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(March 2005) More African Americans are living with HIV or already dead from AIDS than any other single racial or ethnic group in the United States—a crisis one black AIDS activist calls “a state of emergency” for the African American community.¹

Over 40 percent of Americans who have been diagnosed with HIV since 1981 have been African American.² And although AIDS diagnoses and deaths have declined substantially in the United States since the mid-1990s with the advent of highly active antiretroviral therapy (HAART), African Americans have continued to be diagnosed with HIV/AIDS in numbers disproportionate to their percentage of the population.

In fact, between 1999 and 2003, AIDS diagnoses among African Americans increased by 7 percent, compared with a 3 percent decline among whites. Even as AIDS deaths declined by 18 percent among whites over this period, African Americans continued to die at the same rate as before effective treatment became available, according to the Kaiser Family Foundation.³ Black women, youth, and men who have sex with men (MSM) have proven particularly vulnerable to HIV infection.

What accounts for these high infection and mortality rates? Experts say that a mix of factors—including socioeconomic factors, limited access to health care, late HIV testing, high rates of sexually transmitted infections, and limited knowledge of treatment and prevention options—have contributed to the HIV/AIDS crisis among blacks. Analysts add that the best approaches to treatment and prevention will take these factors into account.

Sobering Numbers and Disproportionate Burdens

Although blacks make up 12.3 percent of the U.S. population, they have accounted for 40 percent of the nearly 930,000 AIDS cases diagnosed in the country since the epidemic began here in 1981. And that proportion appears to be growing. In 2003, 50 percent of the estimated 32,000 new HIV/AIDS diagnoses in the 32 states with confidential name-based HIV reporting were among African Americans.⁴

And HIV/AIDS is now the leading cause of death among African Americans ages 25 to 44—ahead of heart disease, accidents, cancer, and homicide.⁵ “It’s a state of emergency,” says longtime AIDS activist Phill Wilson, executive director of the Los Angeles-based Black AIDS Institute and himself HIV-positive for many years.⁶

The rate of AIDS diagnoses for blacks in 2003 was almost 10 times the rate for whites and almost three times the rate for Hispanics. Between 2000 and 2003, African American females had 19 times the rate of HIV/AIDS as white females and five times the rate for Hispanic females. The rate of HIV/AIDS among African American males during the same period was seven times the rate for white males and three times the rate for Hispanic males.⁷

“In America in 2005,” Wilson said recently, “AIDS is overwhelmingly a black and brown disease.”⁸

At Greatest Risk: Black Women, Youth, and Men Having Sex with Men

The epidemic has most greatly affected certain subgroups of African Americans, particularly women, youth, and men who have sex with men (MSM).

The Kaiser Family Foundation says that black women accounted for 36 percent of new AIDS cases among African Americans in 2003, compared with a 14 percent proportion of women among all new AIDS cases for whites (14 percent). Black women accounted for two-thirds of new AIDS cases among all U.S. women with AIDS in 2003, compared with white women (15 percent) and Latinas (16 percent).⁹ African American teens (ages 13 to 19) accounted for 65 percent of new AIDS cases reported among teens in 2002, although they only account for 15 percent of American teenagers.¹⁰

African American MSM have been especially affected by the epidemic. A study of six major U.S. cities found that nearly one-third (32 percent) of black MSM between ages 23-29 were already infected with HIV, compared with 7 percent of white MSM in the same age group.¹¹

Risk Factors and Obstacles to Prevention

Although African Americans are most commonly infected by HIV through sex and drug-using behaviors, the proportions of African Americans infected with HIV from particular risk behaviors vary from other populations. Additional socioeconomic and cultural factors—such as inadequate access to health care, denial about HIV, and conspiracy theories about the virus—also make African Americans particularly vulnerable to infection.

