[dropcap]A[/dropcap]s the United States Conference on AIDS (USCA 2015) will convene shortly (September 10–13) in Washington, D.C.—and its theme is “The Numbers Don’t Lie: It’s Time to End Disparities!”—it might be a good idea to preview some of those disparities when it comes to access to care and treatment.
To understand disparities in general, let’s look at the HIV care continuum. As AIDS.gov defines the continuum, it’s the “series of steps a person with HIV takes from initial diagnosis through their successful treatment with HIV medication.” The five steps include being tested and diagnosed, linked to care, engaged or retained in care, prescribed antiretroviral medicine, and achieving viral suppression.
According to updated 2015 CDC numbers, 1.2 million individuals are living with HIV in the U.S., with about 50,000 new infections occurring every year. Looking at the HIV care continuum, only eighty-six percent of these individuals are diagnosed. Eighty percent have been linked to care. Forty percent are engaged in care. Thirty-seven percent have been prescribed antiretroviral medications. And thirty percent are virally suppressed.
The optimal goal for the the best health outcomes is lowering one’s viral load and, if possible, achieving viral suppression. So the question becomes: How do we stop the cascade—the series of drop-offs in numbers along the care continuum? How do we engage individuals so that they test and then engage in care? And how do we engage in care the sixty-six percent of individuals (roughly three-quarters of 1 million individuals) who are diagnosed but not in care?
One approach is to tackle what prevents people from engaging in all the steps along the continuum. Barriers to care that create the disparities include systemic inequities fueld by homophobia, racism, sexism, discrimination, criminalization, and domestic abuse, among others.
Two of the most pernicious social drivers are racism and homophobia, and when they intersect, such as in the case of Black gay and bisexual men, the healthcare outcomes are life-threatening. According to an amfAR February 2015 issue brief, “HIV and the Black Community: Do #Black(Gay)Lives Matter?” while Black gay men represent only .2 percent of the U.S. population, they represent twenty-three percent of new infections in the U.S. While an overwhelming majority of African Americans (ninety-eight percent) are HIV-negative, only sixty-eight percent of Black gay men are negative. So, one in three Black gay men are HIV-positive, according to estimates.
The report argued that one way to improve linking Black gay men to care is to provide more targeted outreach. Department of Health and Human Services prevention programs could be doing a much better job at targeting Black gay men. Between fiscal years 2009 and 2011, the programs providing services to Black Americans aimed sixty percent of prevention services at heterosexual women, forty-five at heterosexual men, and thirty-nine percent at gay men (with some outreach focused on more than one population). Researchers pointed out that the level of outreach should match the rate of infections.
“This under-prioritization continues at the agency level,” the report continues. “A recent systematic review of funded primary HIV prevention interventions for youth from 1991 to 2010 found that only five interventions focused on gay and bisexual men, and none focused on young Black gay men. And the CDC’s Compendium of Effective Behavioral Interventions has only two of 84 behavioral interventions that focus specifically on Black gay men, only one of ten linkage and re-engagement in care interventions that focus upon Black or Latino gay men, and none of ten HIV medication adherence interventions that focus on Black gay men.”
But the scarcity of public-health interventions was only one reason why Black gay men are not making significant headway along the HIV care continuum. The report also pointed to a lack of social support, homelessness, and less access to healthcare (or substandard and/or discriminatory healthcare) as factors that contribute to this overall barrier to decreasing HIV infection risk and improving health outcomes for Black gay men.
The result is that only sixteen percent of Black gay men living with HIV are virally suppressed nationwide. Compare this to twenty-eight percent of Black Americans who are virally suppressed, and thirty percent of HIV-positive individuals in care as a whole. That’s about half of a number that is not too high to begin with.
This example of disparity is only one among many, and USCA will bring together experts across various fields to weigh in on what we can do to shrink the gap between diagnosis and linkage to care and viral suppression.
For more information about USCA, log on to: www.2015usca.org.
Chael Needle wrote about AIDS-related OIs and rates of survival in the July issue.