Why HIV Rates Are High in African American Communities

Poverty and government inaction fuels ongoing crisis

Upset African American woman sitting on couch at home
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The racial disparity of HIV in the United States has reached almost startling proportions. This is none more apparent than among African Americans who, despite representing only 12 percent of the U.S. population, account for 48 percent of all new infections.

The reasons for this are complex and often misunderstood. While some may suggest that culture and sexual behavior are solely to blame for this, the fault lies more with the social and economic inequities that can fuel any infectious disease outbreak.

Poverty, social injustice, and the lack of an effective government response together enable the spread of disease in communities that simply haven’t the resources to combat it.

In many ways, the HIV epidemic is but a snapshot of the growing disparity in healthcare which places many African American communities at greater risk of not only HIV, but other preventable illnesses and infections.

Current U.S. Statistics

To say that there is a disparity in the racial distribution of HIV in the U.S. is something of an understatement. Currently, African Americans are nearly eight times more likely to be infected than whites and almost twice as likely as Latinos. African American women are especially vulnerable to new infections, running at more than 16 times the rate seen in white women.

Even among high-risk men who have sex with men (MSM), being gay and African American places a person at a startling 50 percent risk of getting HIV during the course of a lifetime (compared to only 9 percent among white gay men).

These statistics only scratch the surface of a problem that is often shrouded in confusion and contradiction. While many people will all too readily assign blame to behaviors they believe to be inherent in a culture, these kinds of responses only serve to perpetuate negative stereotypes that reinforce stigma, discrimination, and societal inaction.

Many of the more common stereotypes ("black men sleep around" or "drug use is rampant among black people") have simply proved untrue within the context of HIV. For example:

  • African American women are far less likely to be infected through injecting drugs than white women. African American women are primarily infected through heterosexual sex, while white women are mainly infected through shared needles.
  • Neither African American men nor women have higher rates of sexual risk behaviors than any other racial group.
  • Black MSM, in fact, report fewer sex partners, less unprotected anal sex, and less drug use than white MSM.
  • African Americans, on the other hand, are far more likely to be tested for HIV than whites (75 percent versus 14 percent).
  • African Americans are just as likely to seek and remain in continuous, HIV-specific medical care as whites (54 percent versus 58 percent).
  • The rate of undiagnosed infection is more or less the same for African Americans as it is whites (11 percent versus 13 percent). Of all the racial groups, Asians were, in fact, most likely to be undiagnosed (21 percent).

Where the differences lie, therefore, is not so much in the community’s response to HIV but other factors that are far more difficult to pin down or isolate.

Today, HIV remains the sixth leading cause of death in African American men and the fourth leading cause of death in African American women between the ages of 35 and 44.  By contrast, HIV is no longer listed as a leading cause of death for any other race.

Multiple Vulnerabilities to Infection

HIV does not affect all communities in the same way. While being African American, white, or Latino doesn’t necessarily alter the way in which a person responds to the disease, there are vulnerabilities that can place a person of one race at greater risk of infection and illness than another.

We see this, for example, with the differing responses to HIV treatment.

While nearly 70 percent of whites are able to achieve an undetectable viral load while on treatment, less than 50 percent of African Americans are able to do the same.

As such, culture or sexual behavior can in no way explain away these differences. Rather, the issue appears far more deep-seeded and institutional, impacted by such things as:

  • Poverty
  • Stigma
  • Lack of access to healthcare
  • Failure of governmental, social, police, and legal services
  • Discriminatory rates of arrest and incarceration
  • High-density urban populations

These inequities play one off the next in a way that creates a cycle of vulnerability that is often difficult to break.

We have seen this, perhaps most tellingly, with African American MSM with HIV. A 2014 study conducted by the Rollins School of Public Health at Emory University concluded that, despite having fewer sexual risk factors than their white counterparts, this population of men were likely to be younger, have less education, be unemployed, have more untreated rectal STDs, and be less likely to discuss HIV with a sexual partner.

These factors together create nothing short of a perfect storm for infection.

Poverty Fuels Infection Rates

Nearly one in every four African Americans lives in poverty, more than twice the rate seen in whites. On its own, poverty creates vulnerabilities by preventing the poor from accessing services that might otherwise prevent or treat infection.

This not only involves access to healthcare but extends to other parts of civil society, as well. Among them:

  • The lack of police and legal protections in poorer communities place vulnerable women, children, and others at risk of abuse.
  • Overtaxed and underfunded social services discourage many from seeking assistance for anything other than their most immediate needs.
  • The absence of substance abuse programs enables the spread of infection not only among users but their sexual partners, as well.
  • Low rates of medical insurance, particularly in states that refused Medicaid expansion, directly correlate to higher rates of HIV infection.

Over time, the failure of these institutions fuels a distrust in both government and authority in general. As a result, people will often access the services they feel are absolutely necessary (such as financial assistance and emergency medical) and avoid those that "can wait" (such as preventive health and treatment).

This largely accounts for why 22 percent of African Americans delay HIV testing until they are seriously, and sometimes critically, ill.

