5 Questions with Faculty – Melonie Walcott on Social and Structural Barriers to Ending the HIV Epidemic

ALBANY, NY (Sept. 28, 2023) -- This year, the University at Albany School of Public Health welcomes several new faculty members, including Melonie Walcott, an HIV researcher whose work focuses on social and structural factors associated with HIV risk behaviors and uptake of HIV prevention and treatment services among marginalized populations.  Her current research focuses on assessing the association between patient-provider relationship and experience of racism in health care, and engagement in HIV care, and viral suppression among Black men who have sex with men. Her work emphasizes the challenges of addressing public health issues in marginalized populations. We sat down with Walcott to get to know her better and introduce her to the wider UAlbany community.

Where is home for you and what drew you to the University at Albany?

Home is Jamaica, in the friendly little city of Montego Bay. I miss the white sandy beaches, yearlong sunshine, live outdoor reggae shows, and of course, the food – especially escovitch fish and bammy.  Although Albany is quite different from Jamaica, I enjoy living in Albany. I love the hiking trails, clean fresh air, and listening to the birds and watching the chipmunks and squirrels while having my coffee in the mornings.  I am grateful that I am able to live in the woods, while being minutes away from shopping, entertainment and the airport. I must confess though; I will always dread the frigid temperatures during winters.

I am thrilled to join the faculty at the University at Albany School of Public Health and am looking forward to thriving at the institution and collaborating with my new colleagues. There are a number of factors that led me to UAlbany, including the institution’s commitment to diversity and inclusivity, creating opportunities for faculty to collaborate and advance their research, and engaging the community.  While I am committed to lifelong learning and teaching, and being part of a process that contributes to the next generation of leaders and innovators, I am passionate about research and its potential to improve population health. Importantly also, it is an excellent opportunity to engage students in research.

How has our understanding of HIV prevention and care evolved over the course of your career?

The approaches and tools we use for HIV prevention and treatment have changed dramatically over the course of the HIV pandemic.  HIV has been transformed from a life-threatening emergency to manageable chronic disease wherein individuals can live long, healthy, and productive lives. Two key developments that revolutionized HIV prevention and management are Treatment as Prevention (TasP) and HIV preexposure prophylaxis (PrEP).  The fundamental goal of TasP is to treat individuals who are living with HIV with antiretroviral therapy (ART) to ensure they achieve and maintain viral suppression or what we call an “undetectable” viral load status. Individuals who maintain an undetectable viral load status will not transmit HIV to their HIV negative partners through sexual contact (including condomless sex).  We call this U=U or undetectable equals untransmissible . PrEP is a highly efficacious and scalable biomedical HIV prevention medication that could significantly reduce the burden of HIV. Both daily and intermittent oral PrEP and the recently approved long-acting injectable PrEP (cabotegravir (CAB-LA)) are highly effective in reducing the risk of acquiring HIV from sexual contact. A third important change is that HIV testing has become easier and more accessible, which has increased HIV screening rates, the crucial first step to accessing treatment and prevention.

In addition, there is a global effort to end HIV. The Joint United Nations Program on HIV/AIDS (UNAIDS) “has been leading and inspiring the world to achieve its shared vision of zero new HIV infections, zero discrimination and zero AIDS-related deaths.”  Many countries across the world have since been motivated to develop country specific Ending the HIV Epidemic (EHE) initiatives. The U.S. EHE plan seeks to reduce the number of new HIV infections by 90 percent by 2030.

To what extent do health disparities still play a role in the HIV epidemic?

While we have made significant progress over the years, HIV inequities and disparities continue to persist globally and nationally. Here in the U.S., African Americans are disproportionately affected by the HIV epidemic, having higher prevalence, morbidity, and mortality rates. In addition, African Americans who are living with HIV are less likely to achieve viral suppression, while HIV negative individuals who are eligible for PrEP are less likely to access (e.g., less likely to be prescribed PrEP) and use PrEP.   What gives me hope is that there now seems to be a general understanding that a multipronged approach including biomedical, behavioral, and structural interventions, coupled with political commitment and community activism, is required to halt the spread of the HIV epidemic.

