Originally published in The Uptowner as “Uptown Health Professionals Scramble as HIV Infections Rise Among Black and Latina Women”

The photos show amorous couples, caught embracing; young, old, gay, straight, men and women. They’re all ready to have sex without the risk of contracting HIV because of a regimen called PrEP, pre-exposure prophylaxis.

That’s the message of a recent Spanish-language health department campaign called “¡Listos!” (“Ready!”), which aims to lower HIV infections in New York City – especially among women.

Rates of new HIV infections dropped among both men and women between 2012 and 2015, but in 2016, the most recent data available, rates among women increased more than 6 percent, while the decrease continued among men, according to city health department statistics.

“More than 90 percent of the women newly diagnosed with HIV were black or Latina,” said Demetre Daskalakis, deputy commissioner of disease control for the city health department. Both are groups that predominate uptown.

A second health department campaign, this one bilingual and focusing solely on women, was released earlier. A lack of accurate messages tailored for minorities has been a problem in reaching Hispanic groups, Daskalakis acknowledged.

PrEP users take Truvada, a daily pill that decreases the risk of contracting HIV by more than 90 percent. It has helped lower the rate of new infections dramatically: Almost 6,000 people in New York City were infected with HIV in 2001, a number that dropped to 2,300 in 2016, according to the city health department.

After successfully persuading many men to take Truvada daily, reaching women, especially women of color, has emerged as the new challenge facing health professionals working uptown. According to AIDSVu, a statistical tool for tracking HIV/AIDS, developed by Emory University, black women are 14 times more likely to get HIV than white women, and Latinas 7 times as likely.

While the FDA approved the drug for HIV prevention in 2012, adoption has been slow. In 2016, there were 77,000 users nationwide according to the CDC. The agency says that 1.1 million Americans could benefit from using Truvada, many of them women. Women account for 19 percent of all new HIV diagnoses, but only seven percent of Truvada users.

Among men who have sex with men, Truvada use has become more common, especially in New York City. Campaigns for the drug have often targeted this group, traditionally at a higher risk of contracting HIV than the general population, and they’ve made a difference.

Among white gay and bisexual men in the city, 30 percent now take the daily pill. But use has lagged among Hispanic and black men, according to the health department’s sexual health survey.

Overall, men are 14 times more likely to use the drug than women, according to AIDSVu.

Jessica Ziemba, a physician assistant working with non-profit health care provider Harlem United, says that she has never once prescribed PrEP to a women. Her women patients argue that they don’t need it. “Their perception is they are at little risk, responding with ‘I don’t need that’ or ‘I’m not having sex like that’,” Ziemba said. She believes their thinking and behavior also reflect the taboo of talking about sex.

Underestimating the risk of contracting HIV and experiencing a stigma surrounding sex are factors that Gustavo Morales, deputy director of programs at the Latino Commission for AIDS, has seen as well. He has even heard stories of health professionals not offering PrEP to married women because they find it “too scandalous” to ask.

Morales believes that PrEP education for Latinas can become more effective if health care providers connect it to other sexual health issues women think about, like family planning. “Any conversation on PrEP needs to be paired with a conversation about reproductive health,” said Morales. “The first part shouldn’t be about HIV prevention, but family health.

At Harlem United’s clinic on West 133rd Street, patients in the waiting room reflect the neighborhood’s diverse community and receptionists talk to patients in Spanish and English.

Ziemba emphasized the need for more targeted campaigns for women of color. “There’s an importance of seeing people you identify with,” said Ziemba, sitting in a quiet examination room at the clinic.

Guillermo Chacón, president of the Latino Commission on AIDS, which worked with the health department on the ¡Listos! campaign, agrees that a lack of diversity in health care and information campaigns have been problematic in PrEP awareness. His organization has also worked to tell trans women about Truvada, another demographic where new infections are on the rise, according to the city’s health department.

Alexander Borsa, a PrEP specialist at New York-Presbyterian Hospital, works primarily with black or Hispanic uptown residents and has prescribed Truvada to many women. He has found that differences in access to health care, insurance coverage, language barriers and medical mistrust keep men and women of color from PrEP.

“All of these problems compound and remove PrEP from daily life,” said Borsa.

He was surprised, when he started working uptown two years ago, at the neighborhood dynamics: everyone appears to know everyone, and he has encountered patients afraid to be seen walking into clinics or talking to sexual health professionals. “People are in their business more,” said Borsa. “It does happen a lot.”

He has also encountered the misconception that people who take Truvada already have HIV, and the perception that the virus is an “LGBT problem,” rather than something anyone can contract, including straight women. One common reason that women come in for PrEP is because their partners have tested positive for HIV, Borsa said.

Too few obstetricians and gynecologists know enough about Truvada, Oni Blackstock, assistant commissioner for HIV/AIDS prevention at the city health department said in an email. Moreover, she said, PrEP is too expensive for many women.

In 2014, New York Gov. Andrew Cuomo announced an effort, “Ending the Epidemic,” aiming to cut the number of annual new infections in the state from 3,000 to only 750 by 2020. Higher PrEP usage is essential in reaching that goal, the state said.

That will require reaching more black and Hispanic people. “People mainly have sex with people their own race,” said Victor Hogue of Ryan Health, which runs several clinics uptown, so infections can spread more easily.

The most likely way for a woman to get HIV is from heterosexual intercourse, according to the CDC. Borsa of New York-Presbyterian Hospital explained that heterosexual men are particularly bad at taking PrEP, but he is hopeful.

If the misconceptions surrounding Truvada can be overcome, more women might be willing to take PrEP. Many women already take a daily pill for contraception, Borsa said. “It’s common for women to be more proactive about their sexual life and for their partner.”