Case 6: Discussion
Impact of the HIV Epidemic on African Americans
In the United States, the HIV epidemic has disproportionately affected African Americans[1,2], causing a devastating effect on the African-American community. During the years 2001-2005, data from 33 states revealed more new diagnoses of HIV (with or without AIDS) among African Americans than in all other racial/ethnic populations combined (Figure 1). These data are particularly alarming considering that African Americans comprised only 13% of the population in the same states during this time period (Figure 2). In 2005, African Americans had approximately an eight-fold higher rate of HIV with or without AIDS compared to whites (Figure 3). Moreover, in 2005, far more deaths in African Americans with AIDS were reported than in any other racial or ethnic group (Figure 4). Among children younger than 3 years of age diagnosed with HIV infection in 2005, 63% were African American.
Factors Related to HIV Epidemic in African Americans
Several factors have played a role in the explosion of the HIV epidemic among African Americans. In particular, the young African-American population has experienced an intersection of poverty, drug use, high rates of incarceration, and the exchange of sex for drugs. Understanding the growth of the HIV epidemic among African Americans requires examination of disparities in socioeconomic status, education, discrimination, illicit drug use, incarceration rates, access to health care, and persistent racial segregation. All of these factors intertwine to influence the sexual behavior and social networks of African Americans, thereby contributing to the transmission of HIV within their community.
Epidemiology of HIV in African-American Men
Surveillance data from 33 states in 2005 showed that male-male sex was the most common route of HIV transmission among African-American men living with HIV (with or without AIDS), followed next by similar rates of injection drug and high-risk heterosexual contact (Figure 5)[1,2]. In a surveillance study that took place in 2004 and 2005 in five large cities in the United States and involved 1,767 men who have sex with men (MSM), the HIV prevalence was 46% among African Americans, 21% among whites, and 17% among Hispanics. This report also noted that among HIV-infected African-American MSM, 67% were unaware of their HIV status, compared with 48% of the Hispanic men, and 18% of the white men (Figure 6). Furthermore, approximately one-third of HIV-infected African American MSM also reported having sex with women. These men do not typically identify themselves as gay, nor do they typically disclose their bisexual activity with female partners[5,6]. They are often referred to as men on the "down low", and studies have shown that MSM who self identify as on the down low are more likely to transmit HIV to female partners than MSM not self-identified as on the "down low".
Epidemiology of HIV in African-American Women
Among African-American women living with HIV (with or without AIDS) at the end of 2005, high-risk heterosexual contact is by far the most common mode of HIV acquisition, followed by injection drug use (Figure 7)[1,2]. Many experts have suggested that women's lack of knowledge of their male partners' risk factors for HIV, particularly with men who are on the "down low", has played a major role in fueling the HIV epidemic among African-American women. In addition, the rates of sexually transmitted infections among African-American women are very high, with gonorrhea rates 20-fold higher and chlamydia rates seven-fold higher than in whites. Moreover, African-American women are nearly twice as likely to have recently had concurrent partnerships (overlapping of sexual partnerships in time) compared to white women. A recent study of HIV transmission among African American women in North Carolina found that women with HIV infection are more likely than non-infected women to be unemployed, receive public assistance, have 20 or more lifetime sexual partners, have a lifetime history of genital herpes simplex infection, have used crack cocaine or cocaine, or have traded sex for illicit drugs, money, or shelter. Some researchers suggest that crack cocaine has played a major role in unsafe sex practices among young African Americans, particularly African-American women.
HIV in Blacks from Countries Outside the United States
In recent years, the population of HIV-infected in blacks in the United States has expanded to include more blacks from other countries who have temporarily or permanently moved to the United States. Various pathways allow for foreign-born blacks to emigrate, travel, or work in the United States, including those who already have HIV infection when they enter this country. As a result, the HIV-1 genetic diversity of HIV among blacks has become more complicated: the African-American population predominantly has subtype B infection, whereas blacks born in African are usually infected with non-B subtypes. With the expansion of on-B subtypes among HIV-infected individuals in the United States, the potential exists for the emergence of recombinant strains and new subtypes.
