The spread of AIDS among blacks and Latinos is a "public health emergency. . . . The complexion of the epidemic has changed. Increasingly it is becoming an epidemic of color." -- Dr. David Satcher, U.S. Surgeon General October 29, 1998

• A Growing Crisis
• Tracking the Epidemic
• Researching Effective Prevention Programs
• Helping Communities Fight HIV
• Conclusions
• The Impact of HIV/AIDS in African-American Communities

A Growing Crisis

The U.S. HIV epidemic, which began primarily among white gay men over a decade ago, has expanded to affect an increasing number of populations, with African-American communities among those most dramatically affected. Today, the disease poses a fundamental threat to the future health, well-being, and human potential of many African-American communities. African Americans are almost ten times more likely to be diagnosed with AIDS than whites, and there is evidence that this disparity is increasing. Race and ethnicity are not, themselves, risk factors, but correlate with other more fundamental determinants of health status such as poverty, access to quality health care, health care seeking behavior, illicit drug use, and living in communities with high prevalence of sexually-transmitted diseases (STDs). Acknowledging the disparity in HIV and STD rates by race or ethnicity is one of the first steps in empowering affected communities to address this problem.

As a result of the continued growth in HIV/AIDS, African Americans are broadly mobilizing to respond to the epidemic. CDC is committed to working in partnership with African-American communities and other government agencies to ensure that all people at risk have access to early testing, treatment, and prevention programs that work. Only through a meaningful, sustained partnership between government and national and local African-American leaders and institutions can this severe and ongoing health threat be brought under control.

Fortunately, extensive prevention science research has demonstrated that sound, science-based prevention programs can significantly reduce the risk of HIV infection among communities at risk. Moreover, an increasing number of African Americans are being reached by STD screening and treatment services known to reduce HIV transmission, and powerful new HIV treatments that may prove to reduce transmission even further.

This report provides basic facts about HIV/AIDS among African Americans and outlines CDC's response to this public health threat. In its efforts to control the spread of HIV nationwide, CDC pursues three basic strategies:

1. Tracking the Epidemic: CDC carefully monitors the status of HIV/AIDS by race, risk group and gender, enabling communities to base public health strategies on the best possible understanding of the epidemic.

2. Researching Prevention: CDC conducts extensive biomedical and behavioral research to ensure that HIV prevention programs are based on sound science.

3. Helping Communities: CDC provides more than $400 million to help communities build and sustain sound, innovative HIV prevention programs. CDC also provides funding and support to enable local communities to deliver the STD treatments that reduce vulnerability to HIV infection.

As African Americans have represented an increasing proportion of individuals affected by HIV infection and AIDS, an increasing proportion of CDC's prevention efforts in all three areas has focused on reaching African Americans. Additionally, CDC has initiated a growing number of national, regional, and community-based programs designed exclusively to reach African-American populations. Working through state and local health departments and directly funded organizations, CDC initiatives have been built in partnership with African-American community and faith-based organizations over time, and have grown from $11 million in 1988 to $137 million today.

Much work remains to be done to turn the tide against HIV/AIDS among African-Americans. As this report makes clear, however, the systems to mount a successful response have been growing, and there is a new commitment among African-American leaders to fight back against this disease.

Tracking the Epidemic

Close monitoring of the epidemic enables communities to tailor prevention strategies to local needs. Since AIDS first appeared, CDC has collected and disseminated the best available information on disease trends, including racial and ethnic differences among people diagnosed with HIV/AIDS.

As early as September 1983, it became apparent from CDC's surveillance data that AIDS was disproportionately affecting African Americans. At that time, African Americans accounted for 26% of all AIDS cases, yet represented only 13% of the U.S. population. In CDC's October 1986 report on AIDS among blacks and Hispanics, CDC documented that the cumulative incidence of AIDS among blacks and Hispanics was over 3 times the rate for whites.

As the U.S. nears the end of the epidemic's second decade, the disease burden among African Americans has grown further still.

Estimates of New Infections By Gender and Race-1998

Disease and Death

• Although African Americans made up 13% of the U.S. population, they represented 48% of all reported AIDS cases in 1998.

• AIDS remains the leading cause of death for African Americans ages 25-44.

• Researchers estimate that 240,000-325,000 African Americans are infected with HIV, and more than 106,000 of these individuals are currently living with AIDS.

• Despite declines in AIDS deaths among all racial/ethnic groups between 1995 and 1998, AIDS mortality rates remain nearly ten times higher among African Americans than among whites.

