual/Gender-minoritized, MSM, Transgender |
46 | Watson et al., 2022 | Cohort | Black/African American |
47 | Young et al., 2019 | RCT | Black/African American |
48 | Horridge et al., 2019 | RCT | Sexual/Gender-minoritized, Transgender, Latine/x/Hispanic |
49 | Desrosiers et al., 2019 | RCT | Sexual/Gender-minoritized, MSM, Black/African American |
50 | Ho et al., 2022 | Scoping review | Sexual/Gender-minoritized |
51 | Carter et al., 2019 | Commentary | Sexual/Gender-minoritized, MSM, Black/African American |
52 | Adeagbo et al., 2021 | Commentary | Sexual/Gender-minoritized, MSM, Black/African American |
53 | Tsuyuki et al., 2022 | Mixed-method | Sexual/Gender-minoritized, MSM, Latine/x/Hispanic |
54 | Sen et al., 2021 | Commentary | Sexual/Gender-minoritized, MSM, AAPI |
55 | Lee et al., 2022 | Prevalence study | Sexual/Gender-minoritized, Transgender, Black/African American, Latine/x/Hispanic |
56 | Howson et al., 2021 | Case report | Sexual/Gender-minoritized, Transgender |
57 | Alarcon et al., 2020 | Mixed-method | Black/African American |
58 | Perucho et al., 2020 | Mixed-method | Physicians, trainees, and medical students |
59 | Agwu, 2020 | Perspective paper | Sexual/Gender-minoritized |
MSM: Men who have sex with men, AAPI: Asian American and Pacific Islander, RCT: Randomized controlled trial | |||
Table 2. “Barriers”* and “Facilitators”* identified during research process
Barrier* Code | Facilitator* Code |
Financial constraints | Availability of inclusive messaging/services |
Inadequate clinician training/education/knowledge | Clinician knowledge/ competence/ training |
Lack of trust/comfort with clinician | Community engagement/effective promotion of services |
Clinician bias/prejudice (unconscious, religious, cultural, including homophobia or racism) | Structural/systems support |
Community sexual/gender discrimination/violence: real or perceived stigma and/or harassment from friends/family/community/public | Gender-affirming respect from clinician |
Lack of culturally relevant messaging/services in Healthcare | Policies/mandates/requirements |
privacy concerns: expressing concerns about confidentiality of testing sites/methods, fears of being outed to community/parents/friends | Continuity of care with clinician |
perceived irrelevance/ inconvenience/ harm/ incompatibility: expressing concerns about medication side effects, consequences of HIV test results, perception of low personal risk | Trust/comfort with clinician |
Racial/ethnic discrimination/violence (from community) | Concern for own health |
Comorbid mental health and/or substance use disorders | Desire to keep partners safe |
Prioritization of other care over HIV screening (gender-affirming, etc.) | Clinician comfort asking about sexual health/practice |
Fear of knowing HIV status | Clinician willingness to educate self |
Internalization of discrimination | Shared social identity between patient and clinician |
Employment status/barriers due to job | Clinician stereotypes about minoritized group (i.e. perceptions of increased risk-taking behaviors) |
Employment status/barriers due to job | Co-location of gender-affirming care and HIV services |
Lack of clinician willingness to learn | Social support: feelings of support/connection from family/community or testing service |
Lack of respect from clinician (misgendering, discrimination) | Perceived convenience/compatibility with lifestyle: convenience associated with testing service/intervention |
Clinician stereotypes about minoritized group (i.e. perceptions of decreased risk-taking behaviors) | Cues to action/provider recommendation: responsible PCP recommendations and referrals |
Lack of open disclosure between sexual partners | Financial accessibility: affordable/free services, insured status |
Inadequate clinic hours/lack of available competent clinicians/long wait times |
|
Language barriers |
|
Immigration status-related barriers |
|
Lack of transportation services |
|
Lack of linguistically appropriate messaging/services |
|
Screening guideline/policy issues |
|
Challenges filling prescriptions |
|
High arrest and incarceration rates |
|
Housing and financial instability |
|
Lack of health literacy |
|
Lack of social support |
|
*The terms “barrier” and “facilitator” were later discarded in favor of “factors” to represent the data more accurately, as discussed in the text. | |
The 49 studies included were published between 2019-2022, and all studies were either conducted in the U.S. or discussed implications for U.S. health systems. Table 1 presents the study characteristics. The final data set included 13 qualitative studies,11-23 10 cross-sectional studies,19-20,24-31 8 literature reviews,15,32-38 6 systematic reviews,33,38-42 4 cohort studies,43-46 and 3 RCTs,47-49 among others.50-59 Thirty-four studies focused on sexual and gender-minoritized individuals:14,18,31-32,43,50,59 18 studies investigated men who have sex with men (MSM),12,17,19-20,23,25,28,30-32,34,38,41,44-45,49,51-54 while 11 studies focused on transgender individuals.11,15,23-24,29,32,35,37,39,42,45,48,55-56 Twenty-eight studies focused on racial and ethnic minoritized groups:18 13 addressed Black/African American individuals,13,16,34,36,43-44,46-47,49,51-52,55,57 9 Latine/x/Hispanic individuals,13,16,21,26,36,44,48,53,55 2 Asian American and Pacific Islander (AAPI) groups,40,54 1 immigrant populations,33 and 1 indigenous populations.16 Three studies specifically looked at physicians, trainees, and medical students as their populations of interest.22,27,58 Studies were quantified based on the study language captured by reviewers during the data extraction and charting process.
