Introduction

Central to the effective care of historically excluded communities is an appreciation for cultural responsiveness, sometimes called cultural competence, among primary care practitioners (PCPs). In the context of primary care, culturally responsive communication refers to a PCP’s ability to engage with patients “based on views of culturally diverse patients rather than the views of health care professionals” [1]. Cultural responsiveness centers unique patient experiences and understandings of health and illness, recognizes the individual biases that clinicians may hold, and seeks to work productively with patients who are not typically represented or valued in the Western understandings of care. The ability to translate diversity, equity, inclusion, and justice (DEIJ)-based values within patient interactions stem from reflexivity and shared power of the health professional alongside the culture of racism. At an institutional level, cultural responsiveness is an extension of DEIJ-based policies, systems, and protocols that allow for effective cross-cultural safety and respect, as well as compassionate, nonjudgmental and antiracist care [2–4]. This type of approach allows healthcare practitioners to work consciously and effectively toward cultivating health equity for historically marginalized groups.

Human immunodeficiency virus (HIV) and coronavirus disease 2019 (COVID-19), for instance, are two preventable, communicable illnesses with significant burdens of disease that are highly stigmatized and disproportionately affect racial, ethnic, sexual and gender minoritized groups, hereafter referred to as “minoritized groups.” Structural factors including systemic oppression and social determinants of health (SDOH) play a significant role in the differential health outcomes of these diseases but may receive less attention than a patient’s personal factors and choices. In the landscape of these existing disparities, patients from minoritized groups are disproportionately harmed by the underutilization of culturally responsive screening practices in the primary care setting. Further, while shifts in research and funding priorities allowed for swift and large-scale responses to COVID-19, the recent pandemic has drawn much needed resources and attention away from HIV prevention and care, exacerbating the disparities of this illness and creating missed opportunities to address both diseases [5].

To address these issues, the study team is undertaking a project to train and build the capacity of PCPs to routinize nonjudgmental HIV, pre-exposure prophylaxis (PrEP) and COVID-19 vaccine screening for all patients while relying on culturally responsive communication for minoritized groups. By providing regular, culturally responsive screening and education, PCPs can begin to bridge the divide in health disparities impacting minoritized communities. This project is multifaceted and includes data collection through scoping literature reviews and qualitative interviews that concern the experiences and beliefs of minoritized groups regarding HIV, PrEP and COVID-19 vaccines. These data will be used to inform and validate: a) a training series for PCPs about HIV testing, PrEP screening, and COVID-19 vaccine screening; b) a social marketing campaign for PCPs and by PCPs to encourage dual testing, screening, and prevention; and c) a culminating white paper on policy recommendations to improve HIV screening guidelines and to better implement existing PrEP and COVID-19 vaccine guidelines. This article discusses the protocol that will be used to perform a scoping review focused on HIV and PrEP screening, specifically.

Background

Despite progress over the last forty years in reducing HIV transmission, morbidity, and mortality, nearly 1.2 million people are still living with HIV in the United States according to most recent data [6]. Among those living with and becoming newly infected with HIV, minoritized groups deal with a greater burden of disease. For example, male-to-male sexual encounters made up more than two-thirds of HIV diagnoses in 2020 [6], and a 2021 CDC special report found that four in ten transgender women in major cities are living with HIV [7]. Similarly, although Black Americans made up only 13.6% of the U.S. population in 2020, they represented more than 40% of HIV diagnoses that year [6,8]. The same year, Hispanic or Latinx individuals made up 27% of HIV diagnoses, despite making up less than 19% of the U.S. population [6,8]. Despite mainstream messaging that still claims these populations are more often engaged in high-risk behaviors, research data support that structural and systemic issues like socioeconomic status, housing, the physical environment, and unequal access to preventative care have contributed to these stark health disparities more significantly than individual risk behaviors [5].

Among those living with HIV, more than one in ten are not aware of their HIV status because they have not been tested [9]. Without an understanding of their HIV status and risk, these patients may be unable to start PrEP or the appropriate therapies to suppress their viral load. Following the current trajectory, without further intervention, close to 400,000 more people will be diagnosed with HIV by 2030 [10]. For these reasons, HIV prevention and diagnosis are central to the U.S. Department of Health and Human Services (HHS) Ending the HIV Epidemic in the U.S. plan for the next decade. The HHS plan aims to reduce new HIV infections by over 90% by 2030 [10]. PrEP coverage, a key indicator of Ending the HIV Epidemic in the U.S., shows a distinct failing. Current US Public Health Service PrEP clinical practice guidelines recommend that all sexually active patients receive information regarding PrEP and that those at substantial risk should be prescribed either daily oral PrEP or a recently approved intramuscular injection every two months [11]. Despite this, in 2020, only one in four people in the U.S. and Puerto Rico who had indications for PrEP were receiving PrEP [12]. Among these individuals, the aforementioned racial and ethnic disparities persist: while 66% of indicated White patients were covered, only 9% of indicated Black patients and only 16% of indicated Hispanic or Latinx patients were receiving PrEP [12].

