The HIV pandemic in the US has developed a stable appearance over the last few years, and that appearance is notably non-white and non-wealthy. When the pandemic was discovered nearly thirty years ago, it was—in the US—primarily a disease of gay men. In Africa, the disease is everyone’s. Women make up significantly more than half of HIV cases in Africa, and tens of thousands of children are infected during childbirth or breastfeeding.
In this country, the disease hasn’t as deep a hold on the general population as it might, but the factors that seem to put people at risk—poverty, lack of access to health care, lack of condom use—are not improving. The majority population in the US has so far remained somewhat shielded from the worst of the epidemic, but this should give us little comfort. As poverty grows, so will HIV rates. Meanwhile, HIV is devastating certain minority populations, exacerbating and exacerbated by poverty, prejudice, and all that goes with them.
First, some basics. Well over one million Americans are infected with HIV—and many don’t know it. Over 55,000 new infections are diagnosed each year, with over half of new diagnoses occurring in men who have sex with men (MSM). This designation—MSM—is critical, as many MSM may not identify as homosexual. Prevention strategies that target male homosexuals while ignoring other men who have sex with men are missing an important at-risk population. African Americans make up nearly half of all people living with HIV in the U.S. As you might surmise, black men who have sex with men are the highest risk group, and more new infections are diagnosed in young black MSM than any other ethnic or age group. At some time in their life, 1 in 16 black men will be diagnosed with HIV, and 1 in 30 black women. The most common routes of transmission of HIV, in order, are male-to-male sexual contact, heterosexual contact (about half as many), followed distantly by injection drug use.
The reasons for African Americans’ unequal suffering in this epidemic are many, and probably not well-understood. Many sources cite subjective, unmeasured suppositions, such as anti-gay bias in black churches and the African American community in general. Homophobia has always been a factor in the US HIV epidemic, but there is much more to this. Nearly half of HIV cases are heterosexually transmitted, and I am far from convinced that African Americans as a group are more homophobic than whites. There are also some biological differences that may help protect Europeans from HIV disease and others that may increase the risk among people with African ancestry, but these factors seem to be much less important than brutal socioeconomic realities.
It seems likely that poverty and poor access to health care and education contribute to the disproportionate burden if HIV among African Americans. There is also empirical evidence to back up the idea that blacks’ suspicions of the majoritarian medical community contribute to poor treatment and outcomes (cf Tuskegee Syphilis Experiment, forced sterilization, and daily humiliating contacts with the health care establishment). African Americans, who in general have less access to good health care, suffer from a higher rate of other sexually transmitted diseases, and having an STD increases likelihood of HIV transmission.
Studies have shown that culturally sensitive educations programs aimed at adolescents and young adults may decrease risky sexual behaviors. Reducing risk of transmission is vital, but so is testing. The high rates people infected who don’t know their status is terrifying. How to we get people to find out their status? One study of black men living in urban areas found that having a test recommended by a primary care doctor was strongly correlated with being tested. It seems obvious that we need to focus efforts (and money) on education (especially sexual education including condom use) and on making primary health care easily available, especially in communities that are hard-hit. Finding primary care physicians in poor urban areas is challenging, not least because doctors like to get paid for their services. If patients can’t afford care, and the government is unwilling to pay for it, doctors will continue to avoid poor communities. Given the impact of HIV on men who have sex with men, we must target our entire society—targeting the “gay community” likely misses a large number of people who don’t feel a part of that community or have risk factors but don’t identify as gay. The CDC recommends HIV screening for everyone. We must take this recommendation not just to those of us who have good access to care, but also to the people who do not, and we must give them the tools to deal with a positive test.
As in the rest of the world, HIV is devastating poor and minority communities in the US. Any HIV policies that don’t directly address this will be a public health and humanitarian failure. HIV is everyone’s problem, but some of us suffer the consequences of our failures more than others.
“PalMD” is an internal medicine physician who blogs at White Coat Underground.
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