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Barriers to Culturally Competent Human Immunodeficiency Virus Care Among the Black, Indigenous, and People of Color Community

Published:September 20, 2021DOI:https://doi.org/10.1016/j.nurpra.2021.08.021

      Highlights

      • Black, Indigenous, and people of color are at higher risk for human immunodeficiency virus in the United States.
      • A lack of cultural humility and competencies among providers caring for communities of color is a factor that contributes to ongoing disparities.
      • Understanding barriers within health care will improve health care outcomes.

      Abstract

      Black, Indigenous, and people of color (BIPOC) are at a higher risk for human immunodeficiency virus (HIV) infection and face unique challenges in the United States health care system. Health care providers can understand the barriers to care for at-risk groups and identify interventions to improve health outcomes. Demographic, social, and economic factors all play a role in the health disparities regarding the HIV infection rate in these at-risk populations. There are many challenges in establishing early diagnosis of HIV infection and linking newly diagnosed people living with HIV (PLWH) to evidence-based care. Systemic barriers include a lack of access to testing resources, a lack of primary care provider training in HIV testing and counseling, and a delay of linkage to care of newly diagnosed PLWH to treatment. Delayed initiation of HIV treatment can increase morbidity and mortality and perpetuate HIV transmission. Consistent use of pre-exposure prophylaxis (PrEP) has proven to decrease the incidence of HIV transmission while maintaining a low side effect profile; however, PrEP usage among the BIPOC population is low, increasing the risk of HIV seroconversion. Increased testing, PrEP utilization, and linkage to care for PLWH promote viral suppression, reducing HIV transmission. Specific population-based interventions for prevention, testing, and treatment can encourage providers to empower patients to seek and remain in care. By decreasing racial disparities in the delivery of care, providers can help achieve viral suppression, improving the overall health outcomes among BIPOC communities.

      Keywords

      In the last 30 years, there have been scientific breakthroughs, with aggressive research and evidence-based practice interventions, in preventing, testing, and treating human immunodeficiency virus (HIV). Advances with pre-exposure prophylaxis (PrEP), diagnostic testing, needle programs, and antiviral therapies have improved community and patient health outcomes. Although the United States has seen a decrease in new HIV diagnoses, the country still had almost 38,000 new cases diagnosed in 2018, with 1.2 million Americans living with the disease.

      Centers for Disease Control and Prevention. HIV Surveillance Report, 2018 (Updated); vol. 31. 2020. Accessed January 24, 2021. http://www.cdc.gov/hiv/library/reports/hiv-surveillance.html.

      It is estimated that 700,000 Americans have lost their lives to HIV since 1981.

      Kates J, Millett G, Dawson L, et al. The broader context of “Ending the HIV Epidemic: A Plan for America” initiative. American Public Health Association; 2020.

      The Affordable Care Act, changes in federal and state policies, and increased funding at the federal level have kept HIV reduction a priority and at the forefront of the nation’s health care agenda. The US Department of Health and Human Services has developed an operational plan called Ending the HIV Epidemic: A Plan for America, which was announced in 2019 at the President’s State of the Union address, to reduce HIV infections by at least 90% by 2030. In collaboration with the National HIV/AIDS Strategy for the US, it provides a strategic plan with funding, goals, objectives, and measurable outcomes at the federal level.

      Kates J, Millett G, Dawson L, et al. The broader context of “Ending the HIV Epidemic: A Plan for America” initiative. American Public Health Association; 2020.

      ,

      House W. National HIV/AIDS Strategy for the United States: Updated to 2020, 2015. 2017. Accessed September 13, 2021. https://files.hiv.gov/s3fs-public/nhas-update.pdf.

      It is crucial for health care providers to recognize that certain underrepresented communities are at higher risk for HIV in the US, specifically Black, Indigenous, and people of color (BIPOC). Health care providers must understand the barriers to care for at-risk populations and identify interventions to improve health outcomes. Social and economic factors, such as access to care, education, housing, transportation, and insurance status, can play a role in the disparities of HIV rates in these at-risk communities. Evidence-based prevention, testing, and treatment strategies must be accessible and tailored to address the unique needs in these communities to break down barriers to care. The clinical information that follows will inform nurse practitioners and community providers on decreasing or eliminating these barriers in their local health care settings to prevent infection and improve outcomes of their communities’ HIV-affected members.

