Making the treatment cascade work in vulnerable and key populations

In a powerful presentation, Dr David Malebranche gave his talk titled “Making the Treatment Cascade work in Vulnerable and Key populations” in the plenary session on Day 4 of the conference. Watch the video here. 

Prior to Dr Malebranche’s presentation, there was a video-link from another location in which the Co-chair of the conference Professor Peter Reiss, was attempting to light a cauldron with the Positive Flame (in honour of being 90 years since the Olympic Games in Amsterdam and also having the AIDS Conference in Amsterdam). However AIDS activists from key populations stormed the room and prevented Prof Weiss from lighting the conference through protest (he eventually did after some time).

The protest was regarding the IAS’s decision to host the next International AIDS Conference in San Francisco in 2020. With President Trump in power, this would likely restrict the representations of communities at the conference most affected by HIV including sex workers, people who inject drugs, and other minority groups such as Muslims at the conference.

Dr Malebranche started his presentation by introducing himself as a HIV and internal medicine physician, public health official and activist working at the Morehouse School of Medicine in Atlanta.  As a black, same-gender loving man, he has worked in the HIV field for over 20 years and described both his professional and personal connection to HIV when his status changed from HIV negative to positive in 2007.

Dr Malebranche focused his presentation to the vulnerable population of black MSM.  African-American MSM are disproportionately affected by HIV in The United States.

  • A slide presented showed that black men in certain areas of US (eg. New Orleans, New York, San Francisco) have a higher prevalence of HIV than in some nations such as Rwanda and Nigeria
  • He stated that in US, 1/3 of cases of HIV infection occur in black MSM but they only represent 0.5% of population
  • African-American MSM have a 1 in 2 lifetime risk of acquiring HIV compared to 1 in 11 for White MSM.








The HIV treatment cascade is how we evaluate how much progress we are making towards the 90 90 90 goals. Ultimately viral suppression is the end target of the HIV treatment cascade, which leads to people less likely to transmit HIV to their partners.

Dr Malebranche stated that black MSM have steeper drops along each step of the cascade.  He used the slide below from a 2014 modelling study to demonstrate that Black MSM usually drop off after linkage of care and are not being engaged in care leading to low rates of viral suppression.














During his talk, Dr Malebranche referred to several factors leading to Black MSM patients dropping off the cascade:

  • healthcare access
  • lack of insurance/income/housing
  • poverty
  • food and housing insecurity
  • lack of social capital

In particular he referred to:

  • HIV stigma
    • Which can comes from several different factors – friends, communities, general society
    • Causes HIV positive people to drop off the cascade due to the patients internalising the stigma which then influences testing behaviour, disclosure and how one accesses medical care
  • Same-sex behaviour criminalisation/stigma
    • 74 countries around the world still criminalise same sex behaviour. It is these countries which have higher rates of HIV compared to where same-sex behaviour is not criminalised.
  • Criminalisation of HIV
    • The criminalisation of HIV-positive individuals contributes to stigma and shame and leads to not being tested, not disclosing their status and not seeking healthcare
    • South-Eastern U.S has the highest number of HIV criminalisation laws and the highest number of prosecutions, and also the highest rates of HIV in the US.
  • Racism in healthcare
    • Influences how individuals navigate the healthcare system

How do we keep vulnerable people engaged in care?

Dr Malebranche gave a good analogy of a newly opened restaurant where 100 people eat, however only 20 people return one month later.  He asked the audience “do we study the consumers of the restaurant OR do we study what ways the restaurant can improve in delivering quality food and service?“

We must investigate what happens in the clinic in understanding what is needed to support the treatment cascade.  Dr Malebranche discussed that much more studies are required to explore the experience of black and other vulnerable patients in clinics as a means to identify clinic level facilitators and barriers that influence patients in continuing in care and engaging in services (eg. communication styles, staff attitudes, protocols, power dynamics, bureaucratic paperwork).

One of his solutions for how we keep vulnerable people living with HIV engaged in care is peer navigation.  He gave an example of THRIVE SS, which is an online community of black men living with HIV. THRIVE SS provides community-led support and has led to rates of viral suppression of over 90%.

Other solutions include:

  • Patient reminders
  • Rapid test and treat options
  • Mobile medical teams
  • Case manager intervention
  • Assistance with social situation (housing, food, education)
  • Overcoming anti-LGBT and HIV criminalisation laws
  • General health initiatives
  • Community interventions (such as positive messages and posters showing black gay male couples together)

Drawing from his lived experience, Dr Malebranche gave some advice for healthcare professionals by asking that they be “vulnerable”. His suggestions included:

  1. Reflecting on the advice one provides which can impact upon patient care and follow-up
  2. Not treating all black patients as if they are less educated or less adherent with ART
  3. Using correct pronouns when speaking with gender non-conforming people
  4. When taking a sexual history, discuss about sex as pleasurable and not just a cause for STIs
  5. Cease using stigmatising phrases such as “HIV-infected” (instead use HIV positive or Living with HIV), “Hard to reach” populations, “Retained in care” (instead use engaged in care)
  6. Not being robotic when interacting with patients, and giving a piece of oneself to show some vulnerability to patients
  7. Lastly, treating patients as if you would want to be treated if you were also living with HIV

He concluded to a standing ovation.