HIV is a crisis in African American communities, threatening the health, well-being and potential of African American men and women of all ages in the United States. Yet as the impact of the epidemic among African Americans has grown, so has the nation's response. With new voices in the community speaking out and evidence that progress against the disease is occurring, there are more opportunities than ever to stop HIV among African Americans. The Centers for Disease Control and Prevention (CDC), state and local public health agencies, and prominent African American leaders are working together to accelerate recent progress and meet the serious challenges that remain.
HIV and AIDS: A Health Crisis for African Americans
African American men and women face the most severe burden of HIV and AIDS in the nation. The harsh reality is that 1 in 16 black men will be diagnosed with HIV at some point in their lifetime, as will 1 in 30 black women.1 While blacks represent approximately 12 percent of the U.S. population, they account for almost half (46%) of the more than one million people estimated to be living with HIV in the United States,2 and accounted for nearly half (45%) of new HIV infections estimated to have occurred in 2006.3 In fact, a recent analysis by the Black AIDS Institute found that if black America were its own country, it would rank 16th in the world in the number of people with HIV -- ahead of Ethiopia, Botswana, and Haiti.4
AIDS continues to claim the lives of too many African American men and women. Since the beginning of the epidemic, more than 200,000 blacks with AIDS have died,5 and today AIDS is the leading cause of death among black women aged 25-34 and the second leading cause of death among black men aged 35-44.6 Within the African American community, gay and bisexual men (referred to as men who have sex with men, or MSM*) and women are the most affected.
The latest CDC estimates of new HIV infections in the U.S. show:
- Overall: Nearly 25,000 blacks became infected with HIV in 20063
- Men: Men accounted for two-thirds of new infections (65%, or 16,120 cases) among blacks in 2006. The HIV incidence rate for black men was about six times as high as that of white men, nearly three times that of Hispanic men, and more than twice that of black women.7
- MSM: Among black men, a substantial majority of estimated new infections (63%) occurred among MSM. Black MSM represented 41 percent of new infections (10,130) among all blacks in 2006; young black MSM (aged 13 - 29) are particularly affected, accounting for more new HIV infections than any other age/racial group of MSM (5,220 infections in 2006).7 Infections among MSM have increased substantially over the past 15 years, representing a major HIV prevention challenge.
- Women: Women represented 35 percent of new infections among blacks (8,810) in 2006. While there were fewer new HIV infections among black women than black men, black women are far more affected by HIV than women of other races. The estimated HIV incidence rate for black women was nearly 15 times as high as that of white women and nearly four times as high as that of Hispanic women.7
Despite these statistics, there are hopeful signs of progress. CDC data show that the annual number of new infections among blacks has remained roughly stable for more than a decade -- despite the fact that the number of people living with HIV, who can potentially transmit the disease, has steadily increased over that time due to improved HIV treatments. In addition, new infections have declined in several transmission categories in which African Americans are disproportionately represented: heterosexuals, babies born to HIV-infected mothers, and intravenous drug users (IDUs).3
Complex Factors Place African Americans at Increased Risk
While race itself is not a risk factor for HIV, a number of complex challenges place African Americans at greater risk of HIV than other races/ethnicities, including:
- Higher prevalence of HIV in African American communities: Because the burden of HIV is greater in African American communities than in any other racial/ethnic group, and because African Americans are more likely to have sexual relations with others of the same race/ethnicity, African Americans face a greater risk of being exposed to HIV infection with each sexual encounter.8 Therefore, despite comparable levels of individual risk behavior (e.g., unprotected sex) compared to other races/ethnicities,9 African Americans continue to become infected at higher rates.
- Higher prevalence of sexually transmitted diseases (STDs) in African American communities: Data also show that the burden of STDs is far higher in African American communities than in any other racial/ethnic group; for example, gonorrhea rates among African Americans in 2007 were 19 times as high as those of whites.10 Because STDs such as syphilis, gonorrhea, and chlamydia can increase the risk of HIV transmission, this likely contributes to higher HIV incidence among black men and women.
- Stigma: The stigma associated with HIV and homosexuality may help to spread HIV in African American communities. Fear of disclosing risk behavior or sexual orientation prevents many from seeking testing, treatment and support from friends and family. As a result, too many in African American communities lack critical information about how to prevent infection.
- Socioeconomic factors: The stark realities of some African Americans' lives can also increase HIV risk. These include higher levels of poverty, racial discrimination, lack of access to healthcare, and higher rates of incarceration which disrupt social networks. Studies have shown, for example, that lower income and educational attainment are significant factors contributing to new infections among African Americans who contract HIV, despite low risk behaviors.11
A Heightened National Response: CDC and African American Communities Working Together to Fight HIV
As the impact of HIV on African Americans has grown over time, so have efforts to combat it. CDC, its public health partners, and African American leaders are working together to reduce the burden of HIV in African American communities through the Heightened National Response to the HIV/AIDS Crisis among African Americans (HNR). Preventing HIV among African Americans is CDC's top prevention priority, and more than half of CDC's HIV prevention budget -- approximately $300 million --
is devoted to efforts in these communities.
CDC has consulted extensively with African American leaders to identify the most urgent unmet needs in HIV prevention and is working with more than 200 African American leaders and organizations to intensify efforts in the four key areas of HNR:
- Expanding the reach of HIV prevention services
- Increasing opportunities for HIV diagnosis and treatment
- Developing new, effective prevention interventions
- Mobilizing broader community action
Expanding the Reach of HIV Prevention Services
Adapting a Proven Strategy to Meet the Needs of African American Gay and Bisexual Men
CDC is helping communities adapt proven behavioral prevention interventions for African American MSM. A recently adapted intervention, known as D-Up!, recruits key individuals in social networks to promote healthy sexual behaviors among their peers and was originally developed and studied in general MSM populations. In 2004-2005, the intervention was successfully adapted for young, black MSM by the North Carolina Department of Health with CDC support, leading to substantial reductions in sexual risk behavior among the MSM who participated. To build on this success, CDC has begun to disseminate this intervention widely, and train health departments and community-based organizations nationwide to implement the program for African American MSM in their communities.
Challenge: The largest share of CDC prevention funds for African Americans -- more than $250 million -- fund the implementation of proven prevention programs for those at highest risk across the country. Yet prevention resources are not sufficient to reach all of those at risk, and many still lack access to needed interventions. For example, a CDC study of gay and bisexual men in 15 cities found that 80 percent of black MSM had not been reached by the intensive HIV prevention interventions that are known to be most effective.12
Response: In order to increase access to the most effective HIV prevention services, HNR works to increase the use of proven interventions for black MSM and women and to expand the number and types of organizations capable of delivering effective HIV prevention services.
Examples of CDC's recently launched or expanded efforts in this area include:
- Widely disseminating two new interventions for African American women -- WiLLOW, a program focused on the prevention needs of HIV-positive black women, and SiHLE, an intervention aimed at reducing risk behaviors among young African American women.
- Expanding the dissemination of Many Men, Many Voices (3MV) -- a program that reduces HIV and STD risk behavior among MSM of color.
Increasing Opportunities for HIV Diagnosis and Treatment
Challenge: Far too many African Americans either do not know their HIV status or delay getting tested until late in the course of infection -- when available treatments are often not as effective in keeping them healthy. It is estimated that the majority of new infections are transmitted by those who are unaware of their infection.13 Reaching more people with HIV testing is a critical step in reducing HIV transmission.
Expanding HIV Screening in Labor and Emergency Departments
Ensuring that people with HIV are aware of their infection and linked to prevention and care services is an urgent priority. CDC recommends routine HIV testing for all adults and adolescents in health care settings. One critical tool is the rapid HIV test, which provides results in as little as 20 minutes. To reach more African Americans with rapid HIV testing and links to care, CDC is conducting a series of regional workshops with staff from hospital labor/delivery and emergency departments in metropolitan areas with a high burden of HIV among African Americans to develop specific plans for implementing routine screening in their facilities, using rapid tests whenever possible.
Fourteen regional workshops have been conducted to date in several cities including Philadelphia, PA, Los Angeles, CA, Hartford, CT, and Raleigh, NC.
Response: To increase HIV testing among African Americans, HNR focuses on expanding access to testing in healthcare and community settings, ensuring that more health care providers receive training to implement routine HIV screening and implementing new efforts to motivate at-risk African American men and women to get tested for HIV.
Examples of CDC's recently launched or expanded efforts in this area include:
- In 2007 and 2008, CDC invested $70 million in a new initiative devoted to increasing HIV testing, primarily among African Americans.
- Providing rapid testing and prevention services at a range of African American community settings such as churches, historically black university campuses, and minority gay pride events.
- Developing a national social marketing HIV testing campaign to encourage regular testing among black gay and bisexual men ages 18 -24 who are at high risk for HIV.
Developing New, Effective Prevention Interventions
Developing Interventions for Incarcerated Men Upon Release
Prisons bring together a population of individuals at high risk for HIV infection, and studies have shown that inmates are nearly five times more likely to have HIV than the general U.S. population. The vast majority of inmates with HIV became infected before they entered the correctional system. While blacks make up 12 percent of the U.S. population, they make up over 38 percent of those incarcerated. Because most inmates are ultimately released, a critical goal of HIV prevention programs in prisons is to help inmates reduce their risk behavior after reentering their communities. CDC has supported research leading to a successful intervention for at-risk men (Project START) and is currently working with three organizations to develop and evaluate new prevention models for HIV-positive inmates to prevent HIV transmission to their partners after release.
Challenge: There is a critical need for additional interventions that meet the specific needs of African Americans who are most at risk, especially gay and bisexual men. There is also a need for interventions that go beyond the individual and address social and structural factors that influence the health of African Americans, such as poverty and racism.
Response: To address the urgent need for additional interventions, HNR prioritizes research into new programs tailored specifically for African Americans at greatest risk, including gay and bisexual men, black women, and incarcerated individuals. CDC is also conducting research to examine the deeper structural factors that put many African Americans at risk. High priority is also placed on increasing the involvement of black researchers in HIV prevention and more quickly translating research into practice.
Examples of CDC's recently launched or expanded efforts in this area include:
- Developing and testing four new behavioral interventions designed specifically for black MSM in Baltimore, Chicago, Milwaukee and New York City to help them reduce risk behaviors.
- Examining ways to reduce HIV risk behaviors among un- and under-employed black women in the southeast through an intervention that helps lift women out of poverty through education, training and support to start their own businesses.
- Providing $2 million per year between 2007 and 2010 to fund African American and Hispanic researchers' work in communities significantly affected by HIV and AIDS.
Mobilizing Broader Community Action
Engaging African American Small Businesses
CDC and state and local health departments are partnering with African American merchants -- from barbershops to music stores -- in several cities to help reach their communities with HIV prevention information and links to testing and prevention services. Participating business owners distribute HIV awareness messages on items such as shopping bags and beverage sleeves, and help reduce the stigma of HIV and HIV testing by initiating conversations with their customers. More than 150 Miami merchants are participating in Liberty City, Overtown and Little Havana, while approximately 75 Detroit merchants are participating in the seven zip codes with the highest HIV prevalence in that city. In Chicago, roughly 60 merchants are participating along the city's historic 87th Street corridor. In February 2009, approximately 100 businesses in Baltimore will also launch the project. Local chambers of commerce and national African American organizations, such as 100 Black Men of America, are helping promote merchant involvement, and the program is expanding to five additional cities.
Challenge: While there have been many bold examples in recent years of leadership in the fight against HIV throughout the African American community -- from heads of major civic organizations to entertainers, faith, business and congressional leaders, and HIV prevention organizations -- ending this epidemic will require an even greater response.
Response: By mobilizing broader community action, HNR harnesses the collective commitment within African American communities to extend the reach of HIV prevention to more people at risk.
Examples of CDC efforts include:
*The term men who have sex with men is used in CDC's surveillance systems because it indicates the behaviors that transmit HIV infection, rather than how individuals self-identify in terms of their sexuality.
- Bringing together more than 200 prominent African American leaders to discuss concrete actions that can be taken to reach all African Americans with the tools and knowledge they need to protect themselves and their loved ones from HIV.
- Partnering with faith leaders to host a series of faith forums to help churches identify specific actions they can take to support prevention efforts, encourage HIV testing and reduce the stigma of HIV.
- Hall HI, An Q, Hutchinson A, Sansom, S. Estimating the Lifetime Risk of a Diagnosis of the HIV Infection in 33 States, 2004-2005.
J Acquir Immune Defic Syndr. 2008. 294-295.
- CDC. HIV Prevalence Estimates -- United States, 2006. MMWR 2008; 57: 1073-1076.
- Hall HI, Song R, Rhodes P, et al. Estimation of HIV Incidence in the United States. JAMA. 2008;300:520-529.
- Wilson P, Wright K, Isbell M. Left Behind: Black America: a Neglected Priority in the Global AIDS Epidemic. Los Angeles: The Black AIDS Institute, 2008.
- CDC. HIV/AIDS Surveillance Report, 2006. Vol. 18. Atlanta: US Department of Health and Human Services; 2008. http://www.cdc.gov/hiv.
- Heron MP. Deaths: Leading causes for 2004. National vital statistics reports; vol 56 no 5. Hyattsville, MD: National Center for Health Statistics. 2007. http://www.cdc.gov/nchs/data/nvsr/nvsr56/nvsr56_05.pdf
- CDC. Subpopulation Estimates from the HIV Incidence Surveillance System -- United States, 2006. MMWR 2008; 57: 985-989.
- Laumann EO, Youm Y. Racial/ethnic group differences in the prevalence of sexually transmitted diseases in the United States: a network explanation. Sex Transm Dis 1999; 26: 250-61.
- Hallfors DD, Iritani BJ, Miller WC, et al. Sexual and drug behavior patterns and HIV and STD racial disparities: the need for new directions. Am J Public Health 2007; 97:125-132.
- CDC. Sexually Transmitted Disease Surveillance, 2007. Atlanta, GA: US Department of Health and Human Services; 2008. http://www.cdc.gov/std/
- Adimora AA, Schoenbach VJ, Martinson FE, et al. Heterosexually transmitted HIV infection among African Americans in North Carolina. J Acquir Immune Defic Syndr 2006;41:616-23
- CDC. Human Immunodeficiency Virus (HIV) Risk, Prevention, and Testing Behaviors United States, National HIV Behavioral Surveillance System: Men Who Have Sex with Men, November 2003-April 2005. Surveillance Summaries, July 2006. MMWR 2006; 55 (No. SS-6).
- Marks G, Crepaz N, Janssen R. Estimating sexual transmission of HIV from persons aware and unaware that they are infected with the virus in the USA. AIDS. 2006: 20:1447-1450