      Blacks

      The Centers for Disease Control and Prevention reports that the Black population currently contracts HIV at the highest rate and constitutes a larger percentage of HIV patients than any other race/ethnicity. This community accounts for 42% of the new HIV diagnoses in 2018, yet they are only 13% of the US population. Black women have a rate of HIV 13 times higher compared with other populations.

      Centers for Disease Control and Prevention. HIV Surveillance Report, 2018 (Updated); vol. 31. 2020. Accessed January 24, 2021. http://www.cdc.gov/hiv/library/reports/hiv-surveillance.html.

      The highest transmission rate is among men who engage in higher-risk behaviors, such as men who have unprotected sex with men (MSM), who account for about 26% of new cases, with 75% under 34 years old.

      Centers for Disease Control and Prevention. HIV Surveillance Report, 2018 (Updated); vol. 31. 2020. Accessed January 24, 2021. http://www.cdc.gov/hiv/library/reports/hiv-surveillance.html.

      ,
      • Marano M.
      • Stein R.
      • Song W.
      • et al.
      HIV testing, linkage to HIV medical care, and interviews for partner services among black men who have sex with men - non-health care facilities, 20 southern U.S. jurisdictions, 2016.
      Health care challenges for this group are complex and multifactorial. Fear, discrimination, and mistrust of the health care system create a challenge for the Black community in seeking preventative health or health promotion services. Higher rates of social and economic issues related to poverty (eg, a lack of stable housing, insurance, and transportation as well as conflicts in prioritizing basic needs) often decrease their ability to access timely care.
      • Marano M.
      • Stein R.
      • Song W.
      • et al.
      HIV testing, linkage to HIV medical care, and interviews for partner services among black men who have sex with men - non-health care facilities, 20 southern U.S. jurisdictions, 2016.
      This underrepresented community also has a higher rate of sexually transmitted disease infections, which places them at a higher risk for HIV transmission. Evidence supports designing and implementing targeted, risk-based testing in non–health care settings and other nontraditional agencies that provide health care to this population.
      • Marano M.
      • Stein R.
      • Song W.
      • et al.
      HIV testing, linkage to HIV medical care, and interviews for partner services among black men who have sex with men - non-health care facilities, 20 southern U.S. jurisdictions, 2016.

      Hispanics

      Hispanics make up 17% of the US population yet account for 27% of the newly diagnosed HIV patients.

      Centers for Disease Control and Prevention. HIV Surveillance Report, 2018 (Updated); vol. 31. 2020. Accessed January 24, 2021. http://www.cdc.gov/hiv/library/reports/hiv-surveillance.html.

      ,

      Linley L, Johnson AS, Song R, et al. Estimated HIV incidence and prevalence in the United States 2010–2016. 2019.

      The overall trend for HIV infection in the Hispanic population has remained stable, and HIV rates among women and young people under 24 years have declined while increasing among MSM with inconsistent condom use.
      • Gant Z.
      • Dailey A.
      • Hu X.
      • Johnson A.S.
      HIV care outcomes among Hispanics or Latinos with diagnosed HIV infection - United States, 2015.
      As is the case with many underrepresented communities, Hispanics may have experienced racism, stigmatization, discrimination, poverty, and lower education levels, all of which are common barriers to accessing care. This population often faces additional challenges in the form of language barriers, cultural biases, and the fear of disclosing their immigration status, which add unique challenges for health care providers in providing education, testing, and treatment.
      • Levison J.H.
      • Levinson J.K.
      • Alegría M.
      A critical review and commentary on the challenges in engaging HIV-infected Latinos in the continuum of HIV care.
      Because of the fear of disclosing their immigration status, some Hispanics may distrust the health care system and avoid health care settings for fear of deportation even when assurances are given. Cultural and family pride (familismo) and strict cultural gender roles also contribute to decreased communication with health care providers with regard to sexual activity, safety, and high-risk factors regarding prevention strategies and testing for HIV.
      • Levison J.H.
      • Levinson J.K.
      • Alegría M.
      A critical review and commentary on the challenges in engaging HIV-infected Latinos in the continuum of HIV care.
      Language barriers decrease patient comfort with regard to asking questions, requesting services and testing, and understanding prevention and management strategies, which increase inequity in health care outcomes for this population.