"Enough is enough . . . This is a national crisis. We will not rest until the crisis is acknowledged and strategies and resources are directed to eliminate it."
-- Representative Maxine Waters, then-chair of the Congressional Black Caucus, March 15, 1999

Disproportionate Infection Rates

• According to estimates, approximately half of all new HIV infections occur among African Americans.

• Approximately 1 in 50 African-American men and 1 in 160 African-American women are believed to be infected with HIV. By comparison, 1 in 250 white men and 1 in 3,000 white women are believed to be infected.

Dramatic Impact Among African-American Youth

• Estimates of infection trends in the early 1990s indicate that half of all young adults (18-22) infected during these years were African-American.

• A 1998 CDC study of entrants to the U.S. Job Corps found that young African-American women were seven times more likely than their white counterparts, and eight times more likely than Hispanics, to be HIV-infected.

• A 1999 CDC study of young men who have sex with men (ages 15-22) in six urban counties found that African-American men were substantially more likely to be HIV-positive (14%) than Hispanics (7%) or whites (3%).

National HIV Reporting Needed

Current estimates of new HIV infections are rough, and are based on specific studies and data from states that track HIV infections, as well as AIDS cases. Prior to recent treatment advances, AIDS cases were generally accurate indicators of HIV infection, because HIV progressed to AIDS at predictable intervals prior to 1996. Although CDC has called for one, there is currently no national system that tracks new HIV infections the same way that AIDS cases are monitored. Only by tracking new HIV infections will we be able to accurately determine the magnitude of the HIV epidemic and the populations most in need of HIV prevention services.

Researching Effective Prevention Programs

"We have to make our response to AIDS have the energy and moral equivalence of a civil rights movement." - Alvin Poussaint, Harvard University May 20, 1998

The CDC conducts extensive research to improve the effectiveness of HIV prevention programs. Given the disease's impact on African Americans, a substantial portion of CDC's prevention research portfolio focuses on this important population.

Behavioral Research

CDC studies the behaviors that place people at risk for HIV infection. By better understanding these behaviors, scientists can devise new and better strategies to help those at risk avoid HIV transmission.

• Developing and Testing Behavioral Programs: In an effort to expand and improve the range of prevention strategies available, CDC develops and evaluates behavioral interventions to determine if they are effective at reducing HIV risk. Among a group of largely African-American and Hispanic women seen in STD clinics, for example, CDC found that an improved counseling technique could significantly reduce new STDs. The 1998 study found that STD clinic patients who received brief, interactive counseling sessions had 20% fewer STDs than those given non-interactive educational sessions.

• Educating Women: CDC recently completed the HIV in Women and Infants Project, a community-level behavioral intervention project targeting young women ages 15-34. The project was designed to improve the understanding of factors influencing women's behavior changes regarding condom and contraceptive use, and to improve the development and delivery of prevention interventions. Given that African Americans comprise the majority of HIV/AIDS cases among women and children, this project will result in important preventive benefits for African-American communities.

• Preventing HIV Among Young African-American Men: CDC also conducted the Young African-American Men's Study, a two-year study to prevent HIV/AIDS in young African-American men. Other ongoing CDC research projects are seeking to better understand risk behaviors and design effective interventions for injection drug users, women who partner with injection drug users, individuals with high rates of STDs, and young gay and bisexual men of color.

Today, antiretroviral therapy has helped to significantly reduce the number of newborns infected with HIV in the U.S.

Biomedical Research

Biomedical treatments that reduce the likelihood of HIV transmission support and enhance the effectiveness of behavior change programs. CDC conducts important research on numerous biomedical strategies to prevent transmission.

• Mother-to-Child Transmission: In 1994 research showed that AZT therapy given to HIV-infected pregnant women from the 14th to 34th week, continuing throughout pregnancy, during labor and delivery, and to the child for six weeks after birth could significantly reduce perinatal HIV transmission. Since that time, CDC has been working with health care providers across the nation to ensure the widespread implementation of voluntary HIV testing and treatment for all HIV-infected pregnant women. Today, anti-retroviral therapy has helped to reduce the number of U.S. infants who acquire AIDS by 73% from 1992 through 1998. These efforts have been critical for reducing the toll of HIV among African-American infants, who represent over 60% of all infants born with HIV.

• HIV and STD Treatment: As the nation's leader in STD prevention and treatment, CDC also conducts research on the impact of STD treatment on HIV transmission. Today, an increasing number of African Americans are being reached with STD screening and treatment services known to reduce HIV transmission, and are gaining access to new antiretroviral HIV therapies that may prove to reduce transmission even further. Additionally, CDC researchers are seeking to determine whether combination antiretroviral therapy actually reduces the risk of HIV transmission.