But it’s not just the late diagnoses doctors are worried about. Untreated sexually transmitted infections like gonorrhea, rampant in poorer communities, can increase the risk of HIV by as much 700 percent. Moreover, inconsistent medical care makes someone far less likely to reap the benefits of HIV therapy and far more likely to develop drug resistance.

In the end, poverty fuels infection by limiting and/or influencing the choices a person can make. Where other, richer communities have the means to overcome many of these barriers, poorer African American communities do not. The spread of HIV within these communities, therefore, occurs simply because there is nothing to stop it.

HIV Stigma Among African Americans

Despite vast changes in the public’s attitude, the stigmatization of people living with HIV persists. The impact of stigma can hit the African American community especially hard, both in situations where it is perceived (felt) and enacted (real).

The consequences of stigma can be profound. Often times, people will resist disclosing their HIV status for fear of being questioned about their sexual orientation or being labeled “promiscuous,” “unclean,” or “dishonest.”

This seems especially true in communities where religious doctrine can sometimes call for the support of people living with HIV while denouncing the behavior as aberrant. A survey conducted in 2014 by the non-profit Public Religion Research Institute concluded that 17 percent of churchgoers in the U.S. still believe that HIV is "God's punishment" for immoral sexual behaviors.

Among the groups most likely to embrace these beliefs are white evangelical Protestants (25 percent), Hispanic Catholics (21 percent), and black Protestants (20 percent).

In African American communities, where 95 percent of women consider religion central to their lives and 50 percent regularly pray or attend church, these attitudes are difficult to escape.

As a result, African Americans are more likely to state that there is a lot of stigma and discrimination toward people with HIV than either whites or Latinos. These attitudes play themselves out in many negative ways:

  • HIV-positive people who perceive stigma are more likely to drink excessively or report substance abuse.
  • People fearing HIV stigma and disclosure are more likely to avoid testing and consistent medical care.
  • Increased rates of depression often translate to an increase in high-risk behaviors.

Moreover, the perception of discrimination paired with actual shortcomings in government response appears to reinforce beliefs among many African Americans that HIV is not only inescapable but, in fact, intentional.

A study published in the April 2010 issue of Journal of the American Medical Association reported that of 1,351 African American men surveyed, 49 percent believed that HIV was engineered by the CIA to kill black people.

While some may find these types of conspiracies laughable or even offensive, most psychologists believe them to be a serious form of denial. Rather than confronting a disease they truly fear, people will often externalize the threat in order to rationalize their own inaction and feelings of hopelessness.

Urbanization and HIV

In the United States, HIV is largely an urban disease. Because these populations are dense and have a high rate of turnover, any infectious outbreak can spread rapidly unless aggressive action is taken by government to stop it.

Failure to do so can lead to the unacceptably high rates of infection seen in the South, where nine U.S. states (Arkansas, Alabama, Florida, Georgia, Louisiana, Mississippi, South Carolina, Tennessee, and Texas) today account for over 40 percent of new infections.

Because African Americans tend to be racially concordant in their selection of sexual partners (as opposed to whites who are more likely to choose partners of different races), the sexual networks in these communities tend to be smaller and denser. As a result, any infection in the community will stay in the community, increasing in numbers as more and more people arrive in search of employment opportunity.

In most of these urban centers, HIV infections are further fueled by governmental policies which actively discriminate against the poor. Among many of the shortcomings:

  • It is no accident that HIV rates are exponentially higher in states that refused Medicaid expansion, including Alabama, Florida, Georgia, Mississippi, South Carolina, and Texas. Research from the Women's Interagency HIV Study concluded that Medicaid, as its own independent factor, more than doubles a person’s likelihood of achieving an undetectable viral load.
  • Similarly, the states that banned needle-exchange programs are also the same states with the highest rates of new infections. These again include Alabama, Florida, Georgia, Mississippi, South Carolina, and Texas.

Because of these and other failures, overcoming the scourge of HIV in African American communities will take more than just treatment. It will require vast changes in public attitude and the ways in which health care and other vital social services are distributed to communities most in need.

Source:

Bogart, L.; Galvan, F.; Wagner, G; et al. "Conspiracy Beliefs about HIV Are Related to Antiretroviral Treatment Nonadherence among African American Men with HIV." Journal of Acquired Immune Deficiency Syndromes. April 2010; 53(5):648-655.

El-Bassel, M.; Caldeira, M.; Ruglass, L. et al. "Addressing the Unique Needs of African American Women in HIV Prevention." June 2009; 99(6): 996-1001.

Friedman, S.; Cooper, S.; and Osborne, H. "Structural and Social Contexts of HIV Risk Among African Americans." American Journal of Public Health. June 2009; 99(6): 1002-1008.

Fry, V.; Bonner, S.; Williams, K. et al. "Straight Talk: HIV Prevention for the African-American Heterosexual Male: Theoretical Bases and Intervention Design." AIDS Education Preview. October 2012; 24(5):389-407.

Sullivan, P.; Petersen, J.; Rosenburg, E. et al. "Understanding Racial HIV/STI Disparities in Black and White Men Who Have Sex with Men: A Multilevel Approach." PLoS One. 2014; 9(3): e90514.

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