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HIV & AIDS Among African Americans

Magic Johnson, who announced he was HIV-positive in 1991To date, over 230,000 African Americans have died of AIDS-related illnesses - nearly 40 percent of total deaths - and of the more than 1 million people living with HIV in the United States of America today, almost half are black.1 And yet, as a racial group, African Americans represent just 14 percent of the US population.2 The estimated lifetime risk of becoming infected with HIV is 1 in 16 for black males, and 1 in 30 for black females, a far higher risk than for white males (1 in 104) and white females (1 in 588).3 In Washington D.C, which has the nation’s highest district HIV prevalence (3 percent), three-quarters of those infected with HIV are African American.4 According to the National HIV/AIDS Strategy, African Americans "comprise the greatest proportion of HIV/AIDS cases across many transmission categories, including among women, heterosexual men, injection drug users, and infants."5

So why are black Americans so disproportionately affected by AIDS in the United States of America and how do black Americans themselves view the epidemic? And what is being done to limit the number of new cases of AIDS being identified in clinics across the country?

AIDS among African Americans

The first cases of AIDS among African Americans were identified in the early 1980s. Initially HIV and AIDS mainly affected gay men and intravenous drug users (IDUs) within the black community, much as it did in the rest of the population. However in 1983 the US Centers for Disease Control and Prevention (CDC) documented the first two cases of AIDS in women. Both women had acquired HIV through sex with an intravenous drug user. One of these women was Latina; the other was black.

From this point on, the AIDS epidemic began spreading rapidly amongst the African American population. Women were particularly affected and by 1988, African Americans accounted for half of all AIDS cases identified in females in the US.6 Today, 60 percent of women living with an AIDS diagnosis are black.7

Much of the problem in the early years was the American media's portrayal of AIDS as a disease of white gay men. Black Americans were given few reasons to believe that AIDS could affect them, even though black men made up a large proportion of the early cases of AIDS in the gay and bisexual community, and from the outset, black heterosexual adults and children were significantly more likely to be infected than white heterosexuals.8

One of the first groups to address this lack of awareness, and the general problems created by the AIDS epidemic among African Americans was the San Franciscan gay community group, Black and White Men Together (BWMT). BWMT was significant not only for giving rise to the USA’s first official black AIDS organisation, the National Task Force on AIDS Prevention, but for counting Reggie Williams as one of its members. Williams was one of the first gay black AIDS activists, and worked for many years to document deaths and raise awareness of AIDS in the black homosexual community. It was his successful lobbying that eventually led the CDC to issue its first ever grant for HIV prevention targeted at black gay men in 1988.9

The seriousness of the AIDS epidemic among African Americans in the 1980s and 1990s was also highlighted by a number of well known African Americans who became infected with HIV or died of AIDS. Max Robinson, the first black US news anchorman, was one of the first African American celebrities to openly admit his status shortly before he died in 1988. His death was followed by that of tennis star Arthur Ashe, who died from AIDS in 1993, and the rapper Eazy-E, who died in 1995.

Perhaps the most famous HIV-positive black American still alive today is former basketball player Earvin “Magic” Johnson, who announced he had HIV in 1991. Magic Johnson’s assertion that HIV “can happen to anyone” represented a greater understanding that AIDS was not just a ‘gay’ disease.

Others who have helped raise the profile of HIV in the black community include the Reverend Jesse Jackson, who in 2000 joined a number of other well-known African Americans in taking an oral HIV test to demonstrate the importance of HIV testing.

