Nmac Report on Hiv Among Minorities, Condoms in Prison - 2006
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PLEASE NOTE: THE REPORT AND PRESS RELEASE ARE EMBARGOED UNTIL THURSDAY, NOVEMBER 16, 2006 AT 10:00 AM (ET) / 7:00 AM (PT). AFRICAN AMERICANS, HEALTH DISPARITIES AND HIV/AIDS African Americans, Health Disparities and HIV/AIDS Recommendations for Confronting the Epidemic in Black America Robert E. Fullilove, Ed.D. Associate Dean for Community and Recommendations for Confronting the Epidemic in Black America Minority Affairs & Professor of Clinical Sociomedical Sciences Mailman School of Public Health Columbia University Draft: October 6, 2006 PLEASE NOTE: THE REPORT AND PRESS RELEASE ARE EMBARGOED UNTIL THURSDAY, NOVEMBER 16, 2006 AT 10:00 AM (ET) / 7:00 AM (PT). A REPORT FROM THE NATIONAL MINORITY AIDS COUNCIL BY ROBERT E. FULLILOVE, ED.D. COLUMBIA UNIVERSITY PLEASE NOTE: THE REPORT AND PRESS RELEASE ARE EMBARGOED UNTIL THURSDAY, NOVEMBER 16, 2006 AT 10:00 AM (ET) / 7:00 AM (PT). © November 2006 National Minority AIDS Council PLEASE NOTE: THE REPORT AND PRESS RELEASE ARE EMBARGOED UNTIL THURSDAY, NOVEMBER 16, 2006 AT 10:00 AM (ET) / 7:00 AM (PT). T his report was written on behalf of the National Minority AIDS Council (NMAC), the premier REPORT ADVISORY PANEL Adaora Adimora, M.D., M.P.H. Richard Payne, M.D. Associate Professor of Medicine, University of Professor of Medicine, Director, Duke North Carolina Institute on Care at the End of Life experts from a cross-section of disciplines — public health, A. Cornelius Baker National Policy Advisory, National Black Gay Beny J. Primm, M.D. medicine, HIV/AIDS advocacy, prisons and national AfricanAmerican leadership organizations — listed on this page. Men’s Advocacy Coalition national organization dedicated to developing leadership within communities of color to address the challenges of HIV/AIDS. It was reviewed by the panel of leading Carl Bean Bishop, Unity Fellowship Church Founder and Executive Director, Addiction Research and Treatment Corporation Chair Emeritus, NMAC Sheryl Lee Ralph The following organizations have endorsed African Julian Bond Actress/Broadway Legend, Americans, Health Disparities and HIV/AIDS: Chairman, National Association for the NMAC Spokesperson Recommendations for Confronting the Epidemic Advancement of Colored People (NAACP) in Black America: The Honorable Donna M. Christensen David Resnik, J.D., Ph.D. Bioethicist, National Institute of AIDS Housing of Washington, Seattle, WA Delegate to Congress (D-U.S.Virgin Islands) The AIDS Institute, Washington, DC The Honorable John Conyers, Jr. AIDS Project Los Angeles, Los Angeles, CA U.S. Representative (D-MI) AIDSNET, Bethlehem, PA Marian Wright Edelman Dean, Mailman School of Public Health, President, Children’s Defense Fund Columbia University Asian and Paciﬁc Islander Health Forum, Washington, DC Brotherhood, Incorporated, New Orleans, LA Comunity Health Outreach Workers (CHOW), Detroit, MI Debra Fraser-Howze President and CEO National Black Leadership Commission on AIDS Sandra L. Gadson, M.D. Community HIV/AIDS Mobilization Project Immediate Past President, (CHAMP), New York, NY National Medical Association Community Enrichment Organization, Tarboro, NC Joseph Gathe, Jr., M.D., F.A.C.P. Florida Department of Health, Bureau of HIV/AIDS, Clinical Instructor, Baylor College of Medicine Tallahassee, Florida Elizabeth Gaynes Harm Reduction Coalition, New York, NY and Executive Director,The Osborne Association Oakland, CA Bruce S. Gordon Health Education Resource Organization, Inc. (HERO), President, National Association for the Baltimore, MD Advancement of Colored People (NAACP) Lambda Legal, New York, NY The Honorable Barbara Lee Los Angeles Gay & Lesbian Center, Los Angeles, CA The National Black Alcoholism and Addictions Council, Inc., Orlando, FL U.S. Representative (D-CA) York, NY National Youth Advocacy Coalition, Washington, DC Project GRACE/Community Enrichment Organization, Tarboro, NC Saint Joseph’s Mercy Care Services, Inc., Atlanta, GA Total Health Awareness Team, Rockford, IL National Institutes of Health Allan Rosenﬁeld, M.D. David Satcher, M.D., Ph.D. Director, Center of Excellence on Health Disparities, Morehouse