Reducing the spread of HIV through intergenerational communication and engagement among African American mothers and daughters

To the Editor

While HIV research, treatment, and prevention methods have improved over the past 40 years, young Black women continue to be disproportionately affected by HIV in 2017, the Centers for Disease Control Prevention (CDC) reported that about 1 in 48 African American women will face an HIV diagnosis in their lifetime (CDC, 2017). While the rate of new infections among Black women decreased from 2010 to 2016, such decline continues to be slower than that of their white counterparts. ¹ Black women also face higher morbidity and mortality from HIV than their White counterparts. ² In 2018, Blacks/African Americans made up 13% of the female population in the United States, but accounted for 58% of diagnoses of HIV infection among females. ³ Furthermore, despite elevated HIV incidence in Black women, recent biomedical and nonbiomedical research have focused primarily on other groups, specifically, men who have sex with men (MSM) and transgender women. Black cisgender women have not been a focus or priority. ¹ There is a need for further research into fostering HIV prevention through leveraging the mother–daughter relationship. A mother living with HIV can help reduce her daughter’s HIV risk behaviors through supportive communication and ongoing engagement. The purpose of this letter to the editor is to examine how the relationship between Black mothers living with HIV and their adolescent daughters potentially lays a foundation for preventative communication, thereby reducing HIV-associated stigma as well as HIV incidence for young Black women as they enter adulthood.

When examining the literature, there is a dearth of information regarding utilization of intergenerational communication to promote HIV prevention for adolescents and young adults. Effective parental communication may be able to effectively prevent and mitigate HIV transmission in future generations. Intergenerational communication has been identified as a key causal pathway to improve testing, linkage to care, disclosure, and reduced stigma for those living with HIV. ⁴ Research shows that the sexual health discussions that take place between parents and their preadolescent children can delay sexual debut and increase condom and contraceptive use. ⁵ In sexual education, the dreaded ‘sex talk’ has been a rite of passage for several generations, yet pervasive stigma continues to be associated with sex education both inside and outside of schools.Grossman et al. ⁶ reported that many parents did not talk to their children about sex, because they perceived them as ‘not ready’. Lindberg et al. ⁷ found that youth who received sex education exhibited healthier sexual behavior, such as delayed sexual initiation and greater use of contraception. Intergenerational prevention dialogue has been examined in adult populations ⁸ and African populations. ⁴ Given the impact of HIV on this population, exploring how intergenerational communication may be used to reduce HIV incidence is critical in order to inform future prevention efforts. Studies have confirmed that parents play a vital role in promoting sexual health among their adolescents. ⁹ Furthermore, Murphy et al. ⁹ affirm that positive communication between mothers and their children is linked with lower rates of risky sexual behavior.

Additional studies have shown that mother–daughter communication about sexual risk behaviors increase adoption of safe sex practices.^10,11 Ford et al. ¹² found open communication and education to be most effective in prevention of sexually transmitted infections (STIs). Thus, mothers living with HIV may be able to promote their adolescent daughter’s uptake of HIV prevention interventions, such as HIV pre-exposure prophylaxis (PrEP). While sex and race strongly influence HIV health outcomes, current HIV prevention initiatives for Black women have thus far largely failed to include these constructs. ² The intersectionality of being both Black and female is often overlooked in matters of health, especially with regard to HIV disease. A focus on intersectionality highlights the experiences of historically oppressed or marginalized groups and guides the development of well-targeted and cost-effective health promotion messages, interventions, and policies. ¹³ An intersectional approach in which race, sex, ethnicity, and socioeconomic status are included in HIV prevention and care is essential.

Thus, to begin an intergenerational shift in Black mother–daughter relationships as it relates to HIV prevention, we must focus on intersectionality, open communication, education, and community engagement. Effective intergenerational engagement between HIV positive mothers and HIV negative daughters facilitates sexual risk communication that will ultimately promote HIV prevention behaviors and support treatment adherence and adaptive coping.^4,14 Lack of communication may result in misunderstanding and underestimation of sexual risk for HIV and increased acquisition of STIs. ¹⁴

In conclusion, the treatment and prevention of HIV in the Black community, particularly among Black women, is historically complex. To further decrease the rate of new HIV infections among Black women, researchers must renew their prioritization of HIV prevention in Black women, particularly in adolescents and young adult women. HIV prevention interventions that incorporate considerations of race, sexuality, class, sex, and age will likely be most effective. A tailored approach supports the promotion of intergenerational communication among Black families to promote HIV awareness, prevention, and reduction of HIV-associated stigma.