Though action is being taken, Rev Jackson is likely one of many who believe that current efforts to combat HIV in the black community are still not enough:

“AIDS has been allowed to stalk and murder Black America like a serial killer because we have been a compliant victim, submitting through inaction. It is now time for us to fight AIDS like the major civil rights issue it is...” - Reverend Jesse Jackson, 200610

Main risk factors among African Americans

Sexual transmission

For both black men and women, having unprotected sex with a man is the leading cause of HIV infection. Among black/African American men living with HIV in 2008, just over half were infected through male-to-male sexual contact.11 One study cited in the National HIV/AIDS Strategy revealed half of black gay and bisexual men in five major US cities were HIV positive.12 13 A larger study (conducted in 21 cities) concluded that almost a third of black MSM were infected with HIV.14 Among this group, the young are particularly affected. In 2006, more black men who have sex with men (MSM) between 13 and 29 were infected with HIV than any other age group, including of other races.15 Furthermore, the HIV epidemic among this group has grown rapidly; between 2001 and 2006 annual HIV diagnoses among black MSM aged 13-24 grew by 93 percent compared to 12 percent among black MSM of all ages.16

There are several theories as to why young black men are so vulnerable to becoming infected through homosexual activity, though none are decisive. One reason is the already high HIV prevalence within this community. The risk is heightened for young men who partner with older men because older MSM tend to have had more sexual encounters and therefore greater exposure to HIV.17

“In the black gay community, very young black men tend to have their first sexual experiences and relationships with older black MSM...It’s a very resource-driven situation. For young black MSM from urban areas, their peers don’t have the resources that they need—a place to stay, food on the table, pay my cell phone bill."18

Young black MSM are also the least likely to be aware that they are infected19 which means they may be less likely to take steps to prevent transmission of HIV. However, other research has shown young, black MSM do not engage in risky behaviour to a greater extent than young white or Latino men, making reasons behind why they are disproportionately affected largely unknown.20

Among women living with HIV, black women are disproportionately affected, with the most likely transmission route being heterosexual sex. Three out of four African American women living with HIV were infected this way and account for over half of the country's entire female epidemic. Of black men living with HIV, 20 percent were infected through heterosexual contact.21

There are a myriad of social and economic factors that result in higher levels of sexual HIV transmission among black Americans. However, higher levels of STDs among African Americans, also shaped by social and economic factors, in turn facilitate sexual transmission of HIV. Black Americans have 8 times the level of chlamydia, and 18 times the level of gonorrhea compared to white Americans.22 An analysis by the U.S Centers for Disease Control and Prevention (CDC) found that 48 percent of black women and 39 percent of black men were infected by genital herpes in the U.S compared to 21 percent of women and 11.5 percent of men overall.23

Drug Use

Injecting drug use is the second most likely HIV transmission route for African Americans and in 2008 accounted for 18 percent of all AIDS diagnoses among African Americans. More black males and females living with AIDS were infected by injecting drug use compared to males and females of any other racial or ethnic group. African American injecting drug users (IDUs) have a high risk of acquiring HIV and of not surviving long after an AIDS diagnosis.24

A direct risk of transmission occurs when IDUs share needles with people of a different HIV status. Indirectly, drug users may also become involved in crime or prostitution to fund their habit. Sex workers who are desperate for a fix, or are high on drugs are less likely to insist their clients use a condom. Crack cocaine, along with drugs such as crystal methamphetamine, can also lower inhibitions and increase the likelihood that users will engage in high-risk sexual behaviour.

See our USA HIV & AIDS Statistics page for more information on the black AIDS epidemic.

Social and economic context of the African American AIDS epidemic

As with the epidemic among other groups, a complex set of socioeconomic factors influence the course of HIV and AIDS among African Americans. No single cause explains why black Americans are disproportionately affected by AIDS although there are a number of overlapping factors that no doubt play their part. Addressing the 'social determinants of health' such as poverty, poor access to healthcare, and unemployment is now seen as an integral part of tackling the disproportionate impact of HIV on the black population.25

Poverty

“Obama will continue to fight poverty and homelessness, key drivers of this epidemic.”

