Prominent advocate Moisés Agosto says innovative strategies needed to face the continuing challenges of the epidemic

Longtime national HIV treatment advocate Moisés Agosto, a native of Puerto Rico, says the challenges facing Latinos in the epidemic haven’t changed much over the decades. Problems with housing, jobs, and education, along with other social determinants of health, continue to hurt prevention and treatment: Immigration status. Language barriers. Access to physical and mental health care. Access to food.

What’s different, he says, is the new medicalization model of treatment and prevention, and how that fits into those social determinants. What good is medicine to prevent infection or AIDS if people don’t have access to health care? “We have a new paradigm for HIV,” said Agosto. “We can think we have the same issues as before, but they’re going to play out differently now because we’re moving more towards biomedical prevention. We’re moving more towards a medical approach to treatment—getting people tested and getting them on medication.”

Today, medication helps stop people from becoming infected and helps those already living with HIV from being infectious as well as staying healthy. It’s a one-two punch against the spread of HIV.

That strategy won’t work if people don’t know about these medications, or face stigma over them, or simply don’t have access.

All of which raise the same old questions about such things as poverty and lack of health insurance. Perhaps insurance is a greater concern today when medication works better than condoms to prevent transmission, and when medication can keep an HIV infection from progressing to AIDS. In his work as Director of Treatment for NMAC (formerly the National Minority AIDS Council), Agosto promotes the use of PrEP (pre-exposure prophylaxis) for HIV prevention, but notes that this biomedical approach—currently consisting of a daily pill for prevention— requires access to health care. “I’m an activist and I’m HIV-positive, and I advocate for PrEP for young gay men of color, black and Latinos,” said Agosto. “At the same time, while I put emphasis on PrEP and biomedical prevention, I can forget that access to those interventions will require access to health care.”

Recent figures provided by Gilead Sciences, the only company with an HIV PrEP medication on the market, show that most of the men who have sex with men (MSM) taking it are white (75%). Yet it is black and Latino MSM who are at greater risk for HIV infection. “So, those who need it the most are not getting it,” says Agosto. He says that means continuing to promote the use of condoms, because “it will take longer for the Latino community to get into PrEP.” (Although the Truvada for PrEP label says it should be used along with condoms and other prevention methods, it’s largely seen by the public as an either/or thing for HIV prevention.) But the strategy of condom distribution (which one young black gay man called “old school”) needs to be updated. Agosto said that while prevention workers still like to pass out condoms in gay bars, millennials like to stay home watching Netflix and meet men online. Still, the new paradigm needs to fit into the old barriers, not the least of which is plain old stigma. In the HIV epidemic, even accessing prevention continues to be stigmatized. Why would you need protection if you’re not some kind of slut? Or so the stigma goes.

He said the “Truvada whore” label attached to the PrEP pill continues to negatively affect uptake. “That’s why I think the whole behavioral component of HIV prevention is so important, because it’s not all about getting people onto PrEP and behaviors that make them adherent to medication. These are people who already have stigma, just for being gay. Then you add to that equation, ‘Do you want another stigma?’ No. So if they want care, they might have to find it away from the people who potentially may be supporting them, like their family. So, it’s tricky. It has so many dimensions.”

Behavioral interventions therefore remain important in the age of the medical model, he said. Emotional support can help people access the new world of medical care, and can help them overcome the stigma that keeps them from getting there.

At the same time, he said, it’s important for testing and biomedical prevention to take a more holistic approach. “It’s an overall health issue. Not only could you be taking care of HIV prevention or treatment, but you could be taking care of other health issues. This gives the context of the importance of caring for your health, even if you’re young and you think you’re super-powerful.” Where Latinos are concerned, he says it’s important to remember the differences among them. “Access to health care plays out differently in the Latino community—and I would say, Latino communities. “You have on the border a population that’s extremely poor, that doesn’t have electricity, that doesn’t interact with health care workers because they’re afraid they’re going to be reported to immigration. So they don’t proactively look for health care or any kind of education. The border is a whole different scenario,” said Agosto. Nor are Latinos necessarily alike just because they live in the same area. He said that there’s a lot of diversity in the Northeast. Regional differences do exist, as well, such as those between Latinos in California and those in Texas.

“It’s a whole different cultural expression. People have highlighted that. It’s very interesting the identity and specific cultural expressions that are not shared by all Latinos. We need to think about those differences. ‘I’m going to go here and there’—it’s a generic approach. ‘We will distribute condoms; we will develop contacts; we will give information; we will give referrals.’ All those efforts that we are so used to doing need to change in order to be effective, especially with this new generation of young Latino people,” Agosto said. He added that it’s therefore important to do prevention work with people individually when possible in order to tease out those issues, and help figure out what someone needs for prevention. The same goes for getting people on treatment.

“We also need to acknowledge that in the past we used to advocate for everyone, but now we need to be more intentional and individualized in our efforts. You have seen that with the black MSM. They have organized themselves, and they have developed prevention programs for themselves, while I noticed that the Latino representation in the discussions about PrEP, the discussions about biomedical prevention, is lacking,” he said. “We don’t have enough representation. So we have to foster leadership among young MSM, in Latinos.” Finally, he believes that addressing structural barriers may sometimes be even more important than simply providing clinical care.

“The biggest obstacle may not even be health care. Housing … is treatment. Housing … is prevention,” he said. “All those socioeconomic aspects of living your life need to be addressed to not just access HIV meds or PrEP or care, but to stay there. And not just to stay, but to be able to achieve viral suppression.”

Agosto said he finds the latest incidence figures of HIV infection for Latino MSM worrisome. “I’m concerned about the incidence of infection. When you look at the latest statistics, we see that whites are going down and blacks were stabilizing, but with the Latinos there was a slightly increase. That tells me that HIV infections are starting to go up. We see—and I’m not saying that it’s bad—very active outreach to black MSM but you don’t see the same reaching out to Latino MSM. That worries me, because we’re not paying attention to what’s happening to that population.”

AUTHOR’S NOTE: Moisés Agosto Rosario is a poet and fiction writer. His books include Plagas del Deseo and Nocturno y Otros Desamparos.