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Black America: A Neglected Dimension of the Global AIDS Epidemic

August 2008

The nearly exclusive concentration of prevention efforts in the U.S. on "risk groups" is an important reason why a broad-based community-wide mobilization has yet to occur in Black America.
In 2000, the global community committed through the Millennium Development Goals to halt and begin to reverse the global AIDS epidemic by 2015. With the rate of new HIV infections in the U.S. roughly 50% higher than previously believed58 -- and with Black Americans experiencing a risk of infection several times higher than other groups -- it is clear that progress in reducing the epidemic's toll in Black America will advance achievement of the worldwide Millennium Development Goals. A new approach to the AIDS emergency in Black America -- one that recognizes the links between the U.S. AIDS response and efforts to address the global epidemic -- is urgently needed.

In reality, what we refer to as the "global epidemic" is a collection of a nearly infinite number of individual epidemics in specific countries, districts, communities and populations. Each of these epidemics is unique. However, there are important parallels between the epidemic in Black America and the AIDS challenge in many other parts of the world. Lessons learned in fighting AIDS in Black America can help inform AIDS strategies in low- and middle-income countries, and disease control efforts in the U.S. could similarly benefit from insights gained in other countries.


A Generalized Epidemic in Black America

AIDS policy in the U.S. continues to rely on a paradigm that has limited relevance to the AIDS challenge in Black America. Specifically, the U.S. relies on an approach that is recommended for less-severe epidemics, while in fact AIDS in Black America belongs to the most serious class of AIDS epidemics.

UNAIDS categorizes national epidemics according to overall HIV prevalence and to the vulnerability of specific populations. There are three primary types of epidemic:

  • In low-level epidemics, HIV prevalence remains low both in the general population and in the groups that are most vulnerable to HIV (e.g., men who have sex with men, injection drug users, and sex workers).

  • In concentrated epidemics, low overall prevalence occurs alongside elevated HIV infection levels (i.e., 5% or higher) in vulnerable groups.

  • Epidemics are said to be generalized when adult HIV prevalence exceeds 1% and when one or more populations has HIV infection levels of 5% or greater. Generalized epidemics are typified by substantial heterosexual transmission and significant numbers of HIV-infected children.


The Risk Paradox

The epidemic among Africans and Black Americans shares many traits, and among them is the disconnect between risk behavior and likelihood of contracting HIV and other STIs. Both populations have high levels of HIV infection despite relatively low levels of risky sexual behavior. One reason for this disconnect is that both populations report relatively high numbers of concurrent partnerships within dense, overlapping sexual networks.

In Sub-Saharan Africa ...

  • Young people have HIV prevalence several times higher than their peers in any other part of the world, but do not appear more likely to initiate sex at an early age or to have more sexual partners;

  • The primary HIV risk factor for many African women is not their own personal behavior but rather the sexual behavior of their husbands or male sex partners.

In Black America ...

  • Young Blacks with low levels of risk behavior are 25 times more likely to be infected with HIV than young whites with similar behavior;

  • Black "men who have sex with men" are as much as nine times more likely to be HIV-positive but are significantly less likely to use drugs or have unprotected anal intercourse.


While the U.S. as a whole fits the definition of a concentrated epidemic, the epidemic in Black America is generalized. HIV prevalence for Blacks exceeds 2%, and specific vulnerable groups (e.g., gay and bisexual men and drug users) have extraordinarily high levels of infection (as the subsequent discussion reveals).

Like other generalized epidemics, AIDS in Black America involves significant transmission among heterosexuals, in addition to the heavy concentration of infections in vulnerable groups. In 2006, heterosexual intercourse was the source of 75% of prevalent HIV infections in Black women and accounted for 22% of infections in Black males.59 In Alabama, where Blacks account for almost 70% of new HIV and AIDS diagnoses, the share of cases stemming from heterosexual exposure now approaches the percentage of infections in men who have sex with men.60 In Washington, D.C., where 1 in 20 residents are HIV-infected, heterosexual contact is now the leading transmission mode for new HIV diagnoses.61 In Newark, women account for 40% of all people living with HIV/AIDS.62

Although widespread implementation of services to prevent mother-to-child transmission has dramatically reduced HIV incidence among newborns, roughly 8,500 children who contracted HIV from their mothers have been diagnosed with full-blown AIDS in the U.S. In 2005, Blacks accounted for 65% of HIV-infected newborns.63

While low-level and concentrated epidemics are primarily centered in urban areas, generalized epidemics tend to involve substantial transmission in rural areas, as well. In Africa, many rural communities are being devastated by HIV.64 Likewise, in Black America, significant numbers of HIV infections have been documented in rural, as well as urban, areas. In particular, HIV prevalence in the Mississippi Delta approaches levels seen in urban areas in the U.S., with particularly high prevalence observed among young Blacks between ages 13-24.65 Such patterns are similar to those seen in rural districts around Lake Victoria in Kenya, where HIV prevalence is much higher than in Nairobi and other urban centers.66

