State of Emergency: HIV/AIDS Among African Americans
Excerpts from an article in the September 1998 issue of Update, published by the National Minority AIDS Council
African Americans Bear the Most Severe Burden of the HIV/AIDS Epidemic
Our national investment in HIV prevention, research, treatment, care and housing has improved the health and quality of life of countless persons affected by or living with HIV/AIDS. Tragically, African Americans are not experiencing the full benefits of this investment. In 1996, for the first time in the epidemic, the number of new AIDS cases among African Americans surpassed that of whites. AIDS is still the leading cause of death among African Americans between the ages of 25-44. Moreover, African American women account for 56 percent of the cumulative female AIDS cases and African American children represent 58 percent of the cumulative pediatric AIDS cases.
There is no question that African Americans bear the greatest burden of the epidemic, yet are the group that is benefitting the least from our national investment in HIV/AIDS programs. African Americans, who represent only 18 percent of the United States population, are disproportionately impacted by AIDS. According to the Centers for Disease Control and Prevention (CDC) African Americans accounted for 36 percent of the 641,086 cumulative AIDS cases reported through December 1997.
The new AIDS treatments have prolonged the lives of people living with AIDS and therefore contributed to the continuing increase in AIDS prevalence. In 1996, an estimated 242,000 people were living with AIDS, an increase of almost 12 percent since 1995. CDC projects that if the declines in AIDS cases persist, there will also be an increase in the number of persons living with HIV (HIV prevalence). This will in turn increase the demand for both prevention and treatment services.
According to CDC's estimates ,650,000 to 900,000 Americans are now living with HIV, and at least 40,000 new infections occur each year. Approximately 240,000-325,000 African Americans are living with HIV and of those infected 93,000 are living with AIDS. One in 50 African American men and 1 in 160 African American women are infected with HIV. In 1997, 45 percent of the AIDS cases diagnosed that year (AIDS incidence) were among African Americans, as compared to 33 percent among whites.
HIV/AIDS Among Children
African Americans account for close to three-fifths (58 percent) of the pediatric AIDS cases in the country. One of the greatest success stories in HIV prevention has been the reduction of perinatal transmission through the administration of zidovudine (ZDV or AZT) during pregnancy, labor, and delivery, and by giving the newborns AZT for the first 6 weeks after birth. During the period between 1992 and 1996, the number of children with perinatally acquired AIDS dropped by 43 percent. The decline in perinatally acquired AIDS was 42 percent among African American infants as compared to 50 percent among white infants. Despite the declines, the majority of perinatally acquired AIDS cases continue to occur among African Americans. In 1997, African American children accounted for 60 percent of the total number of children with perinatally acquired AIDS. The severe impact among African American children indicates the need for intensified efforts to prevent infection among African American women and to reach larger numbers of HIV+ pregnant women with early prenatal care and preventive treatment.
Substance Abuse and HIV/AIDS
The intersection of substance abuse and HIV in African American communities is a monumental public health problem. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), there are approximately 21 million alcohol and other drug abusers in the United States. The National Institute on Drug Abuse (NIDA) estimates that there are 1.5 million injecting drug users in the country, many of whom are multi-drug users. Approximately half of all new HIV infections are occurring among injection drug users in the United States. As of December 1997, the CDC reported that 26 percent of the AIDS cases are attributable to injection drug use, 6 percent are related to men having sex with men who inject drugs, and 4 percent are related to heterosexual contact with an injecting drug user. In 1997, African Americans accounted for 58 percent of the cumulative adolescent/adult AIDS cases attributed to injection drug use. African American men accounted for 52 percent of the new male AIDS cases attributed to injection drug use ,and African American women accounted for 60 percent of the new female AIDS cases among injecting drug users reported by year-end 1997.
In addition to the direct impact of injection drug use on the spread of HIV, many people infected heterosexually are infected through sex with an injection drug user or sex in exchange for drugs or money. Among heterosexuals treated in STD clinics for example, drug use and the exchange of sex for drugs or money are risk factors for persons who become infected with HIV. Prevalence studies among child-bearing women and patients in drug treatment centers show that the heterosexual spread of HIV in women closely parallels the spread of HIV among injection drug users. In addition, all of the prevalence studies in high-risk populations find the rates of HIV among African American populations to be dramatically higher than those among whites.
The devastation wreaked on African American communities by the "twin epidemics" of HIV and substance abuse demands a proactive and aggressive public policy response. HIV prevention among injection drug users and the expansion of substance abuse treatment are top priorities for NMAC's organizations and constituents.
Young Gay Men
AIDS incidence increased among all exposure groups through 1994, with incidence increasing most rapidly among heterosexuals. Despite decreases in aids incidence, high rates of HIV prevalence continue to be seen among young gay men. According to the CDC, a study of young men who have sex with men (ages 15-22) in 6 urban counties demonstrated that between 5 percent and 8 percent were infected with HIV. When compared to other groups, the rates of infection were highest among African Americans (13 percent), compared to whites (4 percent) and Hispanics (5 percent).