High Rates of Sexually Transmitted Infections

African Americans have the highest rates of sexually transmitted infections of any racial or ethnic group in the United States. In 2003, blacks were 20 times more likely than whites to have gonorrhea and 5.2 times as likely to have syphilis.¹² Genital lesions, such as those caused by herpes, increase one’s chance of contracting HIV three- to five-fold. And a person who is co-infected with HIV and another STI is more likely to spread HIV to others.¹³

Sexual Behavior and Injection Drug Use

Among black men, 49 percent of new HIV diagnoses in 32 states from 2000 to 2003 were attributed to unprotected sexual contact with another man—compared with 72 percent of the estimated diagnoses among white men. Injecting drug use accounted for another 18.3 percent of diagnoses.¹⁴ Injecting drug use carries both the risk of infection from sharing needles and other paraphernalia and from users who are more likely to engage in high-risk behavior, such as unprotected sex, while under the influence of drugs or alcohol.¹⁵

Most African American women are infected with HIV through heterosexual contact (80 percent between 2000-2003), followed by injecting drug use (16.7 percent). African American women also are at heightened risk from male partners who are injecting drug users or engage in unprotected sex with other men.

In two studies of African American MSM, 20 percent and 34 percent of these men reported having a female sexual partner within the previous 12 months—even though only 6 percent of African American women reported having had sex with a bisexual male.¹⁷

Socioeconomic Factors

Nearly one in every four African Americans lives in poverty, and studies have found a connection between higher AIDS incidence and lower income.¹⁸ For instance, a study of African American women in North Carolina found that those with HIV infection were more likely than noninfected women to be unemployed; receive public assistance; have had 20 or more lifetime sexual partners; have a lifetime history of genital herpes infection; have used crack or cocaine; or have traded sex for drugs, money or shelter.¹⁹

With blacks accounting for 39.2 percent of all people incarcerated in prisons and local jails in the United States as of mid-2003,²⁰ the nation’s prisons have also played an important role in vectoring HIV into the black community. The Los Angeles-based Black AIDS Institute points out in its 2005 report The Time Is Now that the “astronomically high incarceration rates in black neighborhoods” demand sensible HIV prevention policies in prisons. But the report notes that, despite the evidence of widespread drug use, tattooing, and sex in the nation’s prisons, “the tools proven to be most effective at stopping HIV’s spread—condoms, clean needles, fresh tattoo ink—are banned in most correctional facilities.”²¹

Limited Access to Health Care

African Americans are more likely to be uninsured than whites—a disparity that also holds for blacks and whites with HIV/AIDS, according to the Kaiser Family Foundation. The HIV Cost and Services Utilization Study found that African Americans with HIV/AIDS were more likely to be publicly insured or uninsured than their white counterparts. More than one-half (59 percent) of African Americans with HIV/AIDS rely on Medicaid, compared with 32 percent of whites.²²

Another study found that African Americans also were more likely to postpone medical care because they lacked transportation, were too sick to go to the doctor, or had other competing needs.²³

Limited Treatment, Knowledge, and Access

While more African Americans report being tested for HIV than whites, they tend to have less knowledge about the availability of HIV treatment.²⁴ And blacks also seem to have less access to HAART, according to a study of 10 primary HIV care sites in the United States. Even though the overall prevalence of HAART has increased since the mid-1990s, women, African Americans, and injection drug users are less likely to receive the treatment.²⁵

One cause for this disparity may be the racial gap that seems to exist between patients and their providers. A study of 1,241 HIV-positive adults receiving care from 287 different providers in the United States found that African Americans with white physicians tended to receive HAART later in their illness than did African Americans with African American physicians. And both these groups received HAART later on average than white patients with white physicians.²⁶

Late Testing

Not learning one is infected with HIV until the virus has already damaged the immune system represents missed opportunities for preventing and treating HIV infection. Centers for Disease Control (CDC) data indicate that, between 2000 and 2003, 56 percent of late testers—defined as those who were diagnosed with full-blown AIDS within one year after learning they were HIV-positive—were African Americans.²⁷

African Americans with HIV have tended to delay being tested because of psychological or social factors discussed below—which means they frequently are diagnosed with full-blown AIDS soon after learning they are infected with HIV. For this reason, African Americans with AIDS do not live as long as people with HIV/AIDS from other racial/ethnic groups.²⁸

Dr. Daniel Kuritzkes, director of AIDS research at Boston’s Brigham and Women’s Hospital and associate professor of medicine at Harvard Medical School, describes two unequal tracks of HIV treatment and care in the United States. In what Kuritzkes calls the “ideal track,” a person discovers she or he is HIV-infected, seeks medical care, has regular follow-ups, and follows a HAART regimen without complications. “There is every expectation that this person will lead a normal life,” Kuritzkes says.