School of Medicine 16th Surgeon General of the United States Kimberly Y. Smith, M.D., M.P.H. Associate Professor of Medicine, Rush University Medical Center Valerie Stone, M.D., M.P.H. Associate Chief, General Medicine Unit, Massachusetts General Hospital Associate Professor of Medicine, Harvard Medical School The Honorable Louis W. Sullivan, M.D. President Emeritus, Morehouse School of Medicine David J. Malebranche, M.D., M.P.H. Former Secretary, U.S. Department of Health Assistant Professor, Emory University and Human Services School of Medicine National Black Leadership Commission on AIDS, New Environmental Health Sciences (NIEHS)/ Mark Mauer Executive Director,The Sentencing Project Marc Morial President, National Urban League The Honorable Maxine Waters U.S. Representative (D-CA) Phill Wilson Founder and Executive Director, Black AIDS Institute Frank Oldham, Jr. Executive Director, National Association of People With AIDS (NAPWA) African Americans, Health Disparities and HIV/AIDS: Recommendations for Confronting the Epidemic in Black America 3 PLEASE NOTE: THE REPORT AND PRESS RELEASE ARE EMBARGOED UNTIL THURSDAY, NOVEMBER 16, 2006 AT 10:00 AM (ET) / 7:00 AM (PT). Robert E. Fullilove, Ed.D. Robert E. Fullilove, Ed.D. is the Associate Dean for Community and Minority Aﬀairs and Professor of Clinical Sociomedical Sciences at Columbia University’s Mailman School of Public Health. He and his wife, Mindy Thompson Fullilove, M.D., currently co-direct the Community Research Group at the New York State Psychiatric Institute and Columbia University, as well as a newly formed degree program in Urbanism and the Built Environment. From 1995 to 2001, Dr. Fullilove served on the Board of Health Promotion and Disease Prevention at the National Academy of Sciences’ (NAS) Institute of Medicine (IOM). Since 1996, he has served on ﬁve IOM study committees that have produced reports on HIV/AIDS and other health topics. In 1998, he was appointed to the Advisory Committee on HIV and STD Prevention at the Centers for Disease Control, and was named its chair in 2000. He was designated a National Associate of the NAS in 2003, and was appointed to the National Advisory Council of the National Center for Complementary and Alternative Medicine at the National Institutes of Health in 2004. Dr. Fullilove was awarded an honorary doctorate from Bank Street College of Education in 2002. He currently serves on the editorial boards of Sexually Transmitted Diseases and Journal of Public Health Policy. The National Minority AIDS Council Since 1987, the National Minority AIDS Council (NMAC) has been dedicated to building the capacity of minority faith- and community-based organizations, AIDS service organizations and health departments addressing the challenges of HIV/AIDS in communities of color.To accomplish this mission, the agency provides conferences, capacity-building and technical assistance services, publications and online resources. NMAC’s advocacy arm represents these organizations on Capitol Hill, promoting sound national HIV/AIDS, health and social policies that ensure greater access to health care and services to those living with and/or at risk for HIV/AIDS, particularly in communities of color. For more information about NMAC’s programs and services, please contact us directly at: National Minority AIDS Council 1931 13th Street, NW Washington, DC 20009-4432 E-mail: email@example.com Web: www.nmac.org Telephone: (202) 483-6622 4 African Americans, Health Disparities and HIV/AIDS: Recommendations for Confronting the Epidemic in Black America PLEASE NOTE: THE REPORT AND PRESS RELEASE ARE EMBARGOED UNTIL THURSDAY, NOVEMBER 16, 2006 AT 10:00 AM (ET) / 7:00 AM (PT). TABLE OF CONTENTS Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 HIV and African Americans: A Close Look . . . . . . . . . . . . . . . . . . . . . . .9 African Americans, Health Disparities and HIV . . . . . . . . . . . . . . . . . . . 11 Marginalized Social Status and Stigma Contribute to Disease . . . . . . . . . . . . . . . 12 HIV Testing and the African-American Community . . . . . . . . . . . . . . . 13 Challenges to Implementing Large-Scale HIV Testing . . . . . . . . . . . . . . . . . . . . 