FADE OUT HIV: An Educational Intervention Allying Black Community Barbers, Their Clients, and Community Clinicians

ABSTRACT

Black individuals in the United States are less likely to use medication to prevent HIV (pre-exposure prophylaxis, or PrEP) than White individuals and are significantly more likely to receive a new HIV diagnosis.

Because of America’s long history of unethical medical and research practices and ongoing prejudice and bias, Black Americans have mistrust towards the medical community. This distrust, along with the social determinants of health, leads to low participation in health care. Health interventions at culturally “safe” and familiar venues are a popular strategy to engage Black Americans in health care. In the United States, barbershops are staples of the Black community and the utility of barbershops as a venue for delivering interventions has been successfully explored.

We describe FADE OUT HIV, a program designed to increase barberknowledge of prevalence of HIV in the Black community; facilitatediscussions between Black barbers and their Black clients about HIVexposure, prevention, and treatment; provide free HIV tests forbarbers’ clients; and educate community clinicians via live andenduring webcasts about HIV prevention and treatment.

Clinician education was designed to facilitate HIV screening and ensure that the barber clients would be referred to clinicians who were knowledgeable about HIV. The learning objectives of the education were focused on barriers that prevent HIV screening and PrEP uptake and strategies to overcome these barriers, monitoring recommendations for people using PrEP, the benefits and limitations of new and in-development PrEP, and the importance of rapid initiation of antiretroviral therapy (ART).

As a result of this programme, 308 HIV tests were administered to barber clients at hosted events in Los Angeles and clinician knowledge and competence increased by 33% and 34%, respectively.

KEYWORDS:

• disparities
• HIV
• barber
• Black men
• pre-exposure prophylaxis
• PrEP
• testing

Background

Black individuals in the United States are disproportionately affected by the human immunodeficiency virus (HIV). In 2019, the rate of new HIV diagnoses was approximately 9 times higher for the Black population than for the White population (45.5 per 100,000 vs 5.3 per 100,000) [1]. Pre-exposure prophylaxis (PrEP) is an efficient biomedical HIV prevention tool consisting of either daily single-tablet medication or a bimonthly injection. PrEP reduces the risk of acquisition of HIV from sex by 99% when taken as prescribed [2]. Both the CDC and the US Preventive Services Task Force (USPSTF) recommend HIV testing for all individuals at least one time, with additional testing for those who have continued potential exposure to HIV [3,4]. Unfortunately, PrEP is disproportionately underused by Black individuals, as only 11% of Black individuals with potential exposure to HIV are prescribed PrEP, compared with 78% for White individuals with exposure [5].

Social determinants of health and longstanding medical mistrust that Black Americans have because of systemic racism and stigma contribute to these health inequalities. Mistrust is pervasive. America’s history of unethical medical and research practices and perceived and realised stigma within the health care system impact Black men’s perception of health care system and they view possible health care interventions with suspicion and doubt [6]. This lack of trust translates to low participation in health care, which further increases the racial gap in health care access and outcomes [7–9].

Barriers are further compounded for Black men who have sex with men (BMSM), who are subject to intersectional stigma, the result of discrimination based on both being Black and being men who have sex with men [10]. With intersectional stigma, numerous oppressive factors (eg, racism, HIV stigma, heteroism) are present simultaneously. There is a common misperception that PrEP is for “promiscuous,” irresponsible individuals; this misperception is higher for Black individuals than for those in other racial or ethnic groups [10]. This misperception collides with mistreatment in health care services, racism, homophobia, and structural inequalities and likely contributes substantially to low uptake of PrEP [10].

Health interventions at safe and familiar venues have become an increasingly popular strategy to engage Black Americans in health care [9]. The Black church is an established place of refuge and Black churches have partnered with public health agencies and medical institutions to reach congregants [11]. Barbershops and hair salons are also staples of the Black community. Several studies have examined the utility of barbershops as a venue for delivering interventions [9]. Barbershops are “a trusted place” where Black men congregate [12]. Barbershops attract African American men of all ages and they serve as venues for discussions about local events, politics, sports, news, and other topics [13]. Specifically, Black-owned barbershops draw “a large and loyal male clientele and [provide] an open forum for discussion of numerous topics, including health, with influential peers”. [14]

Numerous examples show that barbershops may also serve as a bridge to health care screening and referral [9,12]. A literature search of articles in scientific databases that referenced interventions at US Black-owned barbershops or hair salons targeting Black Americans for the purpose of reducing risk factors or improving health outcomes yielded 916 unique articles detailing these interventions [9]. The most well-known are likely the hypertension interventions, which demonstrated the success in reducing blood pressure in Black men attending participating barbershops, with pharmacists on site to screen patients and prescribe antihypertensives when required [15,16].

Black barbers are willing to engage in health education activities with their clients, as demonstrated by a survey that assessed the feasibility of an HIV-risk reduction programme for heterosexual Black men. Surveyed barbers believed that their clients were at risk for HIV and most highly regarded an intervention involving barber-facilitated HIV risk-reduction programme [13].