In both Africans and U.S. Blacks, studies have demonstrated that sexual networks in rural areas can often involve extensive overlapping partnerships, rendering them highly conducive to the spread of HIV among lower-risk groups. In a study in Likoma Island, Malawi, for example, researchers found that more than one quarter of young adults were linked through multiple independent chains of sexual relationships.67 Similarly, studies in the rural Southern U.S. have identified the presence of dense social networks among Black heterosexuals that facilitate the rapid spread of HIV and other sexually transmitted infections.68

The generalized nature of AIDS in Black America has an important impact on the type of HIV prevention approach needed. In low-level and concentrated epidemics, UNAIDS recommends that HIV prevention efforts overwhelmingly emphasize services for populations most at risk, with only limited focus on the general population. This approach recognizes that countries with low-level or concentrated epidemics can protect vulnerable groups and prevent HIV from spreading into new populations by focusing on where significant HIV risk exists. By contrast, countries in which HIV has spread to the general population must couple intensive prevention services for vulnerable groups with broader-based prevention efforts in schools, the mass media, workplaces and other community settings. In short, generalized epidemics require more generalized responses in order to curb the spread of infection.69

Gearing its AIDS strategies to the concentrated nature of the national epidemic, the U.S. has pursued a strategy that is overwhelmingly focused on the delivery of targeted HIV prevention services for high-risk groups. Comparatively little priority has been given to efforts to alter sexual norms in the broader heterosexual population. However, in settings where HIV is generalized, controlling the epidemic requires energetic pursuit both of efforts targeting groups most at risk and measures affecting the general population.

Much has been learned in the course of the epidemic about optimal strategies for mobilizing communities to respond to HIV/AIDS.70 However, by divorcing the domestic AIDS response from learning derived from experience in heavily affected low- and middle-income countries, America's policy-makers may be inhibiting the development of a diverse, multi-faceted community mobilization in Black America to address the AIDS threat. Blinded to potential international precedents, policy-makers in the U.S. almost instinctively look to previous experience in urban gay communities in the 1980s when thinking about community mobilization to fight AIDS, even though this unique history of gay AIDS activism has only limited relevance to the challenge confronting Black America. As in all other epidemics, intensive prevention services focused on especially vulnerable populations are essential components of an effective AIDS response in Black America, but these efforts must be supported by broader, population-wide initiatives, such as those used to such powerful effect in Uganda, where widespread changes in sexual behavior resulted in major declines in HIV prevalence and incidence.71


A Shared Paradox: Low Risk Behaviors and High HIV Risk

Controlled trials have validated the efficacy of dozens of program models to change sexual and drug-using behavior, yet comparatively few HIV prevention interventions have been specifically designed for Black Americans.72 The large majority of model behavioral interventions focused on Blacks are individual or small-group programs grounded in one or more cognitive behavioral theories.73 Yet the marginal changes in behavior for which such programs aim have somewhat limited potential in circumstances where the makeup and functioning of social groups, rather than individual behavior, are the principal factors driving the epidemic.

Both Africans and Black Americans experience extremely high rates of HIV infection even though most do not engage in high levels of sexual risk behavior. For example, although young people sub-Saharan Africa have HIV prevalence several times higher than among young people in any other part of the world, they do not appear on average more likely to initiate sex at an early age or to have more sexual partners.74 Similarly, numerous studies have found that the primary HIV risk factor for many African women is not their own personal behavior but rather the sexual behavior of their husbands or male sex partners.75

A similar paradox of high HIV risk in the context of low risk behaviors is apparent among Black Americans. In a seven-city survey of young men who have sex with men, Blacks were nine times more likely than whites to be HIV-infected even though they did not engage in higher rates of sexual behavior or drug use.76 In comparison to whites with similar behavioral characteristics, young Blacks with low levels of risk behavior are 25 times more likely to be infected with HIV.77

A growing body of data suggests that concurrent partnerships within dense sexual networks play a key role in the exceptionally high levels of HIV infection in southern Africa.78 A similar phenomenon is apparent in Black America.79 Data from a national survey indicate that Blacks are more than 2.5 times more likely than the U.S. population as a whole to have had concurrent sexual partnerships in the previous year.80

Black America and sub-Saharan Africa share a common factor driving high rates of concurrent partnerships -- the frequent absence of men from local communities. While in sub-Saharan Africa a typical cause of male absenteeism is migration for work, frequent incarceration is the principal cause for the absence of males in many Black communities in the U.S.81 For example, in Washington, D.C., where an estimated three-quarters of Black males will be imprisoned at some point in their lives, there are only 60 males for every 100 females in some of the neighborhoods with the highest incarceration rates.82 In the rural South, high incarceration rates are strongly correlated with the rapid spread of HIV infection within social networks.83

Programs to change individual behavior will remain a cornerstone of HIV prevention -- both in Black America and in southern Africa. However, there is an urgent need to develop prevention strategies to change social norms to disfavor concurrency and to encourage safer behaviors in communities with high rates of male absenteeism. Greater investments in strategies to affect sexual networks in Black America could yield worldwide benefits.