14 Factors that Cause Poor Outcomes for African Americans With HIV . . . . . . . 14 Diagnosis at Advanced Disease Stages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Social and Environmental Factors That Diminish Treatment Success . . . . . . . . . . 14 Competing Financial Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Distrust of the Medical Establishment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 The Role of Injection Drug Use in HIV’s Spread . . . . . . . . . . . . . . . . . . . . . . . 15 Inadequate Government Funding for HIV/AIDS Services . . . . . . . . . . . . . . . . . 16 Epidemiological Impact of Poverty and Segregation . . . . . . . . . . . . . . . 16 The Rural HIV Epidemic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 The Epidemiological Consequences of Unstable Housing . . . . . . . . . . . . 18 Impact of Aﬀordable Housing on Community Desegregation . . . . . . . . . . . . . . . 18 Impact of Incarceration on HIV/AIDS in Black America . . . . . . . . . . . . 19 The Connection Between Incarceration, Poverty and Homelessness . . . . . . . . . . 20 HIV Transmission in Prisons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Incarceration, HIV Infection and the African-American Community . . . . . . . . . 21 Incarceration’s Impact on the Community’s Health . . . . . . . . . . . . . . . . . . . . . . 21 Policy Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Looking Forward . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 African Americans, Health Disparities and HIV/AIDS: Recommendations for Confronting the Epidemic in Black America 5 PLEASE NOTE: THE REPORT AND PRESS RELEASE ARE EMBARGOED UNTIL THURSDAY, NOVEMBER 16, 2006 AT 10:00 AM (ET) / 7:00 AM (PT). PLEASE NOTE: THE REPORT AND PRESS RELEASE ARE EMBARGOED UNTIL THURSDAY, NOVEMBER 16, 2006 AT 10:00 AM (ET) / 7:00 AM (PT). EXECUTIVE SUMMARY Over the past 25 years, AIDS has had a devastating impact residential instability is associated with school failure for children, a lack of access to on the African-American community.Today, African preventive health care and the aggravation of a host of chronic health conditions ranging Americans become infected with, and die from, HIV/AIDS from cardiovascular disease to HIV/AIDS (Anderson, St. Charles and Fullilove, 2003). far more than any other racial or ethnic group. Another important factor is the high rate of incarceration among African-American In 2004, the most recent year for which national males. Incarceration is one of the most important drivers of HIV infection among African surveillance data were available at the time of writing Americans. In addition to in-prison HIV risk behavior, such as unprotected sex and injection this report, African Americans comprised only 13% of drug use, there are important questions about the role that formerly incarcerated persons play the U.S. population but accounted for half of all new in transmitting HIV to others following their release from prison or in between periods of HIV/AIDS diagnoses. African-American adults and incarceration.There are also major concerns about the level of HIV education and treatment adolescents are 10 times more likely to have AIDS they may receive while in prison. than whites. The disease strikes subgroups of African Americans, especially young women and gay/bisexual, The population with the most disproportionate HIV burden is black MSM, who have HIV or same-gender loving, men (hereafter referred to as prevalence rates that are twice those of white MSM (MMWR, vol. 54 no. 24, 2005).There are men who have sex with men, or MSM). a number of reasons for this disparity. Evidence suggests that black MSM are tested for HIV In an era when antiretroviral therapy can help HIV-infected individuals lead healthier lives, African Americans with HIV/AIDS are more likely than other racial groups to postpone medical care and become hospitalized, with the less frequently and at later stages of their HIV infection, and are also less likely to have been previously aware that they were HIV positive, than MSM of other racial/ethnic groups. In addition, black MSM have higher rates of sexually transmitted diseases, which are known to facilitate the transmission and acquisition of HIV (Millett