Thus, Black-owned barbershops are well-positioned to present interventions that may ameliorate the long-standing health disparities plaguing the community. Harnessing the potential of barbers to engage BMSM, DKBmed designed a programme focused on reducing the burden of HIV in the Black community.

Intervention

Overview

In March 2021, DKBmed, a medical education provider, and The Postgraduate Institute for Medicine received a grant from Gilead Sciences, Inc to pilot a multifaceted programme, called FADE OUT HIV, aimed at barbers in Black neighbourhoods, their clients, and health care clinicians in the surrounding area. The programme was designed to be launched in New York City but was moved to Los Angeles because of COVID-19 restrictions.

The goals of the programme were to (1) increase barber knowledge of prevalence of HIV in the Black community; (2) facilitate discussions between barbers and their clients about HIV exposure, prevention, and treatment; (3) provide HIV screening tests for barbers’ clients; and (4) educate community clinicians about HIV prevention and treatment.

To incentivise the barber clients’ to be screened for HIV, a coupon for a free haircut by the referring barber would be given to clients who returned to the barbershop with a document signed by the clinician who provided the screening. To facilitate HIV screening and ensure that clients would be seen by clinicians who were knowledgeable about HIV, clinicians who completed the education were invited to participate in the referral network.

Medical Education

Community Clinician Educational Programme

To educate community clinicians, an accredited medical education programme was developed by the faculty and DKBmed. The programme was designed as a webinar to air live, to facilitate questions from learners, with a recording of the webinar available as an enduring activity.

Initially, because the programme was intended to launch in New York City, a New York-based clinician served as faculty and the education contained New York-specific epidemiology information. However, COVID-19 activity at the time forced a change of venue to Los Angeles, California. The educational programme was modified to include Los Angeles-specific information with a Los Angeles-based HIV expert (WK).

The programme was initially targeted to Los Angeles-based clinicians using email, telemarketing and social media. The webinar aired on 8 December 2021. Initially, 297 learners were reached through the live and enduring components. DKBmed continued to market the programme in Los Angeles and nationally, eventually reaching 825 learners.

DKBmed reached out to Los Angeles area providers who participated in the education and asked them to join the FADE OUT barber-provider referral network. Eighteen Los Angeles area clinics enrolled in the referral network that was established to receive barber clients who wished to be screened for HIV.

Educational Outcomes

The learning objectives of the educational activity were to (1) describe barriers that prevent HIV screening and PrEP uptake by BMSM and strategies to overcome these barriers, (2) describe monitoring recommendation for PrEP, (3) assess the benefits and limitations of new and in-development PrEP, and (4) describe the benefits of rapid initiation of antiretroviral therapy (ART).

Outcomes for the 297 learners who completed the Los Angeles-based educational programme are shown in Table 1. To assess knowledge, learners were asked questions relevant to the gaps specified before and after participating in the educational activity (eg, “How often should people using PrEP be tested for HIV?”). The percentages of learners answering correctly are shown in the columns labelled pre and post, respectively. Knowledge increased significantly for all learning objectives but was greatest (134%) in the gap focused on PrEP medications [14].

Table 1. Outcomes of Clinician Education (n = 297).

Gap	Knowledge			Competence			Confidence
	Pre	Post	Change,%	Pre	Post	Change, %	Pre	Post	Change,%
Barriers and strategies	66%	91%	38%	68%	88%	29%	49%	85%	73%
Monitoring for PrEP	58%	100%	72%	66%	86%	30%	57%	71%	25%
PrEP medications	35%	82%	134%	59%	88%	49%	68%	79%	16%
Rapid ART	71%	73%	3%	45%	89%	97%	64%	84%	31%

Competence and confidence were assessed with self-rated questions asked before and after the activity. For example, competence was assessed by asking learners to respond to “I assess my patients using PrEP for STIs every three months” with response options ranging from strongly agree to strongly disagree. Confidence was assessed by asking learners to answer, “How confident are you in your ability to determine which of your patients have increased risk of HIV based on sexual history?” with response options ranging from highly confident to not confident. Competence increased significantly for all learning objectives but was greatest for the importance of rapid initiation of ART, and confidence increased significantly for all learning objectives but was greatest for recognising barriers and strategies to improve HIV testing and PrEP use for Black men.

Self-reported intent to change practice after participating in the educational activity was assessed by a question that asked learners if they intended to implement changes to their practice based on information presented in the activity. Immediately after completing the education, 92% of the learners indicated that they intended to change practice or their current practice was reinforced by the information presented. When responding to the 30-day post-curriculum survey, 85% of the learners indicated that they either did not encounter barriers (68%) or they were able to overcome barriers (17%) to practice change.

Barber Participation

Barber Recruitment

Barbers attending Barbercon, an annual convention held in Los Angeles in November 2021, were recruited to participate in the programme. Los Angeles-based faculty (WK), a local health equity activist, and a barber with a large social media following (TJ) led a series of educational events to introduce the FADE OUT HIV programme. In addition to a presentation on the main stage of Barbercon, with an overall attendance of more than 1,000 barbers, FADE OUT faculty presented in-depth information to 123 barbers at an educational session and an additional 262 barbers were educated about the FADE OUT initiative at the FADE OUT HIV booth on the exhibit floor. Overall, 385 barbers attended these sessions.