Women, Gender Norms and HIV Vulnerability

Globally and in Black America, a disease that was once primarily one of men has involved steadily increasing numbers of women and girls. Worldwide, women account for half of all people living with HIV and for more than 60% of infections in sub-Saharan Africa.84 While infection levels among women are lower in the U.S. than in Africa, the HIV/AIDS burden among American women has also substantially grown over the years, with especially severe effects in Black America. While women accounted for only 13% of AIDS diagnoses in 1991,85 women made up 27% of new AIDS diagnoses in the U.S. in 2006.86 In the 33 states with mature HIV reporting systems, Black women represented 65% of new HIV/AIDS diagnoses among women in 2006.87 In the U.S., Black women are 23 times more likely to be diagnosed with AIDS than white women.88

Male dominance, reinforced by societal gender norms, reduces women's ability to protect themselves from infection. According to a recent study in Botswana, individuals with discriminatory gender beliefs (such as the belief that extra-marital sex is less permissible for women than for men) are nearly three times more likely than those without such beliefs to have unprotected sex with a non-marital partner in the previous year.89 In the U.S., computer-assisted interviews with 713 Black women between ages 15-21 found that many young women at high risk of infection experience male-dominated power imbalances that make it difficult for them to negotiate condom use.90

Anywhere from a third to one-half of Black women report having been sexually abused, with higher levels reported for HIV-positive women.91 Likewise, according to surveys in Bangladesh, Ethiopia, Peru, Samoa, Thailand and the United Republic of Tanzania, 40% to 60% of women said they had been physically and/or sexually abused by their intimate partners.92 Studies in various African countries suggest that the risk of HIV infection is up to three times higher among women who have experienced gender-based violence compared to those who have not.93

The role of gender dynamics in elevating women's risk of infection has highlighted the need to improve prevention strategies aimed at altering male sexual behavior.94 Yet few evaluated prevention strategies have specifically aimed to change the sexual behavior of heterosexual men.

Similarly, the evidence base on strategies to generate healthier gender norms remains limited.95 Studies on interventions to empower Black women and to alter male attitudes and behaviors could not only benefit the response to AIDS in the U.S., but also inform more effective approaches in developing countries.

The enduring effects of women's disempowerment also underscore the need for prevention methods that women can initiate on their own, such as vaginal microbicides, pre-exposure chemoprophylaxis, or women-controlled barrier methods. Such prevention tools are needed to address women's limited capacity to insist on abstinence, monogamy or condom use by their male partners. Here, too, additional research is warranted both in the U.S. and in other regions.


Surrendering at Home

Over the last five years, the White House and Congress have increased spending on HIV prevention, treatment and support programs for low-income countries dramatically -- at the same time that domestic spending has remained all but flat. Domestic spending remains by far the largest share of the U.S. AIDS budget, but primarily in the form of mandatory expenditures on Medicaid, Medicare and Social Security, which account for roughly half of overall U.S. HIV/AIDS spending. Congress must pay a fixed share of the expenses for these programs, regardless of how high the cost grows. The graph below compares global spending with discretionary domestic spending, or the budget Congress and the White House decide upon each year for all prevention programs and treatment and support programs for the uninsured.


Year-to-Year Change in U.S. HIV/AIDS Spending, Fiscal Years 2004 to 2008
YearGlobal Change*Domestic Discretionary Change**
2005+21%+0%
2006+22%-0.4%
2007+46%+2.5%
2008+34%+1.2%

* Does not include international research
** Does not include mandatory spending such as Medicaid, Medicare and Social Security

Source: Kaiser Family Foundation. U.S. Federal Funding for HIV/AIDS fact sheets for fiscal years 2004-2008.




Gender Bias Kills

Both globally and among Black women, male dominance, reinforced by societal gender norms, reduces women's ability to protect themselves from infection. Yet, the evidence base on strategies to generate healthier gender norms remains limited. Studies on interventions to empower Black women and to alter male attitudes and behaviors could not only benefit the response to AIDS in the U.S., but also inform more effective approaches in developing countries.

  • In Botswana, a recent study found individuals with discriminatory gender beliefs (e.g., extra-marital sex is less permissible for women than for men) are nearly three times more likely to have unprotected sex with a non-marital partner;

  • In the U.S., a study found Black women between ages 15-21 who are at high risk of infection experience male-dominated power imbalances that make it difficult for them to negotiate condom use;

  • Anywhere from a third to a half of Black women report having been sexually abused, with higher levels reported for HIV-positive women;

  • Studies in various African countries have found the risk of HIV infection to be as much as three times higher among women who have experienced gender-based violence compared to those who have not.


Preventing HIV Among Young People

The centrality of young people to the epidemic's future reveals yet another challenge that Black America shares with other parts of the world. By investing in research to improve strategies to prevent HIV transmission among adolescent and young adults in Black America, the U.S. could also strengthen a critical component of the global AIDS response.