• Microbicides and Vaccines: CDC is also extensively engaged in research efforts to discover effective microbicides and to develop a preventive HIV vaccine. Moreover, CDC is working to determine the factors that influence willingness to use these approaches and how their development may influence risk behaviors.

Helping Communities Fight HIV

As HIV has increasingly targeted more and more sub-populations at risk, the national effort to bring the epidemic under control has become more complex. HIV prevention efforts must take into account cultural issues, as well as social and economic factors -- such as poverty, underemployment, and poor access to the health care system -- that affect many U.S. minority communities. Effectively addressing these issues requires strong partnerships and building basic services that often do not exist.

CDC has devised numerous strategies to strengthen the nation's response to HIV/AIDS in African-American communities. Recognizing the epidemic's disproportionate impact on African Americans, CDC began building partnerships in the late 1980s with community-based organizations and faith communities to reach African Americans at risk of infection.

Over the past decade, these efforts have grown substantially. Today, hundreds of community-based organizations throughout the nation receive CDC funds for HIV prevention activities directed to the African-American community.

Targeted Funding for African-American Communities has Dramatically Increased

Unfortunately, as the sub-populations affected have increased, and the national HIV prevention effort has become more complex, overall funding for HIV prevention activities has remained flat for much of the 1990s.

Even still, CDC funding for HIV prevention programs for specific African-American initiatives has grown from nearly $11 million in 1988 to $137 million in 1999 (see graph). In the last year alone, funding for African-American prevention programs grew by more than 50%. As a result, CDC currently directs the largest share of its community-based HIV prevention efforts to African-American communities.

These funds have closely followed the growing proportion of the epidemic in African-American communities. As African Americans make up an increasing share of AIDS cases, a greater and greater share of CDC's prevention budget has been specifically devoted to fighting the epidemic among this population.

CDC's analysis of HIV prevention funding reveals that the single most important factor in the growth of HIV prevention spending earmarked for African Americans is CDC's initiation of community planning, in which control over CDC grants to local community-based organizations was given to the communities themselves. Community planning alone, instituted in 1993, has resulted in a 228% increase in the amount of federal dollars devoted to HIV prevention services for African Americans.

1987 Faith Initiatives Since 1987, CDC has served African Americans through direct support to the faith community for HIV prevention activities. Funding for African-American faith-based organizations has grown from $10,000 in 1988 to $720,000 during 1998. In 1999, CDC funding to the African-American faith community will increase to $2.2 million.

1988 National and Regional Minority Organizations In 1988, CDC began providing HIV prevention grants to national and regional minority organizations (NRMOs) to provide the consultation and training needed to help organizations build long-term capacity in communities of color. Funding for NRMOs serving African-American communities has grown from about $4 million in 1988 to over $12 million in 1998. In 1999, CDC will fund a new initiative to significantly increase capacity-building efforts in African-American communities.

CDC-funded NRMOs that specifically serve the African-American community include:

• National Organization of Black County Health Officials

• National Minority AIDS Council

• National AIDS Minority Information and Education Program

• National Council of Negro Women

1989 Directly-Funded Community-Based Organizations Although CDC has historically supported community-based organizations (CBOs) through its prevention funding to state and local health departments, CDC has long recognized the need to provide additional support for the HIV prevention infrastructure in hard-hit, under-served communities. In 1989, CDC began providing direct support to local organizations to deliver essential HIV prevention services.

Among the first organizations directly funded by the CDC in the early 1990s, 55% targeted African Americans. More recently, CDC in 1997 awarded multi-year contracts to 94 local organizations, 76% of whom directly serve African Americans. CDC's direct CBO funding for HIV prevention services targeted to African Americans has grown from approximately $3 million in 1989 to $12 million in 1993 to $30 million in 1999.

1993 Community Planning

In 1993, CDC made its most profound change in prevention funding, when it put decisions about state and local funding in the hands of affected communities. Through community planning, CDC helps ensure that limited prevention funding goes to those who need it the most.

The largest share of CDC's overall HIV prevention spending -- $256 million in 1999 -- flows to state and local health departments through the community planning process. These funds support health education and risk reduction programs, as well as counseling and testing services.

A CLOSER LOOK

The Sisters and Brothers Prevention Project SBPP, based in Bridgeport, Connecticut, conducts street outreach -- bringing information and materials about HIV prevention, condom use and other risk-reduction behaviors to hard-to-reach young people. Targeting African-American youth at high risk for HIV infection -- including those involved in the sex industry, young people who abuse drugs or alcohol, pregnant youth, homosexual and lesbian youth, runaways and homeless youth -- the program also provides referral services for substance abuse treatment and HIV, STD and TB testing.