Obama for America presidential campaign

Poverty is a major contributor to the HIV and AIDS epidemic among African Americans. Poverty and a disadvantaged upbringing often cause young people to drop out of school early, preventing them from gaining access to well-paid and stable employment or causing them to lose a sense of self-worth and be drawn into illegal or socially unacceptable activities (such as drug use) that may put them at direct risk of HIV. The symptoms of poverty also influence sexual relationship patterns that encourage the spread of HIV. The need to pay attention to the social and economic context in which HIV flourishes was recognised by Barack Obama who, in his presidential campaign literature pledged to 'tackle the scourge of poverty where HIV and AIDS proliferate'.26

A quarter of African American families live in poverty, with similar poverty rates for single male-headed households (24.9 percent) and even higher poverty rates for single female-headed households (42.3 percent).27

One focus group involving African Americans in North Carolina revealed a link between participants’ social background and sexual networks in the community.28 These contextual factors included institutional racism leading to diminished employment prospects and the inability to get a mortgage; high rates of incarceration; and lack of community recreation.

It was found that skewed sexual ratios resulting from rates of imprisonment and death and drug use among men influenced patterns of sexual networks conducive to the spread of HIV and other STDs. Women, especially those who were poor or had lower educational attainment, were believed to feel dependent on men and more likely to tolerate their partner having concurrent partners. Similarly, women with incarcerated partners were more likely to have other sexual partners.29 The National HIV/AIDS Strategy claims the gender imbalance that occurs in communities with high rates of incarceration also results in an "increased likelihood that the remaining men will have multiple, concurrent relationships with female sex partners" and therefore an increased risk that a single male will transmit HIV to multiple female partners.30

The likelihood of engaging in risk factors such as drug abuse and having sex with an infected sexual partner are increased if a person lives in an area where those risk factors are concentrated. According to the CDC, this situation, otherwise referred to as 'residential segregation' partly explains the disproportionately high level of STDs among African Americans.31

Poverty can also force people, particularly women, to use sex as a form of payment or as a way to earn money. A study by the National Campaign to Prevent Teen Pregnancy32 found that a significant number of young black women partake in ‘transactional sex’ relationships with older men to secure gifts, money or greater financial security. Often a woman in such a relationship will not be in a position to dictate condom use, making it more likely she could become infected with HIV herself, or that she could pass HIV on to her partner if she already has it.

A poor sense of self-worth, due to fewer opportunities to better one's self also means some feel protecting themselves from HIV is simply not a priority when sex may bring more instant gratification. This lack of self-worth was clearly evident in the fatalistic views of black LA gang members recorded in a 2006 study by the Minority AIDS Project33. A quarter of respondents felt it didn’t matter if they got HIV, because they believed they would probably die young anyway.

Stigma

AIDS in the Black Community posterDiscrimination and stigma make life exceedingly difficult for those living with HIV, and prevent open discussion about the behaviours that can result in infection, and the action that could be taken to prevent it. It also leaves people afraid to be tested, meaning many may not seek treatment until they are very sick, and will not take sufficient precautions to prevent onward transmission.

Homosexuality is highly stigmatised in many communities and is also decried by the majority of black churches, who see homosexuality as a sin. As a result, black men may prefer to keep their sexuality a secret. Instead, some black men who have sex with men identify themselves as 'on the down low'. This is where black men, who identify as straight and have a female partner, have sex with other men in secret. In the vast majority of cases, the woman in the relationship will be unaware of her partner’s activities. One man interviewed by the San Francisco Chronicle in 2005, told reporters that the terms ‘homosexual’ or ‘gay’ are rarely used by black men on the down low:

“Gays to me were white men. The brothers that I hung out with, we never called ourselves gay. We just liked men. One brother asked me where my girlfriend was. I told him I didn’t have a girlfriend because I’m gay. Yet he was still like, ‘so why don’t you have a girlfriend?’ He thought I should have a girlfriend as a front.”34Blue Buddha, San Francisco Chronicle, 02 May 2006

African American men labelled or identified as being on the down low are often blamed for a large part of the epidemic in that they are believed to transmit HIV to their unwitting female partners. However, some have criticised depictions of black men on the down low and the undue attention this has garnered with regards to the black AIDS epidemic.35 Others say attention of men “on the down low” has overshadowed discussion of more important factors in the epidemic such as the high prevalence of STDs.36

“Gays to me were white men. The brothers that I hung out with, we never called ourselves gay. We just liked men.”