HIV & Sexually Transmitted Diseases (STDs)
The epidemic of other sexually transmitted diseases (STDs) which disproportionately impacts African Americans is also contributing to the spread of HIV. In a recent study, CDC researcher William Kassler, M.D., examined data from 1990-1997 to identify areas dually impacted by the STD and HIV epidemics. Kassler found that the impact of HIV, syphilis and gonorrhea is highest in the Southern region of the U.S. A national review found that only 50 percent of local health departments provide any STD treatment services and many lack evening or weekend services. An estimated 90 percent of clinics in areas with high rates of STDs turn clients away due to limited resources. The lack of STD treatment services in highly impacted areas is contributing to the spread of HIV. We know that other STDs such as gonorrhea, syphilis, and chlamydia make people 2-5 times as likely to spread and acquire HIV. The rates of these treatable and curable sexually transmitted diseases are skyrocketing among African Americans and contributing to the further spread of HIV/AIDS.
Federal HIV/AIDS Funding
The national investment in HIV prevention, research, treatment, care and housing has improved the health and quality of life of countless persons affected by or living with HIV/AIDS. While African Americans benefit from this federal investment through the various services they receive from the funded HIV/AIDS programs, African Americans still experience glaring disparities in health outcomes when compared with the outcomes for whites.
During a May 11, 1998, press conference following the Congressional Black Caucus's Declaration of a State of Emergency within the African American Community, Dr. Bony Primm, Vice President of the Board of Directors of the National Minority AIDS Council and Executive Director of Addiction Research and Treatment Corporation, Inc., stated, "One only has to look at the statistics ... to know this money ought to be following the epidemic. It has not."
HIV Prevention Funding
To curb the spread of HIV infection among African Americans, HIV prevention must be a top priority. Targeted, culturally- and linguistically-appropriate prevention interventions are sorely needed. To make an impact, these interventions must be ongoing and sustained and consider the social, spiritual, and economic contexts in which the diverse populations of African Americans live.
However, an analysis of prevention resource allocation demonstrates that the needed level of HIV prevention resources are not being targeted to meet the needs of the populations most affected by the AIDS epidemic. Based on a CDC analysis that compared the  allocations made by race/ethnicity and transmission risk, the CDC concluded that prevention allocations are not yet mirroring the epidemic. In the area of health education and risk reduction for example, while African Americans represented 43 percent of the new AIDS cases in 1996, only 31 percent of the total dollars in this category were targeted to serve African Americans.
The CDC concluded that from a national perspective, the level of program support currently directed to racial and ethnic minority communities, injecting drug users (IDUs), men who have sex with men (MSM), and HIV infected individuals is substantially less than the current epidemiological trends indicate is necessary.
Treatment and Treatment Education
Despite the heavy federal investment in HIV care and support services African Americans are not experiencing significant improvements in health outcomes. While African Americans comprise a significant proportion of the clients served under Title I [of the Ryan White CARE Act], their proportions are lower in the Title II programs and the ADAP program than the proportion of African Americans with AIDS in the United States. The reason for the lower proportion of African American clients served in both the statewide programs and the ADAP program which provides drug assistance needs to be further examined. The reports from the Title I and II and ADAP programs do not provide any information on health outcomes for African Americans, leaving the unanswered question of whether or not African Americans are receiving quality care as a result of this funding.
NMAC's Recommendations1. That President Clinton declare a "State of Emergency" in HIV and AIDS among African Americans.
That he direct all agencies of the federal government, responsible for disease prevention and health care, as well as substance abuse prevention and treatment, to garner their collective expertise and resources to address this crisis now and that they be held accountable for closing the health outcomes disparities. That the Secretary of Health and Human Services provide a report on how the agencies (including but not limited to NIH, HRSA, HCFA, CDC, SAMHSA) of the department responsible for HIV/AIDS related prevention, health care and research plan to close the gap by the year 2000. The plan should delineate the specific goals and objectives, time frames for implementation and completion, and the funding allocated to meet the objectives.
2. Federal funds must be directed to follow the epidemiological trends and the HIV epidemic and absent comprehensive HIV case data, trends in surrogate markers such as rates of substance abuse, tuberculosis, teen pregnancy and other sexually transmitted diseases. New resources must be allocated to address emerging needs and to close the gaps in services identified within the African American community.
3. The Federal government should fund a large scale, culturally appropriate, public information and education campaign targeted to African Americans, to educate people about the benefits of knowing their HIV status; to promote HIV counseling, and voluntary HIV testing, and to promote voluntary partner counseling, notification and referral services. The overall goals of this campaign are to reduce further transmission of HIV/AIDS and to promote early intervention and treatment for those who have already contracted the virus.
4. The federal government should fund a large scale public information and educational campaign to dispel the shame and stigma associated with HIV/AIDS and promote the understanding that HIV/AIDS is a treatable and manageable chronic disease.
