Black & White

Fighting HIV in African-American Communities Gets a Boost from the Feds
by Larry Buhl

Dr. Garth N. Graham. Photo Courtesy Office of Minority Health
Amid the encouraging new HIV treatment options comes bad news and worse news regarding the HIV infection rate in the U.S. The CDC’s first multi-year estimates from its national HIV incidence surveillance found that overall, the annual number of new HIV infections in the United States was relatively stable at approximately 50,000 new infections each year between 2006 and 2009. The worse news: HIV infections are extremely high for young, black men who have sex with men (MSM). In response, the federal government is exploring new ways to combat HIV in African-American communities.
Plateaus & spikes
The incidence estimates, published recently in the on-line scientific journal PLoS ONE, show no statistically significant change in HIV incidence overall from 2006 to 2009, with an average of 50,000 for the four-year period. In 2009, the largest number of new infections was among white MSM (11,400), followed by black MSM (10,800), Hispanic MSM (6,000), and black women (5,400).
Health advocates and HIV experts agree that more than thirty years into the HIV epidemic, a plateau of 50,000 new infections is unacceptably high. What’s worse is the growing infection rate among young gay and bisexual men, and particularly young African-American MSM.
While blacks represent fourteen percent of the total U.S. population, the CDC estimated that they accounted for forty-four percent of new HIV infections in 2009. The HIV infection rate among black men was the highest of any group by race and sex—more than six times that of white men—and the rate among black women was fifteen times that of white women.
Other communities of color, while hit harder than whites, don’t come close to the infection rate of black men. Hispanics represent approximately sixteen percent of the total U.S. population, but accounted for twenty percent of new HIV infections in 2009. The HIV infection rate among Hispanics in 2009 was nearly three times as high as that of whites. The HIV infection rate among Hispanic men in 2009 was two and a half times that of white men, and the rate among Hispanic women was more than four times that of white women.
Young MSM of all races are heavily affected, but black MSM were the only group to experience a statistically significant increase in new infections over the four-year time period studied. The CDC estimates that new HIV infections among young, black MSM increased forty-eight percent during that period (from 4,400 HIV infections in 2006 to 6,500 infections in 2009).
The new CDC estimates put a numerical figure on what has been known in the medical and HIV advocacy groups for some time: that young, black gay and bisexual men are at the highest risk for contracting HIV. Studies suggest several reasons: stigma of HIV and homosexuality, which can hinder utilization of HIV prevention services; limited access to healthcare, HIV testing and treatment; higher rates of some sexually transmitted diseases among young black men, which can facilitate HIV transmission; and underestimating personal risk for HIV.
In the larger picture, racial disparity in HIV transmission and treatment mirrors that of other infectious diseases and illnesses, according to Garth N. Graham, MD, MPH, Deputy Assistant Secretary for Minority Health in the Office of Minority Health at the Department of Health and Human Services. “It’s poverty, it’s access to care, it’s where you live, it’s eating habits and even non-tangible factors like stress. But even when you correct for socioeconomic status, there are still racial disparities in who gets sick. The infant mortality rate is higher in African-American women who have a graduate degree than white women with a graduate degree. Why is this?”
Building a social network
Part of the National HIV/AIDS Strategy (NHAS), which was released by the Obama administration last year, was directed at reducing HIV/AIDS in the highest risk communities. To that end, the Minority AIDS Initiative (MAI) Fund, which totals approximately $53 million out of a $3.5 billion domestic AIDS budget for 2012, was refocused to “complement other public and private efforts consistent with the goals of the NHAS,” said Howard Koh, MD, assistant secretary of health for HHS, in a prepared statement.
“Priority consideration will go to funding activities that have been previously evaluated and demonstrated to have high impact, such as reducing disparate infection rates of HIV among women of color or to support interventions to address high rates of undiagnosed HIV infection among Black and Latino gay youth,” the statement said.
Until recently, there was little hope that the government could do anything about the gap between black and white. Graham says that these government entities are working together in several ways to target and eradicate the causes of HIV transmission among people of color in the U.S.: targeting urban populations with the highest HIV prevalence and highest rate of transmissions and boosting the training and recruitment of minority health providers and those who treat minorities.
It takes a while to recruit and train new doctors, Graham admits. The government can’t speed up that process, but it can ease the path for young doctors. “Young doctors have huge bills and will tend to look at other specialties. To that end we’re expanding our loan forgiveness, and making them aware of the programs that already exist to help out financially.” Graham also says that more intellectual investment is needed from the medical community in disparity research.
The federal government, and the Department of Health and Human Services in particular, is making it a top priority to eliminate racial and ethnic disparities in transmission of all diseases including HIV, according to Robert Herskovitz, Deputy Regional Health Administrator for Region Five in the HHS.
“We’re looking at ways individuals can be community health advocates, which is crucial in minority and immigrant communities,” Herskovitz tells A&U. “Many minority groups, and especially immigrants, receive and process health information in a different manner. They want face-to-face interactions with sources that are credible and trusted.”
To that end HHS is using every information stream to inform people about HIV risks, testing and treatment, Herskovitz says. “We use medical providers, plus state and county government leaders, faith leaders and community activists and advocates and bring them all to the table, let them air their concerns, provide them with information, coach them when necessary, and then let them spread the message to their communities. And we keep the pulse going.”
Herskovitz points to “Building a Healthier Chicago,” a collaboration of local and national leaders to promote better health and nutrition, as a model that can be used for reducing HIV infection. “People think of the Federal government as a force that comes in and gives a mandate and leaves. That doesn’t work. You don’t just give a speech or hand out information and walk away. We’re now creating something sustainable by creating community leaders who can mentor others and sustain the effort over the long term. What we can provide is help in managing the resources and crunching the numbers and seeing what’s working and what isn’t.”
Herskovitz and Graham won’t go into specifics on exactly how information is disseminated to and from communities of color in the U.S., partly because every community is a little different, and, they admit, because the community-based model is still a fairly new one and will continue to be tweaked. But the goals are clear: better ways to measure the epidemic, more data about affected populations, and development of new interventions to the hardest hit areas and populations. New biomedical tools such as pre-exposure prophylaxis (PrEP) for MSM and heterosexual men and women, along with expanded testing, treatment and linkage to care, could have an important impact on infection rates, Graham says.
Graham believes the government can play a significant role, but it can’t do everything. “The solution therefore isn’t just one thing. Solutions for reducing the disparity must all work together.”
The best strategy, Graham and Herskovtz agree, is for the Federal government to facilitate, analyze, and motivate, but to avoid the top-down strategy that’s been the hallmark of government intervention for decades. “It’s clear that social networking works,” Herskovitz says.
Larry Buhl wrote about the National Latino Hispanic AIDS Action Network in the August issue.

November 2011