Dr. Adaora Adimora On How HIV Impacts Women and Minorities

For National Women and Girls HIV/AIDS Awareness Day, AIDSVu spoke with Dr. Adaora Adimora about increasing the rate of PrEP use among women and minorities impacted by HIV.

Adaora Adimora, MD, MPH, is a Professor of Epidemiology at the UNC School of Medicine and Co-Director of the Center for AIDS Research.

Q: Your career has largely focused on the epidemiology of STDs and HIV in women and minorities. What drove you towards this specific line of research?

A: For a long time, we have observed marked differences in the rate of STIs between Blacks and whites. Soon after HIV came on the scene, differences between Blacks and whites were observed with HIV as well. Back in the 1980s and early 1990s, there was an emphasis on “risk behavior” and “risk groups”. An underlying implication was that Black people in general had “higher risk” sexual behavior than whites. As a Black person with involvement in the Black community, that generalization just did not ring true to me. One thing I noticed was that a portion of Black people I saw with HIV, especially women, had behaviors that did not differ significantly from those of the general population. Some of them had few sexual partners, no drug use. Many didn’t have partners who use drugs or partners who were men who have sex with men (MSM).

Around the same time in the early-to-mid 1990s, there was increasing interest in sexual network patterns and the spread of infection through networks of connected people. Martina Morris, for example, was publishing her groundbreaking work about concurrent partnerships, which is when an individual has overlapping sexual relationships with more than one person. It seemed to me that this could be contributing to the higher rates of HIV and other STIs among Black people. To be clear, this is not saying that Black people have different moral standards, or that whites don’t engage in these behaviors. Rather, it was clear from my own lived experience as a Black person—and from the work of sociologists like William Julius Wilson—that larger social forces like macroeconomics, racism, and their associated effects likely influence behaviors that increase the vulnerability of Black Americans to HIV and worsen health outcomes.

Importantly, the work of the late Paul Farmer introduced me to the idea of structural violence, which is a concept that was first written about by Johan Galtung in the 1960s. This concept stresses that these forces are structural, that they are baked into the system, and that they damage people in a way that limits their life chances. These forces are also so ordinary that they’re almost invisible. The idea is that, although people’s individual behaviors affect their likelihood of getting HIV and other STIs, there are larger systemic forces that affect groups of people unequally and increase their vulnerability to these infections, as well as worsen their outcomes once they have them.

Q: As part of a six-paper series in The Lancet, you authored a paper titled “HIV and women in the USA: what we know and where to go from here”. In it, you address the U.S. plan to end the HIV epidemic by 2030. What are the unique factors impacting women in the HIV epidemic and how will addressing those specifically help us reach our goals?

A: Black and Hispanic/Latina women are disproportionately affected by HIV compared to white women. The factors that impact women in the HIV epidemic are mostly those, in my view, that are associated with being an oppressed racial minority in the United States. In addition, there are strong intersectional and probably synergistic links between race, poverty, sexism, and HIV. While men who have sex with men bear the lion’s share of the burden of HIV in this country, almost one in five new HIV infections in the U.S. are among women. We will never end the HIV epidemic without attending to HIV among women, as well as the socio-economic factors that contribute to it.

Q: Part of your paper focuses on PrEP use among women. You mention that although the annual percentage change in PrEP use among U.S. men increased by 68% from 2012 to 2017, use among women during the same period only increased by only 5.4%. What factors did you identify that account for this drastic difference?

A: There are several major reasons. First, many women haven’t heard about PrEP at all. In addition, many of those who have heard of it do not think its use is applicable to them, so they don’t ask for it. Second, I suspect that some providers are not comfortable prescribing PrEP at all. Third, some providers do not think of offering PrEP to their female patients or exploring whether its use is warranted. I think some providers make assumptions about their patient’s behavior and the behavior of their patient’s partners or aren’t comfortable talking about sex in general. Consequently, they may not realize that the female patient in front of them might benefit from PrEP.

Fourth, cost is an issue and for uninsured people, and the paperwork required to get free PrEP may be a barrier. Fifth, and this is a huge reason, there is often too little time in the office visit or clinical encounter. Providers are supposed to talk about smoking, screening exams, exercise, mental health, and intimate partner violence, as well as the patient’s existing medical problems, and anything else the patient wants to talk about. You can therefore imagine that providers may have difficulty prioritizing sexual health—including PrEP—during an office visit that is 30 minutes or less, especially if it is not obvious to them that the patient needs or wants PrEP.