      Indigenous Peoples

      American Indian/Alaskan Native individuals make up only about 0.5% of HIV diagnoses in the US, a number that is increasing significantly, with most new diagnoses from MSM without the usage of protection.

      Linley L, Johnson AS, Song R, et al. Estimated HIV incidence and prevalence in the United States 2010–2016. 2019.

      Health care challenges unique to this population include language and cultural barriers related to more than 574 recognized tribes; higher alcohol and injectable drug use; and data limitations due to misidentification, lack of funding, and undercounting.

      Centers for Disease Control and Prevention. HIV Surveillance Report, 2018 (Updated); vol. 31. 2020. Accessed January 24, 2021. http://www.cdc.gov/hiv/library/reports/hiv-surveillance.html.

      Indigenous leaders identify culturally safe care as care that is free of racism and discrimination. A lack of culturally safe care is a primary barrier to preventive care services. In response to HIV education, prevention, and testing, this community values the fact that their perspectives are respected, that the impacts of colonization are acknowledged, and that providers are humble and willing to appreciate their own individual health and wellness journey.
      • Jongbloed K.
      • Pooyak S.
      • Sharma R.
      • et al.
      Experiences of the HIV Cascade of care among indigenous peoples: a systematic review.
      Poverty, systemic violence (including domestic abuse), and a history of oppression are complexities that add to the health care challenges providers face when implementing education, prevention, testing, and management of HIV initiatives in this community.
      • Negin J.
      • Aspin C.
      • Gadsden T.
      • Reading C.
      HIV among indigenous peoples: a review of the literature on HIV-related behaviour since the beginning of the epidemic.
      These factors create significant mistrust of Western medical providers among this population, making it even more difficult to improve health care outcomes.
      • Negin J.
      • Aspin C.
      • Gadsden T.
      • Reading C.
      HIV among indigenous peoples: a review of the literature on HIV-related behaviour since the beginning of the epidemic.
      Geography and the transient nature of Indigenous people create unique challenges with follow-up testing and managing the evaluation of HIV treatments.
      In the US, there are disparities in access to health care, quality of care received, and overall health outcomes for BIPOC communities.
      • Negin J.
      • Aspin C.
      • Gadsden T.
      • Reading C.
      HIV among indigenous peoples: a review of the literature on HIV-related behaviour since the beginning of the epidemic.
      The attitudes, behaviors, and lack of cultural humility and competence among health care providers have been identified as factors that contribute to ongoing disparities.

      Linley L, Johnson AS, Song R, et al. Estimated HIV incidence and prevalence in the United States 2010–2016. 2019.

      BIPOC are faced with more barriers to health care access than their White counterparts, such as preventive services, access to treatment for acute conditions, and chronic disease management including access to PrEP and HIV testing.
      • Marano M.
      • Stein R.
      • Song W.
      • et al.
      HIV testing, linkage to HIV medical care, and interviews for partner services among black men who have sex with men - non-health care facilities, 20 southern U.S. jurisdictions, 2016.
      ,
      • Huang Y.A.
      • Zhu W.
      • Smith D.K.
      • Harris N.
      • Hoover K.W.
      HIV Preexposure Prophylaxis, by Race and Ethnicity - United States, 2014-2016.