But some individuals follow a second, more-dangerous track. These individuals, Kuritzkes says, “come to the hospital with full-blown AIDS as their initial diagnosis. They may have limited access to care because of finances or because other social or medical problems interfere.”

“By and large,” he adds, “the deaths [from HIV/AIDS] are among this group, which tends to be African Americans.”²⁹

Denial

The denial of personal risk has played a large role in preventing particularly African American MSM as well as black women from adequately protecting themselves and their partners. There has been a strong tendency to blame ostensibly heterosexual African American men who secretly have sex with other men—the so-called “down-low”—for the high rates of HIV infection in African American women.

But some observers argue that the fact of men who have secret sex with other men does not absolve either these men’s male or female partners of the need to protect themselves. “The down low is not responsible for the AIDS epidemic,” argues Keith Boykin, an African American commentator on race and sexuality, in his 2005 book Beyond the Down Low: Sex, Lies and Denial in Black America. “HIV is spread by behavior, not identity.”³⁰

The down-low phenomenon was discussed at the March 2005 National Conference on African Americans and AIDS in Philadelphia. At the conference, Phill Wilson said there is no research to quantify how such behavior contributes to the incidence of HIV/AIDS among African Americans. He also argued that emphasizing the down low as a risk for women portrays women as powerless victims, unable to protect themselves against HIV-infected men.

And Celia Maxwell, assistant vice president for health affairs at Howard University in Washington, D.C., said at the conference that women need to be proactive in protecting their health by asking their partners about HIV and other STIs. “You need to keep the lights on,” she said, emphasizing the importance of such awareness.³¹

Conspiracy Fears

There has also been a widespread belief among African Americans that HIV/AIDS was purposely developed by government scientists to exterminate blacks. Though without scientific credence, such views are unsurprising given the troubled relationship between African Americans and scientists harkening to the infamous Tuskegee experiments. In that mid-20th century U.S. government-supported study, scientists observed the effects of untreated syphilis in poor black men over several decades while deceiving the men about the alleged “treatment” they were given.

Conspiracy beliefs like these are widely held and can present a barrier to HIV prevention among African Americans. Researchers have reported that men in particular who hold strong conspiracy beliefs are likely to also hold negative attitudes toward condom use as a preventive measure.³²

Prevention Strategies That Can Work

The Black AIDS Institute sees preventing the spread of HIV among African Americans as part of the broader effort to address the disparities in health and health care between blacks and other racial and ethnic groups in the United States. The institute has called upon African American individuals, political, religious, and cultural leaders to engage in a coordinated campaign of advocacy on behalf of the HIV/AIDS needs of African Americans, including:

• Funding for domestic care and treatment programs;
• Lowering the cost of HIV medications;
• Supporting needle exchange programs;
• Rejecting the scapegoating of so-called “down-low” men;
• Demanding comprehensive sex education that includes credible information on condoms and other protection; and
• Adopting sensible HIV prevention policies in prisons.³³

Targeted interventions are important for those at particular risk of acquiring or spreading HIV. Heterosexual African American men surveyed for one study recommended that interventions targeting them should address condom use; condom availability; skills for using condoms; eroticizing condoms; and substance abuse prevention (because of the high correlation between substance use and unprotected sex).³⁴

The development of prevention methods that women can control themselves (such as vaginal microbicides) will greatly increase the ability of women to protect themselves against HIV even if a male partner refuses to use a condom—which is frequently the case in relationships with men prone to violence.³⁵

Researchers and analysts also point out that to be effective, prevention efforts must address the contextual factors of people’s real lives—such as poverty, discrimination, illicit drug use in the community, the ratio of men to women in a given population, incarceration rates, and racial segregation—and their influences on sexual behavior.³⁶

But perhaps the single most important preventive measure is for people to know their own HIV status. If they are uninfected, this knowledge helps them protect themselves; if they are infected, the information helps them to protect their partners.