“The lifestyle referenced by the term the DL [down low] is neither new nor limited to blacks and sufficient data linking it to HIV/AIDS currently are lacking.”37

Though the contribution to the epidemic by black MSM who do not identify themselves as gay may be exaggerated, many may miss out on HIV prevention strategies that are aimed at openly gay, or at straight black men.

Stigma towards people living with HIV is sometimes believed to have its root in misconceptions about the virus. In a 2004 survey of HIV knowledge and perception, a higher than average percentage of African Americans believed, falsely, that the virus could be transmitted via kissing or sharing a drinking glass. A greater percentage of African Americans, than any other racial group, believed there was 'a lot' of prejudice and discrimination against people living with HIV and AIDS in the USA. However, a greater proportion of African Americans than other racial groups said they would be 'Very comfortable' working with someone with HIV or AIDS.38

Lack of access to healthcare

Healthcare in the US is principally funded through private insurance payments. This either means that those who do not have health insurance may have to be insured by the government through state Medicare or Medicaid schemes (see our HIV treatment in the United States of America page for more details) or that they remain uninsured altogether and have to pay for every individual treatment or consultation they receive. In 2011, a fifth of African Americans did not have health insurance, compared to 15 percent of whites.39 The National HIV/AIDS Strategy, released in July 2010, places a strong emphasis on the impact of the health care reform bill, or the Affordable Care Act, on the future provision of HIV treatment.40 The changes due to come into force in 2014 include expanded Medicaid eligibility, protection for people with pre-existing condition or chronic illnesses (such as HIV/AIDS) that will allow them to access health insurance, and increased access to tax credits.

The cost of treatment, as well as a number of other factors, means that African Americans may not visit a hospital or doctor until they are seriously ill. This can have consequences for HIV prevention, because it means many will avoid taking an HIV test until it is clear that there is something seriously wrong. By this point, an individual may have had unprotected sex with numerous people, because they were unaware of their infection and the need to use condoms. Although it should be recognised that blacks are more than twice as likely than whites to report having had an HIV test in the last 12 months, sufficient coverage of HIV testing among this population is still lacking.41 It has been identified that 'missed opportunities' to diagnose HIV at health settings must be addressed if the racial disparities of the HIV and AIDS epidemic in the USA are to be overcome.42

Access to HIV treatment is a significant issue. Two thirds of African Americans rely on publicly funded programmes such as Medicaid to be able to finance their treatment, compared to half of HIV positive people as a whole. African Americans also feature significantly in the Ryan White CARE Act ‘ADAP’ (AIDS Drugs Assistance Programme) which provides drugs to those who do not qualify for Medicaid or Medicare, but cannot afford private health insurance. However, funding for ADAP (and the Ryan White CARE act in general) has not kept up with demand, and in the past, several states have experienced substantial waiting lists for treatment. As of September 2007, there were no patients on waiting lists, but these had reemerged in three states by March 2009.43 It is feared that public health care systems, relied upon disproportionately by the poor and African Americans, will buckle under budgetary pressures due to the adverse financial situation.44

Poor access to quality healthcare means that the risk of death and the survival rate of African Americans after an AIDS diagnosis is worse compared to most other racial and ethnic groups.45 HIV is now the third leading cause of death in black men and women aged 35 to 44.46

Access to drugs is also an issue for pregnant HIV positive women. With the correct antiretroviral treatment and care, the risk of mother to child transmission of HIV is less than 2 percent. However, if she does not access medical services during her pregnancy or labour or remains undiagnosed, the risk of her infecting her baby is much higher. Of the estimated 3,833 under-13s living with AIDS in 2008 who were infected during pregnancy, labour or through breastfeeding almost two-thirds were Black/African American.47

Prisons

There has been a growth in the US prison population over the last decades, and the effects of social, economical and education inequality have meant that black men have been disproportionately affected by this incarceration-rate.48 Almost one in twenty black men were in prison in mid-year 200849

In 2006, researchers at the University of California at Berkeley published a study showing that the increasing rate of HIV in heterosexuals, particularly women, closely tracked the increasing rate of incarceration among black men during the 1980s and early 1990s.50 A variety of research has shown men in prison to be at high risk of HIV, so their theory was that many black men became infected in jail and then went on to infect their female partners upon release. So convinced were they by this research, that they claimed that it almost entirely explained the disproportionate rate of HIV in African Americans.