In your expert opinion, what are the biggest social/cultural barriers that prevent people from receiving the care/tools they need to prevent/treat HIV today?

That is an interesting question. There are multiple ways that social stigma could prevent individuals from accessing prevention and care. When HIV status intersects with other factors, like race (anti-Black racism is especially damaging through the pathways of medical mistrust and medication skepticism), gender (sexist sexual norms around women being “good girls” or “sluts”), sexual orientation (homophobia is a major barrier for disclosing sexual behavior that can make us vulnerable to HIV), socio-economic status/poverty (also a source of shame and added structural barriers to care access), etc. Further, there are multiple dimensions of stigma that need to be addressed. We experience enacted stigma (actual experiences of stigmatization and discrimination), perceived (negative beliefs/thoughts about prejudicial actions of others towards us), anticipated (fear or expectation of being stigmatized), and internalized (“stigma as perceived and experienced by the individual being stigmatized”), highlighting the multiple ways in which individuals can be affected. Interrupting this cycle and helping individuals get over these barriers is crucial for increasing uptake of HIV prevention and treatment services.

There is presently no cure for HIV; thus, individuals living with HIV must engage in care to effectively manage the infection. This entails taking ART every day or getting injections every two months and maintaining doctors’ appointments.  The fears associated with being seen while taking HIV medications, accessing care at HIV facilities, treated negatively by health care workers etc. are all pathways of stigmatizing experiences that can influence engagement in HIV care.  An example of this experience as expressed by a participant in one of our qualitative research studies: “I was from a rural community and the clinic for HIV was in a different clinic. And their section was in the back. So, you had to go in there and sit in the back… so everybody knew you were going to the HIV clinic. If I come in and see somebody from my hometown, I'm most likely to come in and walk out.” In addition, fears associated with disclosure of one’s HIV status to others, such as rejection or abuse/violence, often reduce HIV disclosure to sexual partners which in turn can increase the rate of HIV transmission. In relation to HIV prevention, stigma may also discourage individuals to seek health information and engage in behaviors that increase opportunities for HIV acquisition and transmission. For example, although PrEP is a prevention medication for individuals who are HIV negative, many individuals are often hesitant to access PrEP due to fears of being labelled HIV positive or judged as being “promiscuous.”  For gay men this was manifest in being called “Truvada whores” at the start of PrEP being available. Similarly, women who use PrEP may be “slut shamed” as well. PrEP stigma has been shown to serve as a barrier to seeking information about PrEP, accessing it, and using it.  The findings from listening sessions that we conducted among stakeholders who provide HIV prevention and support services to women in New York City suggest fears related to “slut shaming” among women is a barrier to PrEP uptake.

As an HIV researcher, how was your work impacted by the pandemic? Has COVID set your work back, or were there perhaps some insights gained as well?

One noticeable difference was the reduced motivation to participate in research studies which primarily targeted men who have sex with men who were living in New York City. Despite increased recruitment efforts and participant incentive, enrollment in the research studies remained low. This was very surprising given the economic challenges presented by the pandemic. Low participation rates increased the duration of the studies considerably, as well as raising the cost and time required to disseminate the findings.

(A bonus question!) Are there any promising developments in your research on HIV and social determinants of health?

Actually, yes! Oral PrEP and new PrEP modalities (injectable PrEP) can really benefit women, Black women in particular, but only if they feel comfortable accessing and taking it. And unfortunately, many do not. Therefore, we need to develop programs that will support their informed decision making and address barriers that prevent uptake. I recently received pilot funding ($20,000.00) from the University of California San Francisco Center for AIDS Prevention Studies (CAPS) to conduct a qualitative study which aims to describe the ways in which social and structural factors influence sexual health and wellbeing, especially the use of HIV/STI prevention services (e.g., HIV/STIs screening) and identify unmet needs among Black cisgender women (BCW). I will also be developing an intervention to build capacity to improve sexual wellness with a focus on PrEP uptake among BCW. The findings from this study will be used inform an NIH grant application to refine and pilot test the intervention developed.