This video is part of the NIDA series At the Intersection: Stories of Research, Compassion, and HIV Services for People who Use Drugs.
One 2020 study found as many as 1 in 3 new HIV transmissions among sexual and gender minorities involve people who regularly use methamphetamine—yet research shows that people who use meth may face barriers to accessing the HIV prevention and treatment tools.
In this video for health care professionals, HIV advocate and artist Ken Williams seeks to learn more about research at the intersection of methamphetamine use and HIV—and about the atmosphere of health care available to gay and bisexual men.
Christian Gov, Ph.D., of the City University of New York (CUNY) School of Public Health, Adam Carrico, Ph.D., of the University of Miami, and Sarit Golub, Ph.D., M.P.H., of CUNY Hunter College share insights from their NIH-supported research on caring for this population. Sime Monell, R.N., of Callen-Lorde, offers her advice on building trust, while people with lived experience at the intersection of substance use and HIV describe how meaningful support has impacted their lives.
Video length: 8:19
Transcript
[Dr. Sarit Golub] One of the most important things we can do to improve public health is to restore trust, in patients, for their providers.
[Ken Williams] So often, the great divide between patient and provider is trust. You know, people who use drugs are often refused the same access to HIV services and care offered to others. Stigma and discrimination in healthcare has been a crisis all its own, and that crisis has created a barrier to care for people who use meth, including gay and bisexual men.
How do providers provide compassionate care for men who are all too often stigmatized and discriminated against? That is what I needed to know.
[Dr. Christian Grov] So, I think it's really important to meet people where they are at and to not judge them for anything that they're doing, whether it's not using condoms, whether it's using methamphetamine.
[Golub] There is this tension, and I think that there is this very real need to help people, right? And one very common strategy is what I refer to as the “don’t you know” strategy. “Don’t you know that meth use can harm you?”
“Don't you know that unprotected sex can lead to X and Y,” right? “Don’t you know?”
And we feel this—incredibly, profoundly—this need. Because I think it’s motivated from love, right? It's motivated often from love for the community. “I love you. I need you to stop doing this.”
But the problem is – there's two problems. One is, “I already know.”
I would challenge you to find a smoker who does not know that smoking causes cancer, right? And so, if I already know it, then what I perceive you to be saying to me—when you say to me, “Don't you know?”—is you're trying to make me scared, and you're trying to shame me.
[Delano Burrowes] And people know when they’re being listened to, and it brings out trust. And for many of us, I don't know, people from marginalized groups, there's already so many layers of distrust.
[Golub] And fear and shame, this is the second piece, are the most alienating of experiences. And, so, any time we root these messages in fear or shame, we are, by definition, alienating individuals from the acceptance of that message and from hearing us at all.
And what they hear is, “You don't care about me.”
And that, to me, is the most damaging thing about this type of messaging.
[Williams] There’s a better way for us to treat people who use drugs without judgment.
[Grov] When you get to something that is highly stigmatized, like substance use, you want to create a space where somebody can be honest with their provider about what they're doing so that their provider can give them the best treatment possible. And that's the important elements of why it's important to meet your clients where they are at, because then they will be honest with you about what's going on in their lives.
[Burrowes] I have enough shame already that I'm bringing to myself. I don't need to look at somebody else’s face and see them judging me or imagine that they're judging me. A lot of this is really thought to stem from the experiences of social stigma and rejection that sexual minority men experience.
That can often be multilayered, right? We think about intersecting identities, like being a drug user, being an ethnic minority man. There are lots of ways that guys experience stigma in their communities.
[Golub] So, for me, the best definition of stigma is the linking of social judgments about a particular characteristic—in this case a behavior—to a person who is engaging in that behavior. And that linking is profoundly a form of social control.
[Williams] What are some of the ways health care providers can start the process of restoring the trust of people who use drugs?
[Sime Monell] They’re humans. Their need is healthcare. Their need is to be understood. Their need is to be taken care of—judgement-free. Their need is to be safe. Their need is to have a place to be where they can just come and express themselves and be themselves.
[Dr. Adam Carrico] Ask your patients, “What's going on? Are you using? Tell me about it,” in a non-judgmental way. Because I think, many times, in PrEP clinics, STI clinics, or general medical doctor visits, people are uncomfortable disclosing, right? They're uncomfortable initiating that discussion about their substance use. And so, just asking can really open that dialogue.
[Golub] “Tell me your biggest concern about substance use right now.” That type of question might enable a person to actually have a conversation about their life, as opposed to a litany of… “Do you do this, do you do this? How often do you do this, how often do you do this?”
And might really focus on the piece that the provider actually needs to help them with most.
[David Marshall] My psychiatrist really asks me questions and makes me think about things. He's earned my trust by asking questions that really mean something.
[Golub] One of the things that I feel very strongly about is that we need to only ask questions that we're going to do something with the answers.
[Monell] You ask people about themselves, not in a way of getting in their business just to know. But, “What can I do for you? What are the services you're looking for? What can I provide for you?”
Because that's what we're here for, right?
[Marshall] And even though I have used, I've always not wanted to use. And I think that that's been a part of my seeking out people that are going to help me and point me in the right direction.
[Carrico] Working in healthcare settings and in medical units, it's widely accepted that drug users can be stigmatized and mistreated. And that is really one of the major things that drove me to do this work is to try and find ways that we can reshape the experience of health care for people who use drugs like methamphetamine and deliver, I think, more compassionate and integrated care.
[Grov] I hope that the work that we're putting out there not only speaks to the scientific community, but it also speaks to, you know, health professionals that are working with people who are using substances—to see their clients where they're at, to meet their clients where they're at, to recognize that this is going on within these communities and asking the best questions to get the best treatment for these individuals.
[Burrowes] There's so much shame about queerness. There’s shame about my addiction that I had to deal with. There’s definitely shame about the HIV that I had to deal with. And once I addressed the fact that there was shame, and I start talking about it and started being real and being vulnerable, that's when I start to connect.
[Monell] You allow them to speak to you freely. You allow them to express what they are comfortable expressing without digging too deep. Of course, first visit they may not give you all of that because they don't know you yet, but that's why you allow them to just speak freely, allow them to know that you're there for them, and you welcome them back.
[Williams] And isn't that just it? Despite the stigma and discrimination, being allowed the autonomy to own your vulnerability and allowing that vulnerability to lead you to a healthier you.
You know, lack of trust might be the great divide—but building that trust back can be the game changer. People living at the intersection of substance, use, HIV, queerness and race deserve more—so let's keep listening.
[Voiceover] To learn more about substance use and addiction research, log on to nida.nih.gov.
If you or someone you care about wants help, you can learn more by calling the National Helpline at 1-800-662-HELP (4357) or by visiting FindTreatment.gov.
References:
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2. McMahan VM, Violette LR, Andrasik MP, Martin A, Garske L, Stekler JD. 'I make sure my doctor doesn't know that I use meth': perceived barriers to pre-exposure prophylaxis (PrEP) uptake among community peer educators in Seattle (WA, USA). Sex Health. 2020;17(1):29-37. doi:10.1071/SH19083
3. Semple SJ, Strathdee SA, Zians J, Patterson TL. Factors associated with experiences of stigma in a sample of HIV-positive, methamphetamine-using men who have sex with men. Drug Alcohol Depend. 2012;125(1-2):154-159. doi:10.1016/j.drugalcdep.2012.04.007
4. Compton WM, Jones CM. Substance use among men who have sex with men. N Engl J Med. 2021;385(4):352-356. doi:10.1056/NEJMra2033007