Testing also provides the entry point to appropriate treatment and care for individuals who test positive. At the March 2005 conference on HIV/AIDS among African Americans in Philadelphia, Rev. Jesse Jackson urged well-known African American men to make a “public stand” for HIV testing to break the stigma associated with the virus.³⁷

Phill Wilson crystallizes these points when he says: “It is time for us to reject the paralyzing denial, stigma, and homophobia promoted by a few lone voices. We must confront the socioeconomic conditions that cause people to do drugs and exchange needles; challenge the lack of affordable medicine and treatment options available to many of us; dispel the myths and misinformation circulating in our communities; and alleviate the myriad of issues that contribute to the spread of AIDS in black communities today.”³⁸

John-Manuel Andriote, author of Victory Deferred: How AIDS Changed Gay Life in America, is founder and president of Washington, DC-based Health & Science Reporting.

References

1. Centers for Disease Control and Prevention (CDC), National Center for STD, HIV and TB Prevention, HIV/ AIDS Among African Americans (fact sheet) (February 2005), accessed online at www.cdc.gov/hiv/pubs/facts/afam.htm, on March 1, 2005; Phill Wilson, quoted in The Drumbeat (newsletter of the Black AIDS Institute), Los Angeles: Black AIDS Institute, accessed online at www.blackaids.org/pub/drumbeat1.pdf, on March 1, 2005.
2. CDC, HIV/ AIDS Among African Americans.
3. HIV/AIDS Surveillance Report: Cases of HIV Infection and AIDS in the United States, 2003, as cited in Kaiser Family Foundation, “African Americans and HIV/AIDS” (fact sheet, Feb. 2005), accessed online at www.kff.org/hivaids/6089-02.cfm on March 9, 2005.
4. CDC, HIV/ AIDS Among African Americans.
5. Robert N. Anderson and Betty L. Smith, “Deaths: Leading Causes for 2001,” National Vital Statistics Reports 52, vol. 9 (2002): 27-33, accessed online at www.cdc.gov/nchs/data/nvsr/nvsr52/nvsr52_09.pdf, on March 1, 2005.
6. Wilson, quoted in The Drumbeat.
7. CDC, HIV/ AIDS Among African Americans.
8. Quoted in Ethan Jacobs, “Soaring Rates: Local AIDS Advocates Talk About HIV in the Black Community,” Bay Windows, Feb. 10, 2005.
9. CDC, HIV/AIDS Surveillance Report.
10. CDC, HIV/AIDS Surveillance in Adolescents, L265 Slide Series (through 2002), as cited in Kaiser Family Foundation, “African Americans and HIV/AIDS” (fact sheet, Feb. 2005), accessed online at www.kff.org/hivaids/6089-02.cfm on March 9, 2005.
11. CDC, No Turning Back: Addressing the HIV Crisis Among Men Who Have Sex with Men( November 2001), accessed online at www.thebody.com/cdc/msm/msm.html#contents, on March 1, 2005.
12. CDC, Sexually Transmitted Disease Surveillance, 2003, accessed online at www.cdc.gov/std/stats/default.htm, on March 1, 2005.
13. D.T. Fleming and J.N. Wasserheit, “From Epidemiological Synergy to Public Health Policy and Practice: the Contribution of Other Sexually Transmitted Diseases to Sexual Transmission of HIV Infection,” Sexually Transmitted Infections 75 (1999): 3-17.
14. CDC, HIV/AIDS Among African Americans.
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16. CDC, HIV/AIDS Among African Americans .
17. CDC, “HIV Transmission Among Black College Student and Non-Student Men Who Have Sex With Men—North Carolina, 2003,” Morbidity and Mortality Weekly Report 53 (2004): 731-34; J.P. Montgomery et al., “The extent of bisexual behaviour in HIV-infected men and implications for transmission to their female sex partners,” AIDS Care 15 (2003): 829-37.