Moreover, while the Centers for Disease Control and Prevention (CDC) has recommended for more than 15 years that routine healthcare include opt-out HIV screening (defined as performing an HIV test) at least once for patients between the ages of 13 and 64, and at least annually for patients with risk factors [13], qualitative data from other arms of this study have already indicated that minoritized patients not only feel targeted and disrespected by HIV testing without context, but they report concerns that opt-out testing is or will be performed without their consent. These feelings exacerbate the mistrust that historically exploited groups have of healthcare practitioners and institutions. Even without this barrier, testing rates have not increased ubiquitously throughout the healthcare system. A 2020 Morbidity and Mortality Weekly Report by the CDC reported that HIV testing has been increasing in community health centers and emergency department settings, but not in physician offices [14].

The above metrics support the idea that a chronic underutilization of HIV screening and prevention practices, especially in the primary care setting, misses a crucial health promotion opportunity, and disproportionately harms members of historically marginalized groups due to the systemic barriers that exist within healthcare and societal institutions. It is the responsibility of PCPs to understand these barriers and to identify the impacts of structural racism on the poor outcomes and delayed identification of HIV in minoritized groups so they may prioritize culturally responsive communication with these patient populations. The definition of HIV screening must expand to include these conversations about HIV and PrEP to conscientiously serve historically marginalized patients. Moving forward, we use the term “screening” to indicate screening conversations and communication practices among PCPs that facilitate informed HIV testing and connection to PrEP.

To begin meeting these aims and the study goals outlined above, we will conduct a scoping review to assess existing literature for insights about this topic. To our knowledge, there has not yet been a scoping review regarding this subject and the target patient populations. A preliminary search of databases identified no ongoing or existing systematic/scoping reviews on this topic. Therefore, the scoping review will be conducted with two specific purposes. Firstly, to inform our understanding of the factors which influence culturally responsive HIV and PrEP screening conversations for historically marginalized populations. The results of this review will inform the design of a training series and social marketing campaign targeted at PCPs. Secondly, the review will identify themes and gaps in the current literature to guide future research opportunities in this field.

Methods

Scoping reviews differ from systematic reviews in that they focus on reviewing the breadth, rather than depth of current literature regarding a particular topic. For this reason, they may be completed much more rapidly than systematic reviews, which take time to assess the quality of evidence among studies. A scoping review was chosen to quickly ascertain the nature of the knowledge base surrounding factors that influence culturally responsive HIV and PrEP screening for patients identifying as members of minoritized groups.

The scoping review will be performed according to the framework first outlined by Arksey and O’Malley [15]. The five steps of this process include: 1) identifying a research question, 2) identifying relevant studies, 3) selecting studies, 4) charting the data, and 5) collating, summarizing, and reporting the results. This will also be guided by the specific steps of the PRISMA extension for scoping reviews (PRISMA-ScR) [16], several of which will be described in relevant sections below.

Step 2: Identifying relevant studies

The scoping review will be conducted across four databases (PRISMA-ScR Item 7: Information Sources): MEDLINE (PubMed), Scopus, Cochrane (CENTRAL; Wiley), and CINAHL (EBSCO). The search strategy includes the use of Medical Subject Headings (MeSH) terms and Boolean terms to clarify the parameters of the review. After conducting the searches on each database, the results will be imported into Covidence to remove duplicates and perform primary screening of titles and abstracts for relevance. The full search strategy (PRISMA-ScR Item 8: Search) is presented in Table 1.

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Table 1. Search terms and limitations.

https://doi.org/10.1371/journal.pone.0281173.t001

Results

Discussion

Culturally responsive HIV and PrEP screening conversations between PCPs and minoritized groups are key to bridging the stark existing disparities in HIV morbidity and mortality in the U.S. To our knowledge, this is the first study to use scoping methods to investigate the barriers and facilitators to culturally responsive HIV and PrEP screening for minoritized populations. After mapping the landscape, gaps, and themes of current research, we plan to disseminate our findings in publication and through the development of relevant and evidence-based training programs to help PCPs routinize culturally responsive HIV and PrEP screening for minoritized groups. Additionally, we anticipate that this study will yield implications important to the work of clinicians, activists, researchers, patients, and public health professionals in this field. The limitations of this study include that as a scoping review, our review does not assess the depth, quality, or risk of bias of the studies the way a systematic review would. Additionally, by limiting the timeline of this review to the years 2019–2022, we may miss valuable studies that were performed before this timeframe.

Supporting information

Acknowledgments

The authors would like to acknowledge Thomas Harrod, Associate Director of Reference, Instruction, and Access at the George Washington University’s Himmelfarb Health Sciences Library for his generous guidance and support in developing the search strategies for this scoping review and Stacy Brody, Reference and Instruction Librarian at the George Washington University’s Himmelfarb Health Sciences Library for her guidance in creating the manuscript for this publication. The authors would like to acknowledge Saylor Pershing, Darrell Bailey, Sheel Singh, and Abigail Konopasky for their assistance in the text screening and extraction process.