A recent CDC study has however found that the vast majority of men are actually infected before they are imprisoned, suggesting that the rate of transmission within prisons is perhaps not as great as the UC Berkeley evidence implies. Nonetheless, it remains an important piece of research in helping to understand the epidemic.51 The National HIV/AIDS Strategy cites a number of studies which link the difficulties faced by men upon leaving jail in accessing treatment to a deterioration in their health and increased chance of onward transmission of HIV.52

Genetic factors

It is possible that genetic difference between people from European and non-European backgrounds may also have a small part to play. Various studies have discovered that some people of European descent have a small genetic mutation (know as CCR5 receptor mutation) that makes their immune T-cells partially or fully resistant to HIV infection.53 Nobody is entirely sure why this mutation occurs (most believe it was a result of past European pandemics, such as small pox or the bubonic plague), but it is thought to affect about 10 percent of Caucasians. This does not mean that an individual with African (or indeed other non-European) ancestry is any more likely to develop HIV than a European without this CCR5 mutation; but as an entire racial group (ignoring other factors), whites are at a slightly lower risk of HIV infection than others.

Genetic factors really cannot fully explain the entire disparity between black and white infections however. Native Americans are statistically far less seriously affected by HIV than African Americans, although they too entirely lack the CCR5 receptor mutation.

How do African Americans view the epidemic themselves?

A 2009 survey by the Kaiser Family Foundation discovered over a fifth of black Americans cite HIV/AIDS as the most urgent health problem facing the US, significantly higher than the 6 percent average. (It should be noted that both figures have declined dramatically since as recently as 2004.)54 In another survey, four-fifths of African Americans believed that government spending on the disease domestically was insufficient. They also reported experiencing the highest levels of HIV-related stigma, were the most aware about transmission routes, were the most likely to have been tested, and were the ethnic group that was the most likely to say that they knew someone who was living with HIV or had died of AIDS.55

The level of concern and awareness about HIV is perhaps unsurprising given the severity of the AIDS epidemic within the black population. Though such surveys reveal higher levels of awareness among African Americans about HIV and AIDS, there are troubling signs that this is decreasing. Between 2004 and 2009, the proportion of black Americans who said they had seen, heard or read a lot about AIDS in the past year declined by almost half from 62 percent to 33 percent.56

A significant proportion of African Americans do not blame the spread of HIV on risky sexual behaviour, but instead hold the government responsible. Around half of African-Americans surveyed by Oregon State University researchers between 2002 and 2003 believed that HIV was a man-made virus. Over half (53 percent) believed that there was a cure for AIDS that was being withheld from the poor, and 27 percent thought AIDS was produced in a government laboratory. 12 percent thought that HIV was created and spread by the CIA and 15 percent thought it was a form of genocide against blacks.57

Such beliefs are perhaps understandable given the context of prejudice and exploitation that many black Americans have grown up with. Indeed, those that were found to have the most extreme conspiracy theory views in the study were unsurprisingly those that had encountered the most racism in their lives. Some cited the infamous ‘Tuskegee’ experiment as the basis for their beliefs. Conducted by the US government between 1932 and 1972, the study aimed to investigate the natural course of the sexually transmitted disease syphilis in the black population. Over 600 black men were enrolled, many of whom were infected with syphilis, but none were ever offered treatment. Many died as a consequence, fuelling outrage throughout the black community, and beyond.58

Such unethical practices have left a scar on the African American population that may never fully disappear. The conspiracy theories that they have given rise to also pose a serious risk to HIV prevention strategies, as they place the blame for infection elsewhere, and can stop individuals from taking responsibility for their own actions.59

What is being done to combat HIV in African Americans?