Q: Your paper also notes that women are under-represented both in HIV research and as subjects in clinical trials. What effect does this underrepresentation have on health outcomes for women? What recommendations do you suggest for increasing the inclusion of women in this field?

A: It is important to note that women are not just men with estrogen. In addition to hormonal and physiological influences that differ by sex, the context of life differs substantially between men and women. The paucity of women in research means that there is less data to understand the health outcomes and conditions that affect them, how these conditions manifest, and how to treat them. We also need to understand how women feel about biomedical products and whether they can access and use them. Products cannot work if they’re not used. A lack of data on women puts them at risk for being left behind by biomedical advances.

In terms of what can be done to increase the inclusion of women in this field or in research generally, researchers need to remember that participation in a clinical trial is a tremendous act of altruism. Research staff should approach them with respect and consideration, and women need to be properly compensated for their time and the unique difficulties that they may have with transportation, childcare, and jobs. Many women may not have the autonomy that men with higher incomes or higher status jobs might have to easily take time off from work to participate in a trial. Working with community-based organizations and others from the community is also essential in terms of getting women into trials.  Funding agencies need to consider all of this as well. They can use carrots and sticks to strongly incentivize researchers to ensure that they include women in research that they’re funding.

Inclusion in clinical trials is critical, but the funders need to make sure that they properly consider other types of research, including qualitative and social science research that explores questions that are meaningful for women. Including, for example, how and why interventions do or don’t work, and their effects on quality of life.

Q: March 10 is National Women and Girls HIV/AIDS Awareness Day (NWGHAAD), which highlights the impact of HIV and AIDS on women and girls. What message do you have for women, girls, and their support community on this day?

A: While new infections among women in the US have decreased in recent years, now is not the time to be complacent. We need to continue our efforts, and in particular continue our fight for social and reproductive justice. One issue that we can all get behind is the need for healthcare coverage and access for all men and women. It is a disgrace that most of the states that have not expanded Medicaid are in some of the poorest areas with the highest rates of HIV, STIs, and other comorbid conditions. We need to vote in our own best interests and encourage others to do so as well.

This article was originally published on March 10th, 2022 on AIDSVu, and the original can be accessed here.

Chi Named Department of Obstetrics and Gynecology Vice Chair for Research and Innovation

This story was originally published March 8, 2022 here.


Benjamin Chi, MD, is Professor of Obstetrics and Gynecology and Adjunct Professor of Epidemiology at the University of North Carolina at Chapel Hill. He has been named Vice Chair for Research and Innovation in the Department of Obstetrics and Gynecology. For nearly two decades, he has worked at the intersection of HIV, maternal and child health, and global health.

Benjamin Chi, MD, is Professor of Obstetrics and Gynecology and Adjunct Professor of Epidemiology at the University of North Carolina at Chapel Hill. He has been named Vice Chair for Research and Innovation in the Department of Obstetrics and Gynecology. For nearly two decades, he has worked at the intersection of HIV, maternal and child health, and global health.

He began his academic career in Zambia during a time of transformative change in HIV and women’s health care. Over this period, he played a key role in the introduction and coordination of new HIV programs, often in places where none had previously existed. He also spearheaded two large public health initiatives funded by the US President’s Emergency Plan for AIDS Relief. Chi’s innovative approach to the care for women diagnosed with HIV led to the identification of new treatment options, improved patient adherence, and reduced the rates of vertical HIV transmission. This work was done in partnership with colleagues at the Zambia Ministry of Health and the University of Zambia, with an emphasis on local capacity building and collaboration.

Since returning to the US in 2015, Chi’s work has continued to be informed by this intersection of clinical and implementation research, research training and mentoring, and public health and policy. His work has been funded by the National Institutes of Health, Centers for Disease Control and Prevention, and numerous private foundations continuously for more than a decade. Cumulatively, he has raised over $30 million in extramural funding to support these efforts.

Chi’s research now spans six African countries. He is studying combination strategies to prevent new HIV infections among pregnant and breastfeeding women. He is also investigating optimal doses of HIV pre-exposure prophylaxis during pregnancy and breastfeeding. These studies are supported by two NIH R01 awards, which he leads as principal investigator.  He is also the protocol co-chair for IMPAACT 2009, a multi-center clinical trial investigating the pharmacokinetics, safety, and acceptability of HIV pre-exposure prophylaxis among pregnant and breastfeeding women.