5. The federal government should develop a comprehensive plan and allocate the necessary funds to ensure that every person in this country with HIV/AIDS has access to the state of the art HIV care, treatment with effective combination drug therapies and treatment for opportunistic infections. We can no longer stand watching only a select few benefit from the enormous national investment in HIV/AIDS research, prevention, treatment and care.
6. President Clinton should direct the Office of the National Drug Control Policy and the National AIDS Policy Office to work with the Secretary of HHS and the Directors of the CDC, SAMHSA and NIDA to develop and implement a coordinated strategy to reduce the devastation of drug addiction and HIV/AIDS on African Americans. The plan should include an increase in resources fort the expansion of culturally appropriate and gender-specific drug prevention and treatment programs, and the integration of HIV prevention and primary HIV health care into drug prevention and treatment services.
7. The CDC should develop and implement an immediate plan to address the long-standing disparities in the allocation of HIV prevention resources. The Secretary of HHS should hold the CDC accountable for the expenditure of HIV prevention community planning resources and make every effort to ensure that States are targeting the resources towards those populations at highest risk and with greatest need for prevention services.
8. The CDC should provide specific guidance to States to direct funding through the Community Planning Cooperative Agreement to programs that focus on closing the ethnic/racial disparities in HIV/AIDS incidence and prevalence among African Americans.
9. The CDC should immediately establish and provide for demonstration funding to examine and test alternatives to HIV prevention community planning, as well as other program models that will address and meet the HIV prevention needs of the African American community.
10. The CDC should undertake a specific and extensive external research program to identify the factors that cause and propagate HIV infections among the diverse populations of African Americans impacted by HIV/AIDS. Specific behavioral research is needed to inform the development of interventions for women, youth, gay men, bisexual men, and heterosexual men and substance users, including but not limited to injection drug users. This research should be conducted by and for African Americans.
11. The CDC should provide funding for a national initiative focused on sustained HIV prevention interventions targeted to African Americans that address the factors which place women at higher risk of HIV infection including substance abuse, poverty, domestic violence and sexual abuse, and low self-esteem. This initiative should be direct funding to African American owned and operated community based organizations with a commitment and history of providing services to women and families. The initiative should be based on existing behavioral science knowledge of HIV/AIDS risk factors and effective intervention strategies that work for African American women. Funds should be targeted to organizations with high HIV incidence among African American women and areas such as the South where HIV/AID and STDs among women, particularly young women, is increasing rapidly.
12. The CDC should provide funding for a national initiative to reduce HIV infection among gay African American men, which incorporates the elements of HIV/AIDS risk reduction that have proven effective among gay African American men. This initiative should be direct funding to African American organizations with a history of service to gay men and emerging organizations that are serving gay men of African descent.
13. The CDC should give priority to African American community based organizations (CBOs) for funding for HIV prevention services targeted to highly impacted and emerging African American populations.
14. The CDC should continue to support and increase the funding to strengthen prevention capacity in African American communities, though the CDC's Directly Funded Minority and Other CBOs Programs, and the National/Regional Minority Organizations Program. There should also be an infusion of funding for the Communities of Color Initiative with sufficient funds as may be necessary to carry out the African American Prevention Initiative.
15. HRSA should increase funding to develop and/or expand initiatives at a) training African American and other minority health professionals on the state of the art HIV diagnosis, treatment and care, and b) the development and implementation of a plan to increase the number of African American and other minority health professionals who specialize in HIV/AIDS and primary care in medically underserved urban and rural minority communities, and in the migrant and community health centers.
16. HRSA should provide direct funding to African American community based organizations for comprehensive outreach and treatment education programs targeted to African Americans. The overall goal is to increase HIV/AIDS treatment knowledge and the benefits of knowing one's HIV status early, to support individual decision-making on treatment options and support treatment adherence for persons on antiretroviral therapies.
17. HRSA should develop specific outcome measures to evaluate Ryan White CARE Act funded programs to ensure that clients receive access to quality, state of the art clinical care and that the disparities in health outcomes in HIV/AIDS morbidity and mortality are significantly reduced.
18. HRSA should provided direct funding to African American community based organizations to conduct education and outreach programs to increase the enrollment of eligible African Americans in the AIDS Drug Assistance Program (ADAP), with a focus on the areas of the country where African Americans are underrepresented in the ADAP program.
19. SAMHSA should provide direct funding for African American community based programs to provide intensive outreach, education and HIV counseling and voluntary testing, and direct linkage to care for African American injecting drug users.
20. SAMHSA should provide funding to increase the availability of drug treatment slots for African Americans in high incidence areas where substance abuse treatment is in high demand and low supply. Funding should also be expanded to support programs that provide comprehensive, culturally competent woman focused substance abuse treatment (for women and their children), and that integrate HIV prevention and primary HIV health care into drug prevention and treatment services.
This article was provided by Body Positive. It is a part of the publication Body Positive.