      Testing

      There are many challenges to achieving an early diagnosis of HIV infection and linking newly diagnosed people living with HIV (PLWH) to care in the BIPOC communities. Systemic testing barriers disproportionately affect BIPOC individuals and include a lack of access to testing resources,
      • Gant Z.
      • Dailey A.
      • Hu X.
      • Johnson A.S.
      HIV care outcomes among Hispanics or Latinos with diagnosed HIV infection - United States, 2015.
      a lack of primary care provider training in HIV testing and counseling,
      • Levison J.H.
      • Levinson J.K.
      • Alegría M.
      A critical review and commentary on the challenges in engaging HIV-infected Latinos in the continuum of HIV care.
      and a lack of linkage of newly diagnosed PLWH to treatment.
      • Jongbloed K.
      • Pooyak S.
      • Sharma R.
      • et al.
      Experiences of the HIV Cascade of care among indigenous peoples: a systematic review.
      Delayed initiation of HIV screening and testing leads to delayed treatment, which can increase morbidity and mortality and perpetuate HIV transmission.
      • Derose K.
      • Griffin B.
      • Kanouse D.
      • et al.
      Effects of a pilot church-based intervention to reduce HIV stigma and promote HIV testing among African Americans and Latinos.
      The US Preventative Services Task Force recommends that all individuals between the ages 15 and 65 years should be offered an HIV test at least once in their lifetime; persons who are at increased risk for HIV should be screened more frequently.
      • Owens D.K.
      • Davidson K.W.
      • Krist A.H.
      • et al.
      Screening for HIV infection: US preventive services task force recommendation statement.
      Creating an opportunity to increase access to HIV testing may be accomplished using conventional laboratory testing or point-of-care testing. Rapid point-of-care HIV testing can be obtained by oral fluid or whole blood and is easy to perform in emergency departments and primary care and community settings. These tests not only are easy to perform but also have a low cost and allow for immediate notification of results.
      • Gamble V.N.
      Under the shadow of Tuskegee: African Americans and health care.
      To improve access to HIV testing for the BIPOC community, testing should occur in a private place where the individual can be tested with peer support without fear of discrimination.
      • Jongbloed K.
      • Pooyak S.
      • Sharma R.
      • et al.
      Experiences of the HIV Cascade of care among indigenous peoples: a systematic review.
      ,
      • Derose K.
      • Griffin B.
      • Kanouse D.
      • et al.
      Effects of a pilot church-based intervention to reduce HIV stigma and promote HIV testing among African Americans and Latinos.
      ,
      • Wilson T.E.
      • Gousse Y.
      • Joseph M.A.
      • et al.
      HIV prevention for black heterosexual men: The Barbershop Talk with Brothers Cluster randomized trial.
      Increased linkage to care promotes viral suppression, which reduces further HIV transmission. During 2014 to 2018, linkage to care within 1 month and viral suppression within 6 months of diagnosis increased (2.9% and 6.8% per year, respectively). Increases were highest among Black and Hispanic MSM. However, among all MSM included in the 2018 analysis, only 67.2% achieved viral suppression within 6 months of diagnosis. Moreover, in 2018, proportionally fewer Black MSM were linked to care and achieved viral suppression than other racial/ethnic MSM groups. Limited health care access, housing instability, poverty, and systemic racism commonly impede linkage to care and viral suppression.
      • Wilson T.E.
      • Gousse Y.
      • Joseph M.A.
      • et al.
      HIV prevention for black heterosexual men: The Barbershop Talk with Brothers Cluster randomized trial.
      ,
      • Riddell Jt
      • Amico K.R.
      • Mayer K.H.
      HIV preexposure prophylaxis: a review.
      Addressing these factors might improve outcomes.

      House W. National HIV/AIDS Strategy for the United States: Updated to 2020, 2015. 2017. Accessed September 13, 2021. https://files.hiv.gov/s3fs-public/nhas-update.pdf.