Globally, people under age 25 are believed to account for 45% of new infections.96 In the U.S., roughly 5,000 young people (aged 13-24) are diagnosed each year,97 although due to low HIV testing rates in young people it is believed that these diagnosis figures significantly understate the extent of actual new HIV infections. Infections among young Americans are heavily concentrated in Black communities. In 2004, Blacks made up 70% of new HIV diagnoses among teenagers.98 Between 2001 and 2006, the number of HIV/AIDS diagnoses among young Black men who have sex with men (ages 13-24) nearly doubled.99

Black teenagers are more likely than white or Hispanic adolescents to have ever had sexual intercourse and to have had four or more sexual partners. However, in 2005, Black teenagers were significantly more likely than other groups to have used a condom during their last episode of sexual intercourse and less likely to have had sex while intoxicated.100

HIV prevention efforts focused on young people share key challenges in Black America and in other parts of the world. For example, young American Blacks, like many young people globally, often have dangerous misconceptions about HIV, worsening AIDS stigma and potentially discouraging young people from taking necessary precautions to prevent transmission. Globally, only 40% of young males (ages 15-24) and 36% of young females had accurate, comprehensive knowledge regarding HIV -- significantly below the 95% global target for 2010.101

Studies have long documented poor knowledge and inaccurate beliefs among Black adolescents,102 although the above-average condom use documented among Black teenagers suggests that certain information deficits detected earlier in the epidemic may have improved, at least among Black teens who are sexually active. Recent surveys in the U.S. find that Blacks and people with lower educational levels are more likely than other Americans to harbor erroneous beliefs about how HIV is transmitted.103 In a recent survey of residents of public housing projects in heavily Black central Harlem in New York City, one-third of individuals surveyed believed mosquitoes could transmit HIV.104 Clearly, improved strategies are urgently needed -- both in Black America and globally -- to equip young people with life-saving knowledge about ways to avoid HIV exposure.

Both globally and among young Black Americans, a high prevalence of inter-generational relationships increases the risk that young people will acquire HIV infection. Surveys of Black teenagers indicate that many young Black girls enter into relationships with older men, frequently obtaining gifts or other financial support.105 Likewise, U.S. studies involving young gay and bisexual men (aged 23-29) have found that higher infection risk among Blacks is associated with having older partners than white peers.106

A similar phenomenon has been observed in sub-Saharan Africa, leading to particularly detrimental effects on girls and young women. Three out of four unmarried, sexually experienced adolescent girls in Uganda say they have received gifts or money in exchange for sex, usually from an older man.107 Adolescent girls in Africa are two to four and a half times more likely than adolescent boys to be infected with HIV,108 in large part as a result of the tendency of girls in the region to have sex with older men.109

Few prevention initiatives have specifically sought to change social norms on inter-generational sex, and little evidence is available on successful strategies in this regard.110 As in many other areas, research on prevention strategies to benefit Black youth would have potential relevance in other countries, as well.


Heightened Risk Among Men Who Have Sex With Men

In all regions, "men who have sex with men" -- the public health term for homosexual and bisexual men -- experience high rates of HIV infection. Much more so than white men in the U.S., Black gay and bisexual men share many behavioral and cultural characteristics with their peers in other regions, underscoring the potential worldwide benefits of enhanced research and programmatic investments in Black MSM communities.

An estimated one in three men who have sex with men in Latin America is living with HIV,111 and a recent survey indicates that 28% of such men in Bangkok are also HIV-infected.112 Emerging evidence also finds that men who have sex with men are at especially high risk in sub-Saharan Africa, with HIV prevalence as high as 43% documented among homosexually active men in Mombasa, Kenya.113

In the U.S., gay and bisexual men represent the largest single share of HIV/AIDS diagnoses by exposure group, and Blacks are at significantly greater risk of infection than other racial or ethnic groups. A five-city study of urban gay and bisexual men in the U.S. found that 46% of Black men were infected -- a rate more than twice as high as reported for whites (21%), and significantly higher than infection levels in Asia, Africa, Eastern Europe and Latin America.114 In New York City's predominantly Black and Latino house ball community, Blacks were recently found to have HIV prevalence (26%) 10 times higher than among Latinos.115

Many gay and bisexual Black men in the U.S. exhibit attitudes and behavioral patterns that are consistent with international studies involving their peers in other regions. In a survey of HIV-infected gay and bisexual men, 34% of Black men reported also having sex with women, compared to 13% of white men.116 In New York City, the population rate of Black men who report having sex with both men and women is four times higher than among whites.117 These patterns are similar to those reported in other regions; in Asia, for example, surveys indicate that one in five men who have sex with men also have sex with women.118

Homosexually active Black men are markedly less likely to self-identify as "gay" than their peers from other racial or ethnic groups in the U.S.119 The fluidity of sexual identification among homosexually active men is also common in many low- and middle-income countries, where development of gay community consciousness is often in a nascent stage.120 Studies in the U.S. suggest that homosexually active men who do not identify as gay engage in behavior patterns that tend to differ from gay-identified men. Younger men who identify as gay tend to initiate sex at an earlier age and have a higher number of sex partners than non-gay-identified, young MSM.121 A recent study among more than 4,000 MSM in New York City found that non-gay-identified MSM, who disproportionately tend to be men of color, have fewer sex partners than their gay-identified counterparts but are less likely to use condoms or be tested for HIV.122

The stigma associated with same-sex attraction impedes effective HIV prevention and treatment efforts for men who have sex with men both globally and among Blacks in the U.S. Qualitative studies in the U.S. consistently find that Black gay and bisexual men perceive significant stigma in their families, communities and churches, reducing their willingness to disclose their attraction to men or to seek social or spiritual support.123 Social pressure to conform to heterosexual norms may also cause homosexually active men to seek female sexual partners, increasing the physical and emotional risks to women.