The prevalence of HIV infection among incarcerated populations is estimated at 1.8%, approximately four times higher than the HIV prevalence in the general United States population. Based on studies from 1997 and 1999, on a yearly basis more than 20% of all persons living with HIV in the United States will pass through a correctional facility[13,14]. The "war on drugs" conducted by the United States federal and local governments has disproportionately affected African Americans and has spurred the high rates of incarceration in this population. Indeed, in the year 2000, nearly 50% of all prison inmates were African American (Figure 8). A 1997 publication estimated that roughly one in four African-American males would be incarcerated during their lifetime (compared with 1 in 23 white males). In addition, high rates of incarceration have been observed for African-American women, particularly those who are poor and from rural areas. Although most HIV-infected incarcerated persons acquire HIV prior to incarceration, a study involving the Georgia Department of Corrections during 1988-2005 reported 88 men who seroconverted to HIV during their incarceration. Among the inmates who had HIV seroconversion, 59 (67%) of 88 were African American. This study, taken together with the high rates of incarceration for African Americans, has generated concern that a significant number of African Americans could become infected with HIV while in jail or prison.
HIV Prevention Messages in African-American Populations
Most HIV prevention research is hampered by the under representation of African Americans in studies that rigorously evaluate behavioral change related to HIV prevention. As a result, major gaps exist in our current knowledge regarding effective HIV risk reduction strategies for African Americans. Nevertheless, available data suggest that effective interventions should be culturally sensitive, of longer duration, and include skills training. For example, African American adolescent men who received social and emotional support from a large family network had fewer HIV sexual risk behaviors, and unmarried African American women's practice of safe sex was influenced by their beliefs regarding condom use. Nevertheless, novel HIV prevention approaches may be needed for African-American men who have sex with men, given that a significant portion of this group identify themselves as heterosexual and therefore may not respond to prevention messages targeted at men who identify themselves as gay or bisexual[5,6].
Conspiracy theories regarding HIV have been widespread for the last 25 years, particularly in minority populations. For example, in 1999 investigators reported results from a door-to-door survey of African-American adults in California and noted that 27% of those surveyed agreed with the statement "HIV/AIDS is a man-made virus that the federal government made to kill and wipe out black people". Similarly, a recent telephone survey of 500 African Americans in the United States found that one in seven believed the government created HIV as a means to control the black population. This same study correlated genocide conspiracy beliefs with negative condom use among men; many of the men who did not trust government information regarding HIV did not trust government information regarding condoms, and some believed that the government has tried to limit the black population by encouraging condom use[23,24]. The significant distrust of the medical community among African Americans stems from multiple factors, including the United States' social history, the heat intolerance testing of slaves in the 1800s, and the infamous and tragic Tuskegee Syphilis Experiment, a study conducted from 1932 to 1972 by the United States Public Health Service that involved 399 black men with syphilis who remained untreated after the availability of penicillin so that researchers could follow the natural progression of untreated syphilis.
Federal HIV-Related Programs for African Americans
In 1998, the Clinton Administration declared HIV/AIDS in racial and ethnic minority communities a "severe and ongoing health crisis". As a result, several HIV prevention efforts were established, including the creation of the Minority AIDS Initiative. This initiative has the primary goal of reducing the impact of HIV/AIDS on racial and ethnic minorities. In 2006, the Ryan White HIV/AIDS Treatment Modernization Act codified the Minority AIDS Initiative as part of the Ryan White program in the Public Health Service Act; this new law recognizes the profound impact of HIV/AIDS on racial/ethnic minorities in the United States, particularly African Americans. In addition, recognizing the importance of culturally competent research and programs, the CDC established the extramural Minority HIV/AIDS Research Initiative in 2002 to create partnerships between CDC epidemiologists and researchers who are members of minority races/ethnicities and who work in communities of color. The Minority HIV/AIDS Research Initiative funds epidemiologic and preventive studies in minority communities, and encourages the career development of young minority investigators.
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