18. U.S. Census Bureau, “Poverty Status of the Population in 1999 by Age, Sex, and Race and Hispanic Origin,” (March 2000), accessed online at www.census.gov/population/socdemo/race/black/ppl-142/tab16.txt, on Mar. 1, 2005; T. Diaz et al., “Socioeconomic differences among people with AIDS: Results from a multi-state surveillance project,” American Journal of Preventive Medicine 10 (1994): 217-22.
19. CDC, “HIV Transmission Among Black Women3North Carolina, 2004,” Morbidity and Mortality Weekly Report 54 (2005): 89-93.
20. P.M. Harison and J.C. Karberg, Bureau of Justice Statistics Bulletin: Prison and Jail Inmates at Midyear 2003 (2004): 11, tables 13, 14, accessed online at www.ojp.usdoj.gov/bjs/pub/pdf/pjim03/pdf, on March 1, 2005.
21. Black AIDS Institute, The Time Is Now (2005), accessed online at www.blackaids.org/stateofaidsreport.htm, on March 1, 2005.
22. M.F. Shapiro et al., “Variations in the Care of HIV-Infected Adults in the United States,” JAMA 281, vol. 24 (1999): 2305-15, as cited in Kaiser Family Foundation, “African Americans and HIV/AIDS” (fact sheet, Feb. 2005), accessed online at www.kff.org/hivaids/6089-02.cfm on March 9, 2005.
23. W.E. Cunningham et al., “The Impact of Competing Subsistence Needs and Barriers to Access to Medical Care for Persons With Human Immunodeficiency Virus Receiving Care in the United States,” Medical Care 37, vol. 12 (1999): 1270-81.
24. S.H. Ebrahim et al., “Race/Ethnic Disparities in HIV Testing and Treatment for HIV/AIDS: United States, 2001,” AIDS Patient Care STDS 1, no. 1 (2004): 27-33.
25. K.A. Gebo et al., “Racial and Gender Disparities in Receipt of Highly Active Antiretroviral Therapy Persist in a Multistate Sample of HIV Patients in 2001,” Journal of Acquired Immune Deficiency Syndromes 38, vol. 1 (2005): 96-103.
26. W.D. King et al., “Does Racial Concordance Between HIV-Positive Patients and Their Physicians Affect the time of Receipt of Protease Inhibitors?” Journal of General Internal Medicine 19, no. 11 (2004): 1146-53.
27. CDC, “Late versus early testing of HIV—16 sites, United States, 2000-2003,” Morbidity and Mortality Weekly Report 52 (2003): 581-86.
28. CDC, HIV/AIDS Surveillance Report.
29. Linda Villarosa, “Patients With HIV Seen as Separated by a Racial Divide,” New York Times, Aug. 7, 2004.
30. Keith Boykin, Beyond the Down Low: Sex, Lies and Denial in Black America ( New York: Carroll & Graf, 2005).
31. Susan FitzGerald, “African Americans Should Take More Responsibility in Fight Against HIV/AIDS, National Conference Speakers Say,” Philadelphia Inquirer, March 2, 2005.
32. Laura M. Bogart and Sheryl Thorburn, “Are HIV/AIDS Conspiracy Beliefs a Barrier to HIV Prevention Among African Americans?” Journal of Acquired Immune Deficiency Syndromes 38, no. 2 (2005): 213-18.
33. Black AIDS Institute, The Time Is Now.
34. E.J. Essien et al., “Strategies to Prevent HIV Transmission Among Heterosexual African American Men,” BMC Public Health 5, no. 1 (2005): 3.
35. J. Saul et al., “Relationship Violence and Women’s Reactions to Male-Female-Controlled HIV Prevention Methods,” AIDS Behavior 8, no. 2 (2004): 207-14.
36. A.A. Adimora and V.J. Schoenbach, “Social Context, Sexual Networks and Racial Disparities in Rates of Sexually Transmitted Infections,” Journal of Infectious Disease 191 (Suppl 1, 2005): S115-22.
37. FitzGerald, “African Americans Should Take More Responsibility in Fight Against HIV/AIDS.”
38. Wilson, quoted in The Drumbeat.