Representation of Local Communities

To ensure that essential community voices are heard in setting prevention priorities, CDC requires that community planning bodies include appropriate representation of hard-hit communities. A CDC analysis of the membership of community planning groups for 1998 and 1999 found that 27% of planning group members were African-American -- substantially below African Americans' share of people living with AIDS (39%).

As a result of this analysis, CDC this spring began comparing planning group membership to the epidemiologic picture in each jurisdiction and providing this information to state and local health officials. Areas that have not yet closed demographic gaps in membership are receiving assistance to ensure adequate representation.

A CLOSER LOOK

Soul Food, Brothers Healing Brothers With the support of CDC, Gay Men's Health Crisis in New York City organized Soul Food, a program designed by black gay men with the goal of helping other black gay and bisexual men and their partners remain HIV-negative. The community mobilization effort has enrolled more than 400 black gay and bisexual men, who have collected more than 1,100 sexual health surveys from other such men across the city. These efforts have led to a better understanding of the needs of this population, including more specifically targeted outreach programs that value cultural affiliations, improved community ability to implement HIV prevention programs, and increased counseling of IV-drug users.

Funding to Match the Epidemic

To obtain information regarding the impact of community planning on the targeting of CDC-supported HIV prevention programs, CDC analyzed state and local prevention spending patterns. CDC found that, between 1997 and 1998, the percentage of behavioral prevention program funding (specifically for health education and risk reduction) targeted to African Americans increased from 31% to 37%, a proportion that approached African Americans' share of people living with AIDS (39%).

For HIV counseling and testing activities, health departments projected that the percentage of such spending directed to African Americans would increase from 23% in 1997 to 29% in 1998. These projections, however, may understate African Americans' use of CDC-supported counseling and testing. In 1997, African Americans actually accounted for 52% of all positive HIV test results in CDC-supported test sites.

To ensure an appropriate, and scientifically-sound, targeting of African-American communities and others at heightened risk, CDC has adopted a "hard triggers" policy that makes sure that state or local prevention plans that depart significantly from local epidemiologic data are investigated and problems corrected. CDC is actively working with communities where African Americans are under-served to ensure that African Americans at risk for HIV receive the prevention services they need.

A CLOSER LOOK

Teen W.I.S.E. (Women Informed Seeking Empowerment) Teen wise reaches young African-American women in settings such as schools, child-care facilities, healthcare clinics and retail stores. This Detroit program uses a variety of activities to increase knowledge about HIV transmission and prevention and to improve safer sex practices among teens. Peer educators act as role models for other teens and provide important prevention information to their peers. Teen wise also conducts street outreach, health education workshops, risk reduction counseling and support groups.

"The response to the epidemic will demand a genuine, long-lasting partnership between CDC and African-American communities." -- Dr. Helene Gayle, Director, National Center for HIV, STD and tb Prevention, CDC

1999 New Initiatives -- New Funds

CDC's efforts to work in partnership with African-American communities were greatly strengthened in 1998, when African-American community leaders joined with the Congressional Black Caucus to obtain substantial new prevention funding targeted to African Americans at risk of HIV infection.

As a result of these efforts, CDC received $18 million in new prevention funding for African Americans and $21 million in emergency funding to address prevention needs of communities of color. In addition, CDC received $10 million in funding to support efforts to reduce mother-to-child HIV transmission, which disproportionately affects African Americans. Of these combined funds, a total of nearly $41 million is specifically targeted to African Americans.

Specifically, this new funding will enable CDC to:

• Support approximately 45 additional community-based organizations for prevention services targeted to African Americans ($10 million).

• Enhance the capacity of under-served communities to provide HIV prevention services ($9.7 million).

• Expand efforts to reduce mother-to-infant HIV transmission, nearly 60% of which occurs among African Americans ($6 million).

• Award grants for HIV prevention services for African-American gay men ($5.6 million).

• As part of a broader strategy designed to reduce HIV transmission through enhanced health care access, undertake extensive activities to encourage African Americans at risk of infection to learn their HIV status, and ensure that infected individuals are referred to treatment and prevention services (Know Your Status campaign: $4 million).

• Increase prevention services to reach high-risk minority populations in correctional facilities ($4 million).

• Increase HIV prevention activities in the faith community ($1.5 million).

