HIV in America---where do we go from here?

Dec 01 2010 Published by under Medicine

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 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.


Jemmott, L., Jemmott, J., & O'Leary, A. (2007). Effects on Sexual Risk Behavior and STD Rate of Brief HIV/STD Prevention Interventions for African American Women in Primary Care Settings American Journal of Public Health, 97 (6), 1034-1040 DOI: 10.2105/AJPH.2003.020271

DiClemente RJ, Wingood GM, Harrington KF, Lang DL, Davies SL, Hook EW 3rd, Oh MK, Crosby RA, Hertzberg VS, Gordon AB, Hardin JW, Parker S, & Robillard A (2004). Efficacy of an HIV prevention intervention for African American adolescent girls: a randomized controlled trial. JAMA : the journal of the American Medical Association, 292 (2), 171-9 PMID: 15249566

Petroll, A., DiFranceisco, W., McAuliffe, T., Seal, D., Kelly, J., & Pinkerton, S. (2008). HIV Testing Rates, Testing Locations, and Healthcare Utilization among Urban African-American Men Journal of Urban Health, 86 (1), 119-131 DOI: 10.1007/s11524-008-9339-y

Bogart, L., Wagner, G., Galvan, F., & Banks, D. (2009). Conspiracy Beliefs About HIV Are Related to Antiretroviral Treatment Nonadherence Among African American Men With HIV JAIDS Journal of Acquired Immune Deficiency Syndromes DOI: 10.1097/QAI.0b013e3181c57dbc

Romer, D., Sznitman, S., DiClemente, R., Salazar, L., Vanable, P., Carey, M., Hennessy, M., Brown, L., Valois, R., Stanton, B., Fortune, T., & Juzang, I. (2009). Mass Media as an HIV-Prevention Strategy: Using Culturally Sensitive Messages to Reduce HIV-Associated Sexual Behavior of At-Risk African American Youth American Journal of Public Health, 99 (12), 2150-2159 DOI: 10.2105/AJPH.2008.155036

Centers for Disease Control and Prevention (CDC) (2010). Prevalence and awareness of HIV infection among men who have sex with men --- 21 cities, United States, 2008. MMWR. Morbidity and mortality weekly report, 59 (37), 1201-7 PMID: 20864920

10 responses so far

  • James Sweet says:

    It is indeed yet another "subjective, unmeasured supposition," but it's worth noting that there are at least two distinct phrases meaning "MSM but not gay" in African-American slang, but no such slang term (that I am aware of) in other American communities. (Those terms being "on the DL" and "G-love") I was not aware of the former until I had to have somebody explain a billboard to me that was targeting this demographic for increased HIV awareness (the billboard was completely incomprehensible to me otherwise) and I was not aware of the latter term until somebody had to explain to me an episode of the The Boondocks. Man, nothing like needing someone to explain slang terms to you to make you feel old and extra-white...

    Not sure why I'm bringing it up, I guess it's just interesting. And I think it possibly reinforces the point that you are making, that targeting only the gay community is a mistake.

    • James Sweet says:

      By the way, the billboard showed two African American heterosexual couples, one sitting on a bench, the other strolling by, with the two men locking eyes in some sort of meaningful look while the women seemed not to notice. The text referred to "on the DL" in some way I can't recall, as well as encouraging HIV testing. From the mention of HIV, I was pretty sure I had more or less inferred the scenario that was being implied, but I still found the billboard very confusing until someone more hip than me explained it...

  • Jim Thomerson says:

    Saw in today's Austin paper that local clinics are beginning to routinely test for HIV. Figure given that one in five HIV infected are unaware.

  • I recently saw a study of a pre-exposure prophylactic protocol here:

    Healthy MSM who followed the regimen were 70% less likely to contract HIV. I can readily see the benefit for other demographics of People Who Have Sex With Other People. If I understand correctly, there's also potential for a similar protocol for other viral diseases like malaria. I think this is a watershed discovery. One of my readers thinks it is dangerous because the unintended consequence is that it will actually reduce condom use. Plus the lack of access to medical care for the populations who are most at risk.

    • Grep Agni says:

      If I understand correctly, there’s also potential for a similar protocol for other viral diseases like malaria.

      Malaria is neither viral nor spread by human-to-human contact. I'm not sure what disease you are thinking of, but malaria isn't it.

  • Grep Agni says:

    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.

    This is true, but perhaps misleading. According to this page among males in 2008 there were about the same number of injected drug transmissions as heterosexual sex transmissions -- 4,100 vs 4,700. The rates are far different for females -- 1,600 injected vs 9.000 hetero -- but as I understand it, most of the heterosexual transmission to females is from male injected drug users. Preventing transmission by drug users may be more important than the statistics indicate at first glance.

  • chall says:

    There is also the fact that African-American woman is the group that has the steepest curve of contracting HIV, looking at the statistics over the last 4 years. Maybe due to the fact that M2M transmission goes to women if you are indeed on the DL. Or maybe because that group was smaller before and therefore will grow exponentially once an epidemic is established? There is after all, a large community of people over 50 contracting hiv .... which surprised me quite a bit (I guess I have prenotions about sex, age and people?!? or that older people would protect themselves more?)

    I've tried to find some of the references I got at a talk yesterday when a sociologist/epidemiologist talked about the difficult task of talking about condom use since many of the sexual encounters are "non-planned" and adding the religious stigma of having planned sex/an affair/having sex with males as a male makes it more of a "it just happened" and then there will be no condoms. Sadly, it seems to be more accepted that way? As I said, I will try and find the references, it's in less biological/chem journals than I usually read ^^