Likewise, recent reports underscore how stigma and discrimination impede effective HIV prevention efforts among men who have sex with men in many developing countries. For example, officially sanctioned discrimination against men who have sex with men, including a public campaign launched by the country's president, is reported to have driven many homosexual and bisexual men into hiding in Senegal, where they are more difficult to reach with HIV prevention services.124 Anti-gay violence is commonplace in Jamaica, where the murder of the country's leading gay rights activist in 2004 was celebrated by demonstrators who chanted homophobic lyrics from popular songs.125 It was also reported this year that Uganda had omitted men who have sex with men from its national HIV prevention efforts, even though other vulnerable groups are targeted and the chair of the National AIDS Commission had acknowledged that "gays are one of the drivers of HIV in Uganda."126

Prevention strategies that are effective in the face of stigma and social isolation are urgently needed for men who have sex with men in all regions, regardless of whether they identify as gay or bisexual. HIV prevention efforts focusing on Black homosexual and bisexual men should help inform, and benefit from, targeted HIV prevention strategies in other parts of the world.


Preventing HIV Infection Among Transgender Populations

Transgender individuals face exceptionally high risk of HIV infection -- both in Black America and globally. In numerous Asian countries, for example, studies have found extremely high infection rates among transgender sex workers.127

In the U.S., seroprevalence data from anonymous testing sites in San Francisco have documented HIV prevalence as high as 63% among Black transgender individuals.128 A separate recent study in San Francisco found HIV prevalence among Black male-to-female transgenders of 42% -- a level of infection nearly twice as high as reported among Latina transgenders and more than three times higher than among Asian/Pacific Islanders.129 A recent meta-analysis found average HIV seroprevalence among male-to-female transgenders of 27% in the U.S., with Black transgender individuals having a risk of infection twice as high as other groups.130

In all regions, stigma and discrimination impede effective HIV prevention for the transgender population. Among more than 300 male-to-female transgender individuals surveyed in San Francisco, 32% reported experiencing daily ridicule, 37% had been victimized by violence, and 61% had been harassed by police.131

While the HIV prevention discourse has at times addressed issues relating to transgender individuals as a subset of homosexual and bisexual issues, transgender individuals face specific challenges and frequently have unique community networks that should be taken into account in carefully focused prevention efforts. Additional research and programmatic investments are needed for prevention programs focusing on transgender communities.


Drug Use and HIV Transmission

Injection drug use plays a key role in the continued expansion of the AIDS epidemic -- both in Black America and in other regions. Persons exposed to HIV through injection drug use represent the third largest group of prevalent HIV/AIDS diagnoses in the U.S. Blacks account for more than half (53%) of HIV/AIDS diagnoses among injection drug users in 2006 in the 33 states with mature HIV reporting systems. In these 33 states, more than 50,000 Blacks exposed to HIV through injection drug use were living with HIV in 2006.132

Injection drug use is the driving force in AIDS epidemics in Eastern Europe, as well as in parts of Asia and Latin America. Nearly two-thirds of HIV infections in Eastern Europe and Central Asia -- and nearly half of infections in China -- stem from injection drug use.133

Both in the U.S. and in other regions where injection drug use is a major source of HIV infection, official hostility toward evidence-based HIV prevention strategies represents a primary obstacle to sustained progress on HIV/AIDS. For two decades, the U.S. government has prohibited the use of federal funds for needle and syringe exchange projects, while effective drug substitution therapies are barred in Russia and other countries with high rates of drug use. Community opposition to harm reduction programs and harassment of drug users by law enforcement personnel are common barriers to effective HIV prevention efforts in many countries.

In the case of injection drug use, Black America has potentially useful lessons for other regions grappling with the role of drug use in national AIDS epidemics. As state and local governments and private funders have begun to fill the funding gap created by the federal ban on support for needle exchange, harm reduction programs have expanded throughout the U.S. As harm reduction coverage has improved, HIV infection rates stemming from injection drug use have sharply declined. In New York City, new infections among injection drug users fell by nearly 80% between 1990 and 2002.134 In diverse settings across the U.S., prevention programs have developed effective strategies to alleviate community opposition to harm reduction and have partnered with law enforcement agencies to avert police practices that might discourage drug users from accessing harm reduction programs. Disproportionately represented among HIV-infected injection drug users, Blacks in the U.S. have been principal beneficiaries of these HIV prevention successes.

In countries where antiretrovirals have only recently become available, health care providers often have limited expertise in engaging HIV-infected drug users in care, ensuring continuity of care, and promoting treatment adherence. Citing widespread hostility of health care providers and other factors, civil society groups report that injection drug users in many countries do not have equal access to antiretroviral therapy.135 Experience in the U.S. can potentially aid other countries in devising effective training and sensitization strategies to reduce stigmatizing attitudes among health care providers. Likewise, U.S. practice is potentially instructive in developing strategies to promote health care access and treatment adherence among drug users.