Chi currently directs four NIH-funded research training programs. He serves as principal investigator for the UJMT Fogarty Global Health Fellows Program, which supports 20-25 individuals each year in mentored research training. As director of the coordinating center, he leads a consortium of four US universities (UNC, Johns Hopkins University, Morehouse School of Medicine, Tulane University) and a large network of 30 international institutions. He is also the lead for the UNC Global Women’s Health Fellowship and co-lead for the UNC-UNZA-Wits Partnership for HIV and Women’s Reproductive Health. Since 2020, Chi has become increasingly engaged in departmental research and faculty development as well. He is the research director for the UNC Women’s Reproductive Health Research Program, an NIH-funded career development program for promising Ob-Gyn researchers. He also developed educational opportunity for fellows across the department.

A dedicated mentor, Chi has advised numerous graduate students, postdoctoral fellows, and junior faculty across the UNC School of Medicine and the UNC Gillings School of Global Public Health. Since 2015, he has mentored over 30 early-stage investigators, including eight who are funded by NIH K career development awards. Chi was awarded a K24 mentoring award from the National Institutes of Health to support these efforts. Many of his mentees have gone on to independent research careers of their own.

Finally, Chi is an internationally recognized expert in the prevention of mother-to-child transmission of HIV and worked with the World Health Organization and UNICEF to translate research into global policy and practice. At UNC, he serves as co-director of the UNC Center for AIDS Research International Core, director of global fellowships and training programs at the UNC Institute of Global Health and Infectious Diseases, and as member of the Lineberger Comprehensive Cancer Center.

Inter-CFAR Transgender Health Scientific Working Group

Writer: Alicia Diggs

The first inaugural Inter CFAR Transgender Health Scientific Working Group took place October 21, 2021. The working group uses a shared leadership model to work together across CFARs. The leadership team consists of Tonia Poteat (UNC), Will Beckham (Hopkins), Laramie Smith (UCSD), Andrea Wirtz (Hopkins). The team initially met to brainstorm on priorities for the Inter CFAR Transgender Health Working Group and what they hoped to accomplish as a group. They aimed to capitalize on the benefits of working across the different CFARs. They discussed three main pillars for the working group:

  1. Advancing the science
  • addressing gaps in data in trans health and HIV
  • addressing community priorities within those gaps with the goal of advancing the health of trans communities
  1. Community empowerment and collaboration
  • meaningful engagement with communities in equitable partnerships
  1. Networking development and strengthening
  • building a network of trans health researchers and community members to collaborate and strengthen relationships across the CFARs

The group also discussed communication strategies that would effectively disseminate research findings in ways that are useful and accessible to communities. JD Davids of Brooklyn New York and one of the co-authors of No Data No More-Manifesto to Align HIV Prevention Research with Trans and Gender-Diverse Realities, presented highlights from the document. The manifesto is a call to action for advocates, researchers, implementers, funders. Trans and gender diverse people are highly underserved and the data show that trans women are up to 49 times and trans men are up to 8 times as likely to be living with HIV compared with cisgender adults. There too few data on non-binary people to make an estimate of HIV burden. Trans and gender diverse populations have been overlooked in research. Trans women have been incorrectly categorized as cis MSM and trans men have been invisible. Given the stigma, violence, and marginalization faced by trans and gender diverse populations, they are less likely to receive HIV testing, start or adhere to PrEP, or maintain viral load suppression compared with cisgender people. The manifesto lists 22 recommendations that reflects a vision for trans-led HIV prevention research with true ownership in trans and gender diverse communities.

The full manifesto can be found on the AVAC website www.avac.org/no-data-no-more

The next meeting of the Inter-CFAR Transgender Health Working Group will be held on January 27th, 2022, 3:30-5:00p ET. The group will be discussing “Strategies for Community Compensation in Research.” For more information, or to register, please contact Tabs Faulkner (tabs_faulkner@med.unc.edu).

Physicians address ‘increasing concern’ about effects of COVID-19 among PLWH – Healio

ada adimora headshotDr. Adaora Adimora, MD MPH, recently spoke to Healio about effects of COVID-19 on people living with HIV. She states that “people with well-controlled HIV have an excellent prognosis from an HIV standpoint. There’s very little information right now concerning the effect of HIV on COVID-19,” though comorbidities “increase the severity and mortality of COVID-19.” She also highlights racial disparities related to COVID-19, noting that “this is probably in large part because of the disproportionate representation of African Americans in occupations that put them in harm’s way for infection — for example, cashiers, factory workers and home health aides . . . prisons are another huge problem, given the inadequate implementation of basic pandemic control measures, such as social distancing — and often inadequate health care in these settings. People with HIV, like other Americans, are especially vulnerable in these settings.”

Read more here at Healio. 

In an effort to make childbirth safer, $14 million awarded to Jeff Stringer’s research team

Jeff Stringer, director of UNC CFAR’s International Core, is leading two studies to improve pregnancy outcomes in the world’s poorest countries. The Bill and Melinda Gates Foundation has awarded $14 million to Stringer’s interdisciplinary team, composed of researchers from the UNC School of Medicine and UNC Gillings School of Global Health. Read more about this at the UNC Health Care and UNC School of Medicine Newsroom.

Eron Moderates New Video Series

Joseph Eron, MD, division chief of infectious diseases and director of UNC CFAR’s Clinical Core, was recently featured on Contagion‘s latest Peer Exchange panel. The four-part discussion, entitled “HIV Screening, Prevention, and Treatment Advances,” is available to the public here.

From the UNC Health Care and UNC School of Medicine’s Newsroom article,

 “This Contagion “Peer Exchange” panel features five distinguished experts: Joseph J. Eron Jr., MD, professor of medicine and division chief of infectious diseases at the UNC School of Medicine, as moderator; Eric S. Daar, MD, of the Harbor-UCLA Medical Center; Ian D. Frank, MD, of the Perelman School of Medicine of the University of Pennsylvania; W. David Hardy, MD, of the Johns Hopkins University School of Medicine; and Paul E. Sax, MD, of Brigham and Women’s Hospital.

The first segment of this “Peer Exchange” series delves into a discussion on screening and prevention of HIV. In the second segment, the experts provide a brief overview of the current HIV treatment landscape. The third segment focuses on additional considerations for therapy, such as the importance of adherence to treatment and care. In the final segment, our experts discuss upcoming treatment options that are exciting for the HIV community.”

Reducing Stigma and Exploring Resilience Among Young Black Men

In a study published on January 11th, investigators considered of the digital resilience behavior of young, black gay, bisexual, and other men who have sex with men (GBMSM). CFAR investigator and assistant professor of health behavior at the Gillings School Kathryn E. Muessig, PhD, participated as senior author to this study, entitled “Stay strong! keep ya head up! move on! it gets better!!!!’: Resilience processes in the healthMpowerment online intervention of young black gay, bisexual and other men who have sex with men.

The study focused on participants’ forum use of healthMpowerment, an anonymous online intervention system designed by Hightow-Weidman. Investigators analyzed conversations according to the four forms of resilience behaviors: exchanging social support, engaging in health-promoting cognitive processes, enacting healthy behavioral practices and empowering others. Their findings suggest that interventions based on resilience and empowerment may position black GBMSM to better combat negative stereotypes and social institutions that perpetuate HIV-related stigma, racism and blame. This is in contrast to preexisting risk-based frameworks that may reinforce stigma and negative stereotypes associated with this already marginalized group.

Read more about the study’s findings here.

CFAR-Wide Webinar Series: Brian Mustanski

For our January 2019 webinar, Brian Mustanski, PhD, presented “Don’t assume if you build it they will come: Two hybrid effectiveness-implementation trials of eHealth HIV prevention programs for diverse adolescent and young adult MSM.” In case you missed it, a recording can be viewed here.

Next month’s webinar is planned for February 25th at 3:30 ET and will feature Robin Lanzi and Pam Foster from UAB CFAR discussing the Inter-CFAR Faith Initiative Working Group. The 2019 webinar schedule and registration information can be found here.

Brian Mustanksi, PhD, is director of the Institute for Sexual and Gender Minority Health and Wellbeing at Northwestern University, Co-Director of the Center for Prevention Implementation Methodology for Drug Abuse and HIV, and Co-Director of the Third Coast Center for AIDS Research. Additionally, he is a professor of both Medical Social Sciences and Psychiatry and Behavioral Sciences at the Feinberg School of Medicine. Dr. Mustanski’s research focuses on the health and development of LGBT youth and the application of new media and technology to sexual health promotion and HIV prevention with young men.