et al., 2006). result that they are more likely to die from HIV-related In addition, black MSM are less likely to identify as gay or disclose their sexual behavior to causes. In fact, more than half of all people who died from others. Research suggests that the homophobia and related stigma that many men feel for AIDS-related causes in the U.S. in 2002 were African being both African American and MSM carries into their experiences with the healthcare American. And while advances in medicine have resulted system, and can interfere with accessing HIV testing and other medical services (Malebranche, in AIDS deaths among whites falling by 19% from 2000 Peterson, Fullilove and Stackhouse, 2004). to 2004, they declined only 7% among African Americans (Kaiser Family Foundation, 2006). This report also focuses on traditional public health approaches to confronting HIV, such as testing and treatment eﬀorts. In September 2006, the U.S. Centers for Disease Control and HIV’s racial divide is not new. Each year when Prevention (CDC) issued new guidelines urging that HIV testing become a routine part of national surveillance data are released, we see the ever- medical care for U.S. adolescents and adults (ages 13-64).The CDC’s emphasis on testing is increasing toll the AIDS epidemic is taking on the based on evidence that HIV-positive persons who know their HIV status are signiﬁcantly less African-American community. Each year, we ask the likely to engage in HIV risk behaviors than those who are HIV-positive but unaware of their same question: Why is AIDS hitting black Americans status, and that ﬁnding HIV-infected persons who are unaware of their status will facilitate hardest? While much of the existing literature focuses their entry into treatment.While identifying undiagnosed infections is an important goal, we on quality of care, health care access or individual risk must look beyond medical interventions as the sole solution to our nation’s problem with behaviors, we believe that the HIV/AIDS epidemic in HIV/AIDS. By itself, a national testing strategy will not prevent or eliminate HIV/AIDS, African-American communities results from a complex particularly if it results in large numbers of individuals who have no access to care. Simply set of social, individual and environmental factors. By put, the epidemic is rapidly outpacing our eﬀorts to control it using standard public health, examining these underlying causes of African Americans’ infection-control procedures. vulnerability to the HIV/AIDS epidemic, this report attempts to provide an answer – and a way forward in the ﬁght against AIDS. What is needed? Given the social and economic characteristics of poor African-American communities, a more systemic approach must be taken to help build stable communities. Public policies that address the root causes of the health disparities that devastate the African- One factor that plays a particularly signiﬁcant role in American community are urgently needed.These policies must eﬀectively deal not only fuelling the African-American HIV epidemic is unstable with unstable housing and incarceration, but also with the poverty and social disadvantages of housing. When families need to spend too much of their poor African-American neighborhoods. Policies that address the role that homophobia plays income on rent and food, medical care and other basic in driving new HIV infections among black MSM must also be adopted so that programs necessities may be sacriﬁced (Freeman, 2002). Family mitigating that impact can be implemented. African Americans, Health Disparities and HIV/AIDS: Recommendations for Confronting the Epidemic in Black America 7 PLEASE NOTE: THE REPORT AND PRESS RELEASE ARE EMBARGOED UNTIL THURSDAY, NOVEMBER 16, 2006 AT 10:00 AM (ET) / 7:00 AM (PT). Policy Recommendations Homelessness, housing conditions, risk of incarceration and the concentration of poverty in 3. Eliminate the marginalization of, and reduce stigma communities of color are more than just “complicating factors” for people being treated for and discrimination against, black gay and other men HIV/AIDS.They are the forces that produce marginalized communities and marginalized who have sex with men. people. