Passing the HIV Test for Black America

HIV is a complicated virus, and combating it has demanded everyone involved -- from scientists to community activists to policymakers -- to develop inventive, often complex solutions. But one of the most powerful public health tools for controlling infectious disease is also among the most straightforward: HIV screening. That is what makes our collective performance on HIV testing so disappointing. And it is what makes recent efforts at both the governmental and the community level to finally universalize HIV testing so exciting.

In the last decade, Black community leaders and federal and state policymakers alike have focused like never before on increasing the number of people who know their HIV status. In doing so, they have challenged long-held assumptions and re-examined foundational ideas about how and why HIV testing should be done. These are welcome developments, which this report will explore in detail.

But these efforts, while promising, also show signs of being unsustainable. That's because they have largely been neither coordinated nor fully resourced. Policymakers and community leaders are now working to correct both of these shortcomings; their success in doing so will determine, perhaps more than any other factor, whether America's AIDS epidemic can be brought to an end, or whether it will continue spiraling out of control.

Our HIV testing failures have particularly dire consequences in Black America. With HIV prevalence several times higher among Blacks than in the U.S. as a whole, HIV testing is a central component of health care for all Black Americans. While Black Americans are indeed more likely to report to have ever been tested than people of other races and ethnicities, current testing rates are far short of what is needed to mount an effective fight against the disease in Black America.

Up to 70 percent of all new infections in Black America are the result of risky behavior among people who do not know they are infected. And because these individuals don't know of their infection, they first seek medical services for their condition only late in the course of disease, when they are at considerably higher risk of experiencing a life-threatening opportunistic illness. The late diagnosis of HIV infection is a critical reason why HIV-positive Black Americans are twice as likely to die as HIV-infected whites.

As this report explains, the CDC, state and local health departments, and professional medical groups have joined together in recent years to revolutionize the policy approach to HIV testing. Moving away from the historic "risk-based" focus of HIV testing initiatives, the public health consensus now recommends routine HIV testing in health care settings and annual testing for individuals at high risk. Yet this change in national policy has resulted in remarkably little follow-through. According to recent surveys, most Black Americans are still not offered an HIV test when they receive medical care.

Community-based efforts to promote HIV testing follow a similar pattern -- a strong start that hasn't been sustained. Beginning with the announcement by basketball great Earvin "Magic" Johnson in 1991 that he was HIV-positive, Black leaders increasingly urged their constituents to know their HIV status. Public awareness campaigns encouraged Black Americans to get tested, and Black politicians, clergy and celebrities publicly served as role models by publicly taking an HIV test. The number of Black Americans receiving an HIV test soared as a result. In recent years, though, testing rates in Black America have flattened or even begun to decline.

This report argues that community efforts to encourage HIV testing must be dramatically intensified. Black Americans from all walks of life need to become re-engaged in promoting HIV testing -- by talking to their friends, families and neighbors; by volunteering at a community-based AIDS organization or becoming involved in a local HIV testing coalition; and by urging their political and community leaders to raise awareness of the importance of knowing one's HIV status.

The take-home message of this report is simple: Unless knowing one's HIV status becomes the norm in Black America, AIDS will continue to devastate Black communities nationwide.

AIDS in America: A Black Disease

AIDS in America today is a Black disease. Regardless of the lens used to study the epidemic -- gender, age, class, sexual orientation, or geography -- Black people are more heavily affected by HIV than any other group.

Black people account for 46 percent of all Americans living with HIV¹ and for 45 percent of all new HIV infections² each year, though we represent just 12 percent of the U.S. population.³ In 2006, Black people were 7.3 times more likely than whites to become newly infected with HIV.⁴ Over the course of a lifetime, Black men are 6.5 times more likely to become infected than white men, while Black women are more than 19 times more likely than white women to contract HIV.⁵

Although HIV's burden upon the Black community has grown steadily over the course of the epidemic, the epidemic's disproportionate impact in Black America is not new. As early as the mid 1980s, when AIDS was still considered a disease relevant only to white gay men, Blacks were already logging more new HIV infections every year than whites.⁶

Today, Black America is experiencing what's called a generalized epidemic -- meaning it touches even individuals who engage in relatively low levels of risky behavior, like having unprotected sex or sharing needles. If Black America were a country in its own right, it would rank 16th globally in the size of its HIV-positive population. Outside of sub-Saharan Africa, only four countries have HIV prevalence as high as the most conservative estimate of HIV prevalence in Black America.⁷ (For more detail on the comparison between the Black American epidemic and the worst epidemics globally, read the Black AIDS Institute's 2008 report, Left Behind -- Black America: A Neglected Priority in the Global AIDS Epidemic.)

The emergence of highly active antiretroviral therapy -- known as HAART, or more popularly as "combination therapy" -- has helped drive down AIDS deaths for all of the U.S. over the last decade. Yet, much of Black America is not benefiting from the treatment revolution. Even in the era of effective HIV therapies, AIDS is still one of the leading causes of death among Black men and women.⁸ In New York City -- home to one in seven AIDS cases nationwide -- Black people living with HIV have an age-adjusted death rate that is twice as high as their white peers.⁹ Nationally, in 2006, Blacks accounted for nearly 4 in 10 AIDS deaths.¹⁰

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