The barbers in attendance were informed about the risk of HIV infection in the Black community and the role barbers can play in keeping their clients safe, and the barbers were encouraged to participate in FADE OUT HIV.

After Barbercon, TJ and the local health activist visited 15 preselected barbershops in Black neighbourhoods around Los Angeles to recruit barbers to participate in FADE OUT HIV. They held “lunch and learn” sessions to describe the FADE OUT HIV programme and provided a brief educational session about the prevalence of HIV in Black men and the role that barbers can play in speaking to their clients about the importance of HIV testing and prevention. The use of appropriate language was included in the education, to avoid use of stigmatising terms.

After the live visits, TJ and TW conducted two Instagram Live and four Zoom sessions to further discuss the logistics of the programme and provide guidance and support to overcome any lingering barriers on how to initiate the conversation with clients regarding HIV screening.

Barber Intervention

Ultimately, 38 barbers from 26 barbershops opted to participate in FADE OUT HIV. Barbers were not compensated for participating in the programme. However, the costs of the haircuts provided at no charge to clients was subsidised by the grant received for this programme.

Barbers who agreed to participate were provided with patient education pamphlets, stickers with the message” FADE OUT HIV - Get Tested Today” and coupons for a free haircut to encourage clients to be tested for HIV by community clinicians. Barbers were encouraged to engage their clients in conversations about testing for HIV and recommend testing at one of the clinics in the referral network.

However, we learned that some barbers were reluctant to discuss HIV with their clients due to time constraints and other concerns. This is in line with experience from other barbershop initiatives, which showed the benefit of co-locating the screening interventions at the same location as the haircut [17].

To overcome this obstacle, DKBmed partnered with the Charles Drew Medical Center (CDMC), an organisation with a history of providing free rapid HIV testing for Los Angeles County residents. In partnership with CDMC, DKBmed held two outreach events on the grounds of the CDMC. Barbers were set up to provide haircuts outside, on property adjacent to the HIV rapid testing station.

HIV Testing

Overall, 308 HIV tests were conducted at the CDMC events and the other community clinic-based testing sites. Data pertaining to prior testing status, race, gender and sexual identity, etc were not collected from people who were tested for HIV for patient privacy concerns.

Lessons Learned

The pilot FADE OUT HIV was ultimately successful, with more than 300 HIV tests completed and notable gains in clinician knowledge, confidence, and competence. However, several challenges emerged that led to increases in costs, delays in the launch, and extensions in the duration of the programme.

COVID-19 Challenges

Because of COVID-19 restrictions in New York City at the time of the programme’s launch, the New York Barbercon convention was cancelled. As Barbercon New York was intended as the recruitment vehicle, the programme was moved to Los Angeles, where Barbercon LA was held in November 2021. Los Angeles was chosen in part because of the interest of WK, who attended an earlier New York clinician education webcast and expressed a desire to replicate the programme in Los Angeles, where his clinic is located.

The medical education component had been developed for clinicians based in New York City but was then re-recorded with WK and local epidemiology.

Barber Challenges

Barber recruitment was an unexpected challenge, despite high interest and enthusiasm generated at the Barbercon event. The planners discovered that many of the barbers attending Barbercon were from outside of the Los Angeles metro area, making it difficult for them to participate in our on-the-ground follow up with local barbershops. In addition, there were barriers to some barber’s active engagement as noted above. These included time and business constraints (e.g. next client waiting), remembering to bring up the conversation, and confidence/comfort with discussing HIV. Conversations around sexual health and behaviour necessitated personal time with the client. Unlike other conversations that might happen after the client left the chair (eg, sports, dating, etc.), the nature of these conversations was better done in a more intimate setting while the client received a haircut.

Social media marketing was extensive, with significant effort to engage barbers. In addition, the use of coupons to motivate the barbers’ clients to return for a free haircut was cumbersome, with logistical and technical obstacles.

Conclusion & Future Direction

To ameliorate health disparities and inequalities, FADE OUT HIV engaged BMSM in venues that are known to be safe and trusted by Black individuals. Several hundred HIV tests were provided to people with potential exposure to HIV. We did not collect data related to prior testing status, results of HIV tests, or discussion of PrEP; however, HIV testing is not only recommended by the CDC and USPSTF [3,4] but is also the first step along the HIV status-neutral care continuum, which recognises the importance of continual engagement for people either living with HIV or with potential exposure to HIV [18].

FADE OUT HIV is being proposed for additional cities in the United States, with several changes made from our pilot programme. HIV testing will be co-located with haircuts to facilitate testing and remove the burden of locating a testing site and redeeming a barber coupon. Expanding FADE OUT HIV to other locations will engage more barbers and their clients, increase HIV testing, and hopefully promote the use of preventive services and, when necessary, HIV medications to reduce the burden of HIV, particularly in the Black community.

Disclosure statement

WDK is on the Speaker’s Forum of Viiv Health Care. All other authors have no other competing interests to declare.

Additional information

Funding

Gilead Sciences, Inc provided an independent medical grant to fund the programme as described in the manuscript.