Summary of Funds Targeted to African-American Communities (in millions)
	1988	1993	1998	1999
State and Local Health Departments (Community Planning)	5.75	8.43	66.22	66.22
Capacity-Building and Technical Assistance	5.17	5.35	5.09	22.81
Community-Based Organizations		11.85	14.64	30.00
Faith Initiative	0.01	0.10	0.72	2.22
Other Minority Initiatives		1.80	3.56	1.73
Mother-to-Child Transmission				6.00
Correctional Facilities				4.00
Know Your Status				4.00
TOTAL	10.93	27.53	90.23	136.93

"Don't let anybody tell you it is a gay disease . . . it doesn't just happen to 'them;' it happens to your brother and, more and more, to your sister, too." --Julian Bond, chairman of NAACP July 12, 1998

Conclusion

No single community can, on its own, cope with the immensity of the HIV/AIDS tragedy. This may be especially true for communities that have been historically under-served, such as African Americans. Nor can CDC, or state and local health departments, turn the tide against HIV/AIDS without the active involvement of African-American leaders and institutions.

Overcoming barriers to HIV prevention among African Americans will not happen overnight. It will require a sustained community mobilization against the disease, supported by sound, scientifically-grounded prevention strategies, and a national commitment to expanded access to HIV prevention and care. As HIV and AIDS increasingly expand to disadvantaged communities, the response to the epidemic will demand a genuine, long-lasting partnership between CDC and these communities.

As CDC enters the next era, the agency will continue to expand its efforts to reach African Americans, by increasing programs that:

• Reach uninfected people at risk

• Reach infected people with HIV testing, treatment referrals, and sustained prevention

• Build capacity among community organizations and the faith community, recognizing that the ability to deliver prevention and treatment is not the same in all communities.

The many CDC programs outlined in this report are intended to nurture, strengthen, and support mobilization against the disease, and to forge an effective, enduring partnership between African-American communities, CDC, and the public health agencies and local organizations supported with CDC funds.

"We cannot rest while HIV and AIDS is escalating in the African-American community." -- President Clinton, Remarks to Congressional Black Caucus September 19, 1998

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The Impact of HIV/AIDS in African-American Communities

• July 1982: CDC reports that 37 cases of AIDS-related pneumonia have occurred among African Americans

• 1984: HIV is identified as the cause of AIDS June 1984: CDC reports that 50% of all pediatric AIDS cases are among African Americans

• 1985: CDC begins providing funds to state and local health department HIV prevention efforts October

• 1986: CDC issues special Morbidity and Mortality Weekly Report on "AIDS Among Blacks and Hispanics," finding that African Americans account for 51% of all AIDS cases among women and have an overall AIDS rate three times higher than whites

• 1987: CDC begins earmarking a portion of its state and local health department funding for African Americans and other minorities

• 1988: CDC begins providing funding to National and Regional Minority Organizations and to the faith community

• July 1988: In a special surveillance report, CDC finds that African Americans account for 70% of all AIDS cases among heterosexual men, 70% of those in women, and 75% of those in children

• 1989: CDC begins direct funding for community-based organizations serving African Americans to help close gaps in access to HIV prevention services in under-served communities

• August 1989: CDC reports on first 100,000 AIDS cases

• 1990: CDC issues surveillance reports on HIV/AIDS among IV drug users, children and women, noting disproportionate impact on African Americans

• August 1992: CDC report on publicly-funded counseling and testing reveals substantially higher HIV-positive rate among African Americans than among whites

• 1993: CDC funds a U.S. Conference of Mayors study to assess the HIV prevention needs of gay and bisexual men of color

• November 1993: CDC reports that HIV has become the leading cause of death for African-American men, ages 25-44, and the second leading cause of death for African-American women in the same age range

• December 1993: CDC begins requiring state and local health departments to ensure that local communities have input into making decisions about how HIV prevention funds are used

• September 1994: CDC issues special MMWR report on AIDS among racial and ethnic minorities

• 1994: CDC publishes recommendations on use of AZT to reduce mother-to-child transmission

• 1995: CDC report on AIDS among men who have sex with men notes that African-American men have highest AIDS incidence of all racial/ethnic groups

• 1995: CDC publishes recommendations for voluntary HIV counseling and testing for pregnant women

• 1996: CDC reports that in 1994 HIV had become the leading cause of death for African-American women, ages 25-44, and remained the leading cause of death for African-American men in the same age range

• 1998: African-American community leaders join with Congressional Black Caucus to obtain substantial new funding for HIV prevention services in the African-American community

• 1998: CDC assessment of community planning finds an increase in the share of funds directed toward African Americans

• 1999: With additional support for prevention activities in the African-American community, CDC begins the process of distributing funds for new HIV prevention initiatives