HIV and Prisons

HIV prevalence among inmates in federal, state and local prisons and jails is three times higher than the national average.136 Between 20-26% of Americans living with HIV/AIDS are believed to be incarcerated at some point each year.137

Just as Blacks are more likely than other racial and ethnic groups to be imprisoned in the U.S., they are also more heavily affected by HIV in correctional settings. In New York State correctional facilities, for example, HIV prevalence is six times higher among Black inmates than among their white counterparts.138

The disparity in infection rates between the correctional and non-correctional population in the U.S. is consistent with international patterns. In virtually all countries studied, HIV prevalence is markedly higher in prison populations than in the non-incarcerated general population.139

At least in the U.S., it is believed that the vast majority of HIV-positive prisoners contract HIV before they become incarcerated.140 This stems from the fact that some of the very factors that place individuals at risk of HIV infection -- i.e., illicit drug use and sex between men -- also place people at higher risk of imprisonment. However, it is also clear -- both in the U.S. and in other countries -- that many prisoners engage in behaviors during their incarceration that can result in HIV transmission, including sexual behavior, drug use, and tattooing. As in the rest of the world,141 U.S. prisons lag in the provision of life-saving HIV prevention services to inmates. Only two prisons and five jail systems in the U.S., collectively covering less than 1% of prisoners, currently make condoms available to inmates.142 Although prisons in at least eight countries have begun introducing needle and syringe exchange services,143 no correctional facility in the U.S. offers such prevention services to inmates.144

Even though correctional systems in the U.S. are constitutionally obligated to provide medically necessary care to incarcerated individuals, 38% of correctional care providers recently surveyed said no HIV specialist was available to see patients in the facilities where they work.145 HIV-related death rates (per 100,000 prison inmates) were 3.5 times higher among Black inmates than among their white counterparts in 2006.146 Globally, few prison systems provide antiretroviral treatment for HIV-infected prisoners.147

Policy reforms that enhance HIV prevention and treatment services in prison settings are required to promote the health of HIV-infected inmates in Black America and globally. Research, advocacy and capacity-building initiatives should focus on improving HIV services for Black prison inmates, and information and lessons gleaned from such studies should be rapidly communicated globally.


Stuck on Needles

Injection drug use plays a key role in the continued expansion of the AIDS epidemic both in Black America and in many developing world countries. And both in the U.S. and abroad, official hostility toward evidence-based HIV prevention strategies represents a primary obstacle to sustained progress.

For two decades, the U.S. government has banned federal funding for syringe exchange projects, while effective drug substitution therapies are barred in Russia and other countries with high rates of drug use. Community opposition to harm reduction programs and harassment of drug users by law enforcement personnel are also common barriers.

But Black America has useful lessons for other regions grappling with this issue. As state and local governments and private funders have filled the resource gap created by the federal funding ban on needle exchange, harm reduction programs have expanded throughout the U.S. -- and infection rates stemming from injection drug use have sharply declined.


Promoting Knowledge of HIV Serostatus

People who are diagnosed late in the course of HIV infection have a much poorer prognosis than individuals whose HIV diagnosis is more timely. In New York City, individuals whose HIV and AIDS diagnoses occur within 31 days of one another are twice as likely to die within four months of diagnosis as people with a non-concurrent AIDS diagnosis.148 Early knowledge of HIV infection plays a key role in reducing HIV-related morbidity and mortality.

Both globally and in Black America, however, many HIV-infected individuals are diagnosed only in response to symptoms, usually several years after initial exposure to the virus. While testing rates have increased in low- and middle-income countries, most HIV-infected people worldwide are unaware of their infection.149

In the U.S., nearly four in 10 (38%) Blacks diagnosed with AIDS in 2006 had only learned of their positive HIV status in the previous 12 months.150 In New York City, more than 26% of Blacks diagnosed with HIV in 2006 received an AIDS diagnosis within one month.151 In Washington, D.C., late diagnosis among Blacks is even more apparent; in a city where 81% of new diagnoses are among Blacks, 69% of AIDS cases were diagnosed with HIV less than a year earlier.152

According to surveys in six U.S. cities, Black homosexual and bisexual men are eight times more likely than their white peers to be unaware of their infection.153 Among HIV-positive Black homosexual and bisexual men who participated in a CDC-sponsored multi-city study, 67% were previously unaware of their infection.154 In a recent study of participants (55% Black) in New York City's house ball community, 73% who tested HIV-positive had not known of their infection prior to the survey, with Blacks more likely than others to be infected.155

In both the U.S. and in low- and middle-income countries, the need to increase knowledge of HIV serostatus has prompted implementation of new policies and public health initiatives. In the U.S., for example, CDC's Advancing HIV Prevention initiative, which provides the strategic framework for current CDC-sponsored HIV prevention efforts, prioritizes testing promotion and effective linkage to care. Likewise, many developing countries, especially in southern Africa, are energetically promoting HIV testing through public awareness campaigns, door-to-door outreach, and other means.156 In the U.S., as in many other countries, increasing use is being made of rapid testing technologies, and public health agencies are aiming to make HIV testing a routine component of medical care. Additional efforts are merited both in Black America and in other countries to document "best practices" in the promotion of HIV testing.