The "100 days to fight AIDS" march in Washington D.C. in November 2008The common perception among African Americans is that the government is not doing enough to protect African Americans from AIDS. Roughly half of the Centers for Disease Control and Prevention's (CDC) budget is directed towards African Americans, proportional to their share of annual HIV infections. However, it is argued directing the CDC's entire HIV budget towards the black AIDS epidemic would not be sufficient. What could be improved, therefore, is the size of the HIV budget itself. For the 2009 financial year the CDC said $1.6bn was needed for HIV prevention, far in excess of the $753m allocated for 2008, indicating how financial need has so far been greatly unmet.60 Although Obama's 2011 budget shows a 4 percent increase in funding for HIV prevention to the CDC, some leaders from the HIV/AIDS community see the new budget as a setback, stating that

"With the growing number of new infections and people needing lifesaving treatment and services, we are disappointed in the level of spending proposed by the government." - Carl Schmid, deputy executive director of the AIDS Institute61

The CDC currently funds several projects around the United States that address the epidemic in African Americans.62 These include rapid HIV testing programmes in traditionally black universities and colleges across the country, a variety of epidemiological research programmes and the ‘Minority AIDS Initiative’ which aims to address health disparities and provide prevention programmes to ethnic minority groups at high risk of HIV. The CDC also runs a variety of social marketing and advertising campaigns, many of which target black churches - the focal points of many African American communities (around 80 percent of African Americans are thought to belong to a church). In 2007, they provided $35 million to facilitate HIV testing and improve early HIV diagnoses in areas with high levels of HIV within local black communities.63

Many black churches have already been mobilised against AIDS by groups such as The Balm in Gilead. Founded in 1989 by devoted AIDS activist Pernessa C. Seele, ‘The Balm’ works through black churches around the US to stop the spread of HIV and provide support to those infected.

“There is no doubt that the link between HIV/AIDS, drug abuse and sexual activity has been a stumbling block for churches who feel that such behavior is contrary to their tenets… Fortunately, increasing numbers of churches are realizing that providing AIDS education and social services is consistent with the teachings of Jesus Christ. Clearly, Jesus’ actions on behalf of the sick show us how we should behave during this age of AIDS.” - Pernessa C. Seele, founder of The Balm in Gilead64

In 2006, a wide range of black politicians, senior clergy members, civil rights icons and community leaders signed a "National Call to Action and Declaration of Commitment to End the AIDS Epidemic in Black America" in which they promised to do everything in their power to address the epidemic in their communities.65 This was followed by a meeting of eight high profile African American organisations at the 16th AIDS conference in Toronto, where leaders pledged to work together to reverse the spread of HIV in the black community by 2011, and to openly discuss homosexuality, drug use and sex within prisons.66

The CDC's "Heightened National Response to the HIV/AIDS Crisis Among African Americans" was intended to intensify efforts to tackle the black AIDS epidemic focusing on four different areas: Expanding the reach of prevention services; increasing opportunities for diagnosing and treating HIV; developing new prevention interventions; and mobilising broader community action.67 By 2009, Dr Kevin Fenton, the CDC's director of HIV prevention, believed good progress was being made on all four focus areas.68 The nation's first national public awareness campaign, Act Against AIDS, was also launched in 2009, with African Americans the first vulnerable group to be targeted. As part of the initiative, the CDC has partnered with 14 African American civic organisations to integrate HIV prevention into their core work.69 Some of the CDC's main partners launched a campaign in 2009 called 'Greater Than AIDS' in support of Act Against AIDS, targeting African Americans in particular.70 In 2010, it was announced that a testing programme to widen access to HIV testing among African Americans would be expanded.71

The National HIV/AIDS Strategy does not make any commitments to new funding but identifies the black community as a priority for targeted prevention efforts.72

The Future

Any effective, sustained effort to tackle AIDS in the US should have positive outcomes for African Americans seeing as they constitute such a large proportion of the overall epidemic. The CDC's acknowledgement of and research into entrenched social factors, such as poverty, which are a major contributor to the ongoing HIV transmission rate, is a positive step and should be reflected in all concrete action taken to reverse the trend of HIV transmission in the African American community.

 

References

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