After charting data and consolidating our list of factors through our confirmation and elimination process, the research team conducted a multi-phase summation and analysis process. First, we conducted a frequency count of similar “barriers” and “facilitators”, which yielded 30 “barriers” and 19 “facilitators” to culturally responsive HIV and PrEP screening (Table 2). Then, author MW organized and wrote them according to the four tenets of culture identified within our framework of culturally responsive communication: culture of the patient, culture of the clinician, culture of medicine, and culture of racism.60 This thematic analysis gives nuance supporting culturally responsive communication in the care of minoritized patients. Terms used below to refer to specific racial, ethnic, sexual, and gender-minoritized populations reflect the language used in corresponding studies.
The values, preferences, and interests of patients are important to strengthening the patient-PCP relationship and integrating patient-centered HIV and PrEP screenings across healthcare settings.60 Two key themes emerged related to this tenet.
Availability of inclusive messaging and services. Patient risk perception is socioculturally determined, so health messaging and services must follow suit.11,33 These values should be reflected in all areas of the healthcare experience51 and can look like trans-inclusive questions on symptomatology, anatomy, and surgical history during interviews;29 PrEP visuals including cisgender women;46 graphics showing insertive and receptive sex risks for MSM;17 low-literacy Spanish-translated material;48 and developmentally appropriate conversations with adolescent patients.13,20,38,59 Hiring healthcare teams that reflect the identities of the patient populations served35 will aid in developing such messaging if everyone is adequately trained in upholding general patients’ rights to confidential services and holistic referrals that address legal and social health needs.23 Community-based participatory research (CBPR),36 which amplifies the voices of community stakeholders alongside researchers, can elucidate these needs by acknowledging cultural viewpoints18 alongside multi-level factors that shape clinical interventions.
Community engagement and effective promotion of services. Evidence-informed strategies to increase community visibility and trust include reliance on nurses in community settings26 and the use of CBPR.51 Key to these strategies is identifying community gatekeepers such as elders, faith-based figures, and other opinion leaders33,48,54 within patients’ social networks to disseminate key messages on wellness. Additionally, expanding screening services beyond the clinic through street-based HIV testing in homes and mobile clinics47 has increased access to care. The changing landscape of care necessitated by the COVID-19 pandemic has also popularized different types of access.12 Patients, particularly adolescents, desire means of communication that increase confidentiality and convenience – namely text-based and mobile device-based access to clinicians, counseling, and follow-up.12,34,49 Efforts like these are only as effective as the partnerships that exist between policymakers, schools, community-based organizations, and healthcare settings.35,41 These partnerships are mutually beneficial and engage community members, including sexual and gender-minoritized patients, as mentors, peer educators, and healthcare workers.15,23,38
The values and beliefs of clinicians influence their patient encounters and the HIV and PrEP screening behaviors they practice.60 Three key themes emerged, as follows:
Clinician bias/prejudice. Clinicians, like everyone, hold biases. Without careful reflection, clinicians may judge, discriminate, or mistreat patients seeking HIV testing.24,32 When minoritized patients perceive or experience transphobia from clinicians39 or discrimination based on their racial or gender identities, they are less inclined to talk openly, adhere to PrEP, or seek HIV screening, lab testing, and follow-up.15,25,26,34,36 In addition to delaying care,23 concerns of mistreatment exacerbate the misinformation patients believe about PrEP’s adverse effects.18 These negative outcomes are most pronounced for Black women and sexual and gender-minoritized patients, particularly Black MSM in southern U.S. states.50,51
Adequate clinician knowledge and competence. Naturally, clinicians perceived as proficient and understanding of the needs of minoritized groups encourage confidence and engagement from patients in HIV-related preventative care.20,23 Additionally, understanding the basic and specific needs of LGBTQ+-identifying patients allows clinicians to actively counsel their patients.37,39 Clinicians identifying as more competent about PrEP report more PrEP-related behaviors in their practice.27
Respect from clinicians for gender-affirming care. Minoritized individuals look for markers of inclusiveness in their healthcare experiences like any other patient. Often overlooked are simple and sincere efforts like asking a patient what name they would like to be called.15 Sexual and gender-minoritized patients report an increased likelihood of accessing healthcare,24,56 initiating PrEP,17 and seeking HIV-related services35,39 when clinicians are nonjudgmental,17 do not presume sexual and gender identity,23 know proper terminology and LGBTQ+-specific health disparities,23,37 and maintain the confidentiality of HIV testing. For example, non-English speaking patients may feel more secure using telephone-based interpreters even when in-person interpreters are available due to fear of accidentally disclosing to clinic staff who are personally known to them.22 While inclusive environments are important for all patients,43 they are especially so for minoritized patients. Inclusivity can look like coupling HIV services with hormone therapy35,39,42 – including for adolescent and young MSM.28