Addressing HIV Stigma

Black America shares yet another paradox with sub-Saharan Africa. Extensive awareness and concern about AIDS is accompanied by sometimes-serious stigmatization of the disease, which impedes efforts to translate public concern into effective action.

Just as Blacks in the U.S. display the greatest concern about AIDS of any racial or ethnic group, sub-Saharan Africa exhibits the highest levels of concern about the global epidemic. According to surveys in 47 countries conducted by the Henry J. Kaiser Family Foundation and the Pew Global Attitudes Project, Africa is the only region where national publics consistently rank AIDS as the world's greatest threat.157

Yet stigmatizing attitudes about AIDS and people living with HIV inhibit effective national and community responses in both Black America and sub-Saharan Africa. Surveys in the U.S. have consistently found widespread AIDS stigma among Black Americans, with several studies indicating that stigmatizing attitudes are higher among Blacks than among other racial or ethnic groups.158 High levels of AIDS stigma have similarly been reported in Africa and other regions.159

Fear of contagion and prejudicial assumptions about people living with HIV are the primary sources of AIDS stigma.160 These roots of AIDS stigma can be addressed through various public awareness programs and policy responses, although such anti-stigma measures have often not been brought to scale, and many have not been rigorously evaluated.

Alleviating AIDS stigma is vital to progress in controlling HIV/AIDS. Where HIV/AIDS is highly stigmatized, individuals are discouraged from learning their HIV serostatus, disclosing their HIV infection to others, or from seeking HIV prevention or treatment services. AIDS stigma also reduces the willingness of leaders to prioritize the AIDS response.


The Role of STI Control in HIV Prevention

Although studies have consistently determined that sexually transmitted infections significantly increase the likelihood of HIV acquisition and transmission -- potentially by several orders of magnitude161 -- evidence has yet to demonstrate how best to use STI control to slow the spread of HIV in mature epidemics.162

In 2005, Black Americans were 18 times more likely than whites to be diagnosed with gonorrhea and five times more likely to have syphilis.163 In 2008, CDC reported that one in two Black adolescent girls had an STI -- a rate twice as high as for American teenagers as a whole.164 Black homosexual and bisexual men have higher prevalence of lifetime and current STIs than their white counterparts.165 As in the case of HIV infection, differences in individual behavior do not explain these wide disparities in STI prevalence.166

High prevalence of sexually transmitted infections has also been found in sub-Saharan Africa and other regions.167 In some parts of Africa, up to 70% of adults are infected with herpes simplex virus type 2, which significantly increases the likelihood of HIV transmission.168

Although it is clear that STI prevention has a role in averting new HIV infections, studies to date of the HIV prevention potential of STI control strategies have often been disappointing. Most recently, international trials found that community-based acyclovir treatment for HSV-2 did not reduce rates of new HIV infections.169

Additional study is urgently needed to identify optimal strategies to mobilize STI control for HIV prevention. Like others worldwide, Black America has a critical stake in such research.


Finding Out Too Late

While testing rates have increased in low- and middle-income countries, most HIV-infected people worldwide are still unaware of their infection. The same is true for Black America, where many HIV-infected individuals are diagnosed online in response to symptoms -- usually several years after initial exposure to the virus. These late diagnoses mean Black Americans share the global treatment challenge of initiating care at an advanced stage of infection.

Share of Blacks Diagnosed with AIDS within 12 Months of Testing Positive, 2006


4 in 10 (38%)

4 in 10 (38%)



Reducing Inequities in Medical Outcomes

Although many Blacks in the U.S. are benefiting from antiretroviral therapy, medical outcomes tend to be more favorable in HIV-positive whites than among Blacks living with HIV. An analysis of medical statistics from 140 counties across the U.S. found that Black-white differences in HIV-related mortality have actually widened since advent of combination antiretroviral therapy in the mid-1990s.170

In New York City, Blacks living with HIV/AIDS have an age-adjusted death rate that is nearly 2.5 times higher than among HIV-positive white people.171 HIV-positive people living in the largely Black, low-income Manhattan neighborhood of central Harlem were more than twice as likely to die in 2006 as HIV-infected residents of the affluent, predominantly white Chelsea neighborhood.172 While 86% of Hispanics in Washington, D.C. were alive 10 years after their AIDS diagnosis, only 59% of Blacks had survived.173

These patterns are similar to those seen globally. Although improved treatment access is extending the lives of millions of people worldwide in all regions,174 medical outcomes nevertheless remain poorer in low- and middle-income countries than in high-income countries such as the U.S. At both six and 12 months after initiation of antiretrovirals, survival is at least 28% lower in resource-limited settings than in high-income countries.175

Several factors contribute to less favorable treatment outcomes in resource-limited settings, including initiation of antiretrovirals later in the course of infection in low-income countries, greater frequency of co-occurring medical conditions (such as tuberculosis, hepatitis or malnutrition) in such settings, and sub-optimal adherence with medication regimens.176 These same factors are also the ones that can inhibit effective treatment among Blacks in the U.S.