      Prevention

      Using PrEP in conjunction with a physical barrier, such as condoms, provides maximum protection against HIV. Individuals who have sex with inconsistent or no condom use run an increased risk of HIV. Consistent use has been proven to lead to a lower rate of HIV transmission and a low incidence of adverse effects from an antiviral.
      • Riddell Jt
      • Amico K.R.
      • Mayer K.H.
      HIV preexposure prophylaxis: a review.
      However, despite this outcome, racial and ethnic disparities and inequities persist. One concern is that BIPOC communities may distrust the medical community
      • Jongbloed K.
      • Pooyak S.
      • Sharma R.
      • et al.
      Experiences of the HIV Cascade of care among indigenous peoples: a systematic review.
      ,
      • Gamble V.N.
      Under the shadow of Tuskegee: African Americans and health care.
      or not believe that PrEP is a valid option.
      • Bogart L.M.
      • Ransome Y.
      • Allen W.
      • Higgins-Biddle M.
      • Ojikutu B.O.
      HIV-related medical mistrust, HIV testing, and HIV risk in the National Survey on HIV in the Black Community.
      ,
      • Ogunbajo A.
      • Storholm E.D.
      • Ober A.J.
      • et al.
      Multilevel barriers to HIV PrEP uptake and adherence among Black and Hispanic/Latinx transgender women in Southern California.
      PrEP should be recommended to individuals with a history of inconsistent or no condom use or a history of sexual activity with persons of unknown HIV status, those in a serodiscordant relationship, or those who have been diagnosed with a bacterial sexually transmitted infection within the last 6 months.
      • Riddell Jt
      • Amico K.R.
      • Mayer K.H.
      HIV preexposure prophylaxis: a review.
      When providers are with a BIPOC patient, they should educate the individual on the benefits of PrEP and clarify misconceptions, such as utilization exclusively for MSM.
      • Jongbloed K.
      • Pooyak S.
      • Sharma R.
      • et al.
      Experiences of the HIV Cascade of care among indigenous peoples: a systematic review.
      ,
      • Calabrese S.K.
      • Tekeste M.
      • Mayer K.H.
      • et al.
      Considering stigma in the provision of HIV pre-exposure prophylaxis: reflections from current prescribers.
      ,
      • Calabrese S.K.
      • Krakower D.S.
      • Mayer K.H.
      Integrating HIV preexposure prophylaxis (PrEP) into routine preventive health care to avoid exacerbating disparities.
      When inquiring about a person’s sexual history, it is essential to remember that a specific sexual practice with another person does not denote sexuality. Internalized homophobia and associated stigma are concerns within the BIPOC community. It is imperative to create an atmosphere of trust in discussing a person’s sexuality. Despite the significance of a patient’s sexual practices in relation to prescribing PrEP, it may be perceived by the patient as not clinically relevant, causing a barrier to care.
      • Drumhiller K.
      • Murray A.
      • Gaul Z.
      • Aholou T.M.
      • Sutton M.Y.
      • Nanin J.
      “We Deserve Better!”: perceptions of HIV testing campaigns among Black and Latino MSM in New York City.
      Access to PrEP is equally crucial to reducing barriers to care. Historically, initiation and continuation have been problematic to BIPOC communities, making initiation and continuation a challenging process.
      • Ojikutu B.O.
      • Bogart L.M.
      • Higgins-Biddle M.
      • et al.
      Facilitators and barriers to pre-exposure prophylaxis (PrEP) use among black individuals in the United States: results from the National Survey on HIV in the Black Community (NSHBC).
      Barriers such as lack of health insurance, low health literacy, economic hardships, ineffective communication, and distance from providers prevent access to PrEP.
      • Page K.R.
      • Martinez O.
      • Nieves-Lugo K.
      • et al.
      Promoting pre-exposure prophylaxis to prevent HIV infections among sexual and gender minority Hispanics/Latinxs.
      By reducing these barriers, interested individuals are substantially more likely to initiate and continue PrEP.
      • Ojikutu B.O.
      • Bogart L.M.
      • Mayer K.H.
      • Stopka T.J.
      • Sullivan P.S.
      • Ransome Y.
      Spatial access and willingness to use pre-exposure prophylaxis among Black/African American individuals in the United States: cross-sectional survey.