Healthcare system design and operation matter for access. Available and affordable healthcare is as important as clinician relatability and health literacy.60 Two key themes are represented in the literature, as follows:
Financial constraints. Patients feel challenged in accessing HIV testing or initiating PrEP if they expect out-of-pocket costs.42 If patients are experiencing insecurity in income, housing, or employment, they are less likely to be employed and insured.16,51,55 Even in regions like Miami, where HIV testing and PrEP are available for free to patients through the AIDS Drug Assistance Program (ADAP), a program of the Ryan White HIV/AIDs Program, there is an assurance that people with HIV have access to HIV services and medications regardless of their insurance status and/or ability to pay. This also includes programs like the Miami Department of Health’s “Getting to Zero” and the national “Ready, Set, PrEP”,18 limited knowledge of these programs and patients’ perception of expenses deters PrEP and HIV testing uptake.17 This is especially pronounced among undocumented patients21 and those who have engaged in sex work.24 Across studies, racially and ethnically minoritized patients expressed concerns about the costs of HIV testing, office visit copays, prescriptions, and additional “monitoring labs” for PrEP.34 In some cases among LGBTQ+ patients, the inability to pay for gender-affirming care led to participation in dangerous and unregulated procedures overseas.11
Services that address structural barriers. The factors producing unfair racialized outcomes are structural. As such, we must focus on clinical interventions that address the structural inequities that patients face, in addition to patient counseling. For example, healthcare settings must include referrals focusing on resource allocation if their patients report poverty and food and housing insecurity,47,51 as these are among the reasons minoritized patients have increased exposure to HIV or lower utilization of HIV testing and PrEP. Clinical interventions must rely on intersectional14 and interdisciplinary best practices36,52 to address mental health,15 support adherence,45 and promote adolescent-friendly services.34 When the screening questions and visuals are cis-centered and heteronormative,56 they may not engage or appeal to sexual and gender-minoritized patients, which negatively impacts the reach of interpreter services21 and the capacity of healthcare teams to address macro issues like incarceration44 that affect care continuity.
Culturally responsive HIV and PrEP screening conversations between PCPs and minoritized groups are key to bridging HIV morbidity and mortality disparities in the U.S. This scoping review answered the gap we identified among existing literature prior to our study by allowing us to identify a range of factors that shape culturally responsive HIV and PrEP screening in the primary care setting. An iterative selection process narrowed the research articles included in our data analysis to those that focused on patient-clinician interactions for historically marginalized groups. The factors positively influencing HIV and PrEP screenings include trusting patient-clinician relationships, clinician competence, community engagement, inclusive messaging and services, and gender-affirming care. The factors negatively influencing these screenings include mistrust of clinicians, clinician incompetence and bias, community stigma, and financial costs.
We were also able to identify key themes and gaps in addressing culturally responsive screening practices. For instance, our study populations included racial, ethnic, sexual, and gender-minoritized individuals, but patients also identify with youth, rural, immigrant, elderly, or other communities. This underscores the importance of recognizing minoritized patients as fully human with a range of intersecting identities who benefit from referrals that address the other facets of their lives.34 For instance, value social support including birthday calls, appointment reminders, and support groups.53 Services must be accessible,34 holistic,45 and compassionate,31 as well as designed to meet the ecological and intersectional needs of minoritized populations.56
Our findings also remind us that clinicians, like everyone, are human and have their own biases. Given deeply ingrained social norms, medical expertise is a prerequisite but on its own deficient facet of the therapeutic relationship and does not inherently protect against gender discrimination.33 Therefore, clinicians need PrEP training alongside anti-bias training without being limited to continuing medical education topics. Education must begin in health professions schooling and continue throughout practice. The health workforce must unlearn outdated and stereotypical examples and messages in textbooks and case studies36,42,51 to intentionally care for patients who have historically been failed by medical institutions. Additionally, clinicians must be trained on how to equitably incorporate patients’ lived experiences and health needs into the medical decisionmaking. Our research team modeled how to communicate this skill during a training series for PCPs that included a lecture on how to share power with patients.61 Future research may include longitudinal evaluations that identify the impacts of health curricular innovations like these on the practice and perceived effectiveness of clinicians.
Finally, our findings corroborate knowledge that medical mistrust remains a leading cause of why minoritized patients do not engage in health-seeking behaviors. Mistrust, learned or passed on, is often justified within the context of structural and systemic injustices. However, when the lived experiences of the most marginalized populations are centered,54 screening efforts can effectively address the multicultural and multilevel factors that shape health.48 In doing so, we can strengthen therapeutic relationships with PCPs to effectively advance the health of historically marginalized populations. Local and regional research on this topic may be beneficial to identify unique needs among different backgrounds and cultures.
The major study limitation was the process of coding barriers and facilitators. Despite operationalizing each code, some of the codes with varied implications counted as more than one barrier and facilitator. As such, we could not determine predominant themes by quantifying codes across studies, alone. Due to this limitation, we shifted our framework from a focus on quantifying facilitators and barriers to more accurately reflecting the factors and themes identified in HIV and PrEP screening. While this change slowed our process and data analysis, it allowed for a meaningful and accurate conceptualization of our findings. Another limitation was the restricted time frame of this review, which only includes literature available until 2022, as mentioned above.
This study has important implications for clinic and practitioner-level HIV and PrEP screening policies. Additionally, these results offer avenues to pursue effectively tailored, culturally responsive interventions to promote HIV and PrEP screening for historically marginalized groups.
We would like to acknowledge Thomas Harrod, Associate Director of Reference, Instruction, and Access at the George Washington University’s Himmelfarb Health Sciences Library for his generous guidance and support in developing the search strategies for this scoping review and Stacy Brody, Reference and Instruction Librarian at the George Washington University’s Himmelfarb Health Sciences Library for her guidance in creating the manuscript for this publication. We would also like to acknowledge Saylor Pershing, Darrell Bailey, Sheel Singh, and Abigail Konopasky for their assistance in the text screening and extraction process. The authors would also like to acknowledge Bobga Gang, Bailey Moore, and Hasina Chimeka-Tisdale for their assistance in the data coding process. Funding was made available by Gilead Sciences Inc. The grant funder had no role in the design of this program or in the research discussed in this article.
The authors have no relevant financial disclosures or conflicts of interest.
Julia Xavier is a third year medical student at The George Washington University School of Medicine and Health Sciences. She attended GW as an undergraduate student and received a BS in Public Health. Currently, she is a full-time student in clinical training and works on research initiatives focused on antiracism and health equity in the training and practice of health professionals and learners. Her areas of interest include racial equity, clinician-patient relationships, and reproductive justice. Julia serves as a research assistant for the Two in One Model.
Dr. Maranda Ward is an Assistant Professor and Director of Equity in the Department of Clinical Research and Leadership in the GW School of Medicine and Health Sciences. She is an expert in advancing anti-racism efforts within health professions education to competently promote health and racial equity in practice. As the PI of the Two in One: HIV and COVID Screening & Testing Model, she led a national research-informed educational intervention aimed at eliminating HIV, PrEP, and COVID-19 vaccine stigma. She earned degrees in sociology and anthropology from Spelman College, in public health from Tulane University, and in education from The George Washington University.
Dr. Paige McDonald is an Assistant Professor and Vice Chair in the Department of Clinical Research and Leadership at the GW School of Medicine and Health Sciences. She has 20 years of experience in qualitative research and has applied a variety of methods to advance the understanding of learning within health sciences, including phenomenography, phenomenology, basic interpretivist, case study, and mixed methods. She has expertise in designing interview and focus group protocols, observation protocols, and methods for document review. She is the Director of the GW Health Research and Education Collaboratory and the Co-PI for the Two in One Model.
Nikhil Kalita is an MPH candidate at The George Washington University Milken Institute School of Public Health, concentrating in Epidemiology. He has experience in research and developing educational materials for healthcare professionals. Specifically, he published two CME-accredited modules focused on teaching the significance and methodology of equitable community-based participatory research to physicians of the Children’s National Hospital in Washington, D.C. Nikhil is a research assistant for the Two in One Model.
Dr. Patrick Corr, EdD, Med, AFAMEE is an assistant professor in the Department of Clinical Research and Leadership at the George Washington University (GW) School of Medicine and Health Sciences (SMHS); Vice Program Director, Integrative Medicine; and the principal investigator with the Frame-Corr Research Lab. Dr. Corr has experience in designing and leading qualitative and mixed methods health research and is currently leading a study on the role of nutrition education in outpatient oncology clinics. Dr. Corr teaches coursework in research methodology, public health, and health education. Dr. Corr’s research interests are in subjective well-being, whole body health, and nutrition education.
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