Trying to Survive

HIV positive people in both Black America and in low-income countries are having a harder time beating back the virus, even once in therapy. Several factors contribute to less favorable treatment outcomes in both settings, including later initiation of antiretrovirals and greater frequency of unrelated but complicating medical problems, such as tuberculosis, malnutrition and heart disease. m In the U.S., an analysis of medical statistics from 140 counties found that Black-white differences in HIV-related mortality have actually widened since the advent of combination antiretroviral therapy in the mid-1990s; m Globally, studies have found that survival is at least 28% lower in resource-limited settings than in high-income countries, when measured at both six and 12 month periods after starting antiretrovirals.


Late Initiation of Treatment

In addition to the large percentage of Blacks who are diagnosed late in the course of infection, many Blacks who test HIV-positive are not effectively linked to care, potentially delaying the timely initiation of therapy. For example, Blacks in New York City are nearly 60% less likely to have entered HIV primary care within three months of their HIV diagnosis.177


Other Health Conditions

Like many people living with HIV in other regions, HIV-positive Blacks often suffer from other health conditions that can contribute to illness and death. Blacks represent a disproportionate share of HIV infections from injection drug use and consequently are more frequently co-infected with Hepatitis C.


Treatment Adherence

Although surveys in the U.S. and in other regions demonstrate that high levels of treatment adherence are achievable in patients with multiple health, social and economic challenges, difficulties associated with poverty and co-occurring conditions can interfere with treatment adherence. In New York City, for example, Blacks make up 62% of HIV-infected homeless people.178

By investing in strategies to address the factors that contribute to unequal medical outcomes in the US, funders can help learn lessons that benefit the worldwide AIDS treatment agenda.


Financial Resources

As AIDS in the U.S. transitioned from a disease primarily centered in white men -- and as public interest turned from the domestic epidemic to the global AIDS crisis -- financial commitment to address continuing high rates of infections among Blacks in America has lagged. Here again, the epidemic in Black America echoes shortcomings in the global response. While financing for HIV programs in low- and middle-income countries has significantly increased, the sums mobilized to date are far short of the amounts needed to achieve the international goal of halting and beginning to reverse the global AIDS epidemic by 2015.179

Thanks to the leadership of the Congressional Black Caucus, Congress in 1998 established the Minority AIDS Initiative, with the aim of reducing racial and ethnic disparities in HIV-related medical outcomes by creating focused prevention, treatment and care initiatives in heavily affected communities of color. In establishing the Minority AIDS Initiative, Congress recognized that broad-based AIDS programs, while vital, were failing to address the epidemic's disproportionate burden in Black America and other minority communities.180

During the decade in which the Minority AIDS Initiative has existed, the epidemic's toll in Black America has deepened, with up to 300,000 new HIV infections occurring in Black communities across the country. Yet funding for this essential program has failed to reflect the urgency of the crisis in Black America. Between 1999 and 2008, federal appropriations for the Minority AIDS Initiative roughly doubled, rising from $199 million to $403 million. During the same period, by contrast, U.S government funding for global AIDS programs (excluding research) rose 37-fold -- from $146 million to $5.5 billion.181 Since 2004, appropriations for the Minority AIDS Initiative have remained flat, while global AIDS spending from the U.S. government (excluding research) nearly tripled.182

Especially striking is the U.S. government's meager commitment to HIV prevention at a time when high infection rates continue in Black America. While international spending on AIDS by the U.S. government increased more than 14-fold between 1995 and 2004, HIV prevention spending rose by a mere 46%, or at a rate roughly comparable to the increase in the cost of living.183 In 2008, spending on HIV prevention programs in the U.S. represents only 4% of all federal outlays for AIDS.184


The Absence of a National Strategic AIDS Plan in the U.S.: Another Way Black America's Fight against AIDS is Shortchanged

The federal government's divergence in strategic approach between its international and domestic program is illuminating. For its global AIDS efforts, the federal government is guided by a strategic plan, clear benchmarks (e.g., the prevention of 7 million HIV infections by 2010), and annual progress reports to Congress. By contrast, no strategic plan exists for the AIDS response in the U.S., and no national target has been established for reducing the number of new HIV infections.185

When the U.S. sets out to help a country address its AIDS epidemic, one of the first things the U.S. ensures is that a national AIDS strategy is in place. In tackling its own epidemic, which has not ceased growing from year to year, the U.S. fails to follow the advice it energetically dispenses in developing countries.

America's failure to adopt a strategy to fight AIDS in the U.S. also ignores the advice of global authorities. According to UNAIDS, every country should have a national multisectoral AIDS strategy and costed action plan. To ensure achievement of global commitments to move towards universal access to HIV prevention, treatment, care and support by 2010, UNAIDS recommends that countries establish clear national targets and monitor progress. Ironically, the U.S. government is the third largest contributor to UNAIDS yet fails to heed UNAIDS guidance when it comes to America's own epidemic.





  
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This article was provided by Black AIDS Institute. Visit Black AIDS Institute's website to find out more about their activities and publications.
 

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