When approved in 2012, a pill that prevents infection from the AIDs virus was considered a game changer, one that finally could help halt the pandemic that, to date, has killed nearly 33 million people worldwide. Yet, eight years later, many people at high risk of acquiring HIV have never heard of the pre-exposure prophylaxis (PrEP) medication, much less are taking it.
Rosina Cianelli, an associate professor in the University of Miami School of Nursing and Health Studies, is determined to change that reality among heterosexual Hispanic women—particularly those who face the cultural barrier of machismo when it comes to protecting themselves from HIV. Recognizing that Latina women can’t always convince partners who embody the macho standard of sexual dominance and promiscuity to use condoms, Cianelli and her co-investigators plan to augment a proven HIV prevention strategy to increase PrEP use among an overlooked population of at-risk heterosexual Hispanic women, Latina farmworkers in rural south Miami-Dade County.
“Women account for about 19 percent of new HIV diagnoses, yet only about 7 to 10 percent of PrEP users are women, and only about 11 percent of Hispanic women are familiar with PrEP,” Cianelli said. “Given that the rate of Hispanic women living with HIV is 2.5 times higher than for non-Hispanic white women, they need to be more aware of PrEP. That is the reality we are confronting.’’
Cianelli’s PrEP initiative is the newest of four University of Miami proposals funded by the National Institutes of Health to advance the federal government’s Ending the HIV Epidemic (EHE) plan. Unveiled by President Donald Trump last year, EHE aims to reduce the roughly 40,000 new HIV cases still diagnosed annually in the United States by at least 90 percent by 2030. And it aims to do so by supporting community-based initiatives that the NIH’s Centers for AIDs Research (CFARs) and the National Institute of Mental Health’s AIDS Research Centers (ARCs) are pursuing with existing and highly effective tools for diagnosing, preventing, and treating HIV.
The University is home to both a CFAR, the 13-year-old Miami Center for AIDS Research, and a new ARC, the Center for HIV and Research in Mental Health (CHARM) and for a good reason. As CHARM director Steven Safren said, “With its large diverse and, in many ways, marginalized populations, Greater Miami remains one of the nation’s most challenging epicenters, if not the most challenging epicenter, for new HIV cases and optimal HIV treatment. Each of the projects that the University is pursuing with EHE funding targets a population here in Miami that can truly benefit.”
Administered by the Miami CFAR, Cianelli’s proposal is one of only seven the NIH selected across the nation to help reduce barriers to PrEP use among heterosexual women. It builds on a culturally tailored, behavioral-change strategy pioneered two decades ago by Nilda Peragallo Montano, the former dean of the nursing school. Known as SEPA—for Salud, Educación, Prevención, y Autocuidad (Health, Education, Prevention and Self-Care)—the intervention has successfully employed group discussions and role playing to empower low-income heterosexual Hispanic women how to negotiate condom use and better communicate with male sexual partners.
For their EHE initiative, Cianelli and her co-investigators—associate professor Joseph De Santis and assistant professor Giovanna De Oliveira, both also from the nursing school, and professor Jose Castro, of the Miller School of Medicine—are working with three community organizations in Homestead to enlist 60 women who will help develop a strategy for incorporating PrEP into SEPA for women who cannot count on condoms for protection.
“SEPA works very well when women can negotiate the use of condoms with their partners, but for Hispanic women whose partners refuse to use condoms, or who use drugs, or who have multiple partners, it doesn’t work,” Cianelli said. “So, adding this biomedical component to SEPA will give at-risk Hispanic women another possibility to prevent HIV.”
Through its second round of EHE grants, the NIH also green-lighted three pilot projects University researchers launched with first-round funding last year. The recipient of another grant administered by the Miami CFAR, the Miller School’s Susanne Doblecki-Lewis, an associate professor of clinical medicine, is also focused on increasing PrEP access. She plans to use near real-time epidemiological analysis and a mobile clinic to deliver the medication that, when taken daily, reduces the risk of getting HIV from sex by about 99 percent.
With the expansion grant, the UM PrEP Mobile Clinic is now operating in Liberty City, in addition to four other sites across Miami-Dade. At these locations, Doblecki-Lewis and her team provide PrEP testing for HIV and other sexually transmitted infections (STIs), and STI treatment at no cost to clients, regardless of their insurance or immigration status.
Administered by CHARM, the other two pilot projects are focused on two different groups that are critical to ending HIV infections in Miami—Latino men who have sex with men (LMSM), and Black individuals, who comprise the racial group most disproportionately impacted by the HIV epidemic across the U.S. In Miami-Dade alone, 1 in 31 Black adults are living with HIV compared to 1 in 127 Hispanics and 1 in 103 white adults.
To curtail the epidemic among LMSM, Mariano Kanamori, an assistant professor in the Division of Prevention Science and Community Health, and his collaborators are exploring how to promote awareness and utilization of HIV diagnosis, treatment, and prevention services based on how LMSM identify themselves—as gay, bisexual, or straight.
“Our research has shown that bisexual Latinos are the bridge between Latino men who have sex with men and with Latinas,” Kanamori said. “They have sex with gay guys, but they don’t view themselves as gay, so they are exposing women to HIV. That’s why we need to customize strategies to target both groups, not just those who are gay.”
To curtail the epidemic’s impact in Black communities, Sannisha Dale, assistant professor of psychology and the director of CHARM’s mental health disparities core and her community partners—Roxana Bolden, George Gibson, Gena Grant, Kalenthia Nunnally, and Alecia Tramel—are engaging residents at five neighborhood places they frequent in high-risk ZIP Codes. Teaming up with the owners of corner stores, car-repair garages, barbershops, beauty salons, and laundromats, they’ll chat with customers about HIV prevention and give those who complete a survey and take a rapid HIV test vouchers to spend at the business.
“Will this by itself end the HIV epidemic? No,” Dale said of the Five Point Initiative she hatched while waiting for her own car repair. “But ending the HIV epidemic requires multiple approaches aimed at the same end goal. And by engaging people where they naturally frequent, we remove the barriers that stop them from coming to medical centers to be tested, to learn about PrEP, to engage about their sexual health. So, it has the potential to make an impact.”