      Treatment

      HIV treatment guidelines state that antiretroviral treatment should be initiated immediately after diagnosis, ensuring that newly diagnosed individuals are linked to care immediately and thereby increasing the likelihood of continuity of care.
      • Lundgren J.D.
      • Babiker A.G.
      • et al.
      INSIGHT START Study Group
      Initiation of antiretroviral therapy in early asymptomatic HIV infection.
      PLWH can then be referred to specialty care after the initiation of treatment, if necessary. Early initiation of antiretroviral therapy (ART) is critical to reducing the progression to AIDS. In addition, early initiation of ART can preclude AIDS-defining clinical events and mortality.
      • Owens D.K.
      • Davidson K.W.
      • Krist A.H.
      • et al.
      Screening for HIV infection: US preventive services task force recommendation statement.
      Blacks living with HIV have lower levels of care and viral suppression than other racial groups.
      • Dailey A.F.
      • Johnson A.S.
      • Wu B.
      HIV care outcomes among blacks with diagnosed HIV - United States, 2014.
      Provider attitudes, beliefs, and behaviors associated with HIV-related stigma, including homophobia, transphobia, and racism (referred to as clinical bias
      • Geter A.
      • Herron A.R.
      • Sutton M.Y.
      HIV-related stigma by healthcare providers in the United States: a systematic review.
      ), have led to a delay in treatment postdiagnosis, especially for BIPOC individuals, people living with substance abuse, and those experiencing homelessness.
      • Negin J.
      • Aspin C.
      • Gadsden T.
      • Reading C.
      HIV among indigenous peoples: a review of the literature on HIV-related behaviour since the beginning of the epidemic.
      ,
      • Mimiaga M.J.
      • Reisner S.L.
      • Grasso C.
      • et al.
      Substance use among HIV-infected patients engaged in primary care in the United States: findings from the Centers for AIDS Research Network of Integrated Clinical Systems cohort.
      This clinical bias creates an atmosphere of mistrust, which can extend throughout many patient populations, not just among PLWH. This is particularly true among BIPOC patients who may have experienced culturally insensitive care in the past. Providers must work to improve bedside manners, examine implicit biases (ie, provider health beliefs that may impact treatment recommendations, quality of care, diagnostic and treatment decisions, and patient outcomes
      • Andrasik M.
      • Broder G.
      • Oseso L.
      • Wallace S.
      • Rentas F.
      • Corey L.
      Stigma, implicit bias, and long-lasting prevention interventions to end the domestic HIV/AIDS epidemic.
      ), and provide culturally sensitive care devoid of prejudice and discrimination. For example, providers can work to reduce delays in initiating HIV care, never deny care to PLWH, and ensure patient linkage to care. They can ensure that patients are prescribed and counseled on ART and the importance of drug adherence while patients wait to see a specialty provider. Providers and staff must be culturally sensitive to foster an environment of trust (ie, a supportive and respectful environment that encourages patients to remain in care). Poor clinical experiences are additionally detrimental to this vulnerable population.
      • Azfar-e-Alam Siddiqi X.H.
      • Hall H.I.
      Mortality among blacks or African Americans with HIV infection—United States, 2008–2012.
      In 2016, the Prevention Access Campaign launched the Undetectable = Untransmittable (U=U) initiative to further reduce the stigma associated with HIV and combat HIV criminalization. The concept is based firmly on scientific evidence that PLWH maintaining an undetectable viral load cannot sexually transmit HIV to others.
      • Eisinger R.W.
      • Dieffenbach C.W.
      • Fauci A.S.
      HIV viral load and transmissibility of HIV infection: undetectable equals untransmittable.
      For the initiative to be successful, providers must educate and empower their patients on U=U. Informed patients are empowered patients; empowered patients are better equipped to make decisions that lead to positive health outcomes.
      • Okoli C.
      • Brough G.
      • Allan B.
      • et al.
      Shared decision making between patients and healthcare providers and its association with favorable health outcomes among people living with HIV.
      The management of HIV is ongoing, and to remain virally suppressed, PLWH must remain in care. Patient education includes providing PLWH with the tools to become active participants in their care.

      Implications for Practice

      Disparities in the care and outcomes of BIPOC patients at risk or living with HIV continue despite vast advances in diagnostics and treatment. Understanding the barriers to care for at-risk groups living with HIV, particularly BIPOC populations, and identifying interventions aimed at providers and the health care setting will improve health care outcomes. Specific population-based interventions for prevention, testing, and treatment can encourage providers to empower patients to seek and remain in care. By decreasing racial disparities in the delivery of care, providers can help achieve viral suppression, improving the overall health outcomes among BIPOC communities.

      References

      1. Centers for Disease Control and Prevention. HIV Surveillance Report, 2018 (Updated); vol. 31. 2020. Accessed January 24, 2021. http://www.cdc.gov/hiv/library/reports/hiv-surveillance.html.

      2. Kates J, Millett G, Dawson L, et al. The broader context of “Ending the HIV Epidemic: A Plan for America” initiative. American Public Health Association; 2020.

      3. House W. National HIV/AIDS Strategy for the United States: Updated to 2020, 2015. 2017. Accessed September 13, 2021. https://files.hiv.gov/s3fs-public/nhas-update.pdf.

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        HIV testing, linkage to HIV medical care, and interviews for partner services among black men who have sex with men - non-health care facilities, 20 southern U.S. jurisdictions, 2016.
        MMWR Morb Mortal Wkly Rep. 2018; 67: 778-781
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      Biography

      Justin M. Waryold, DNP, ANP-C, ACNP-BC, is an assistant professor at SUNY Upstate Medical University College of Nursing in Syracuse, NY, and can be contacted at [email protected]
      Courtney Shihabuddin, DNP, CNP, is a clinical assistant professor of clinical nursing at The Ohio State University College of Nursing in Columbus.
      Randee Masciola, DNP, WHNP-BC, is a clinical associate professor of clinical nursing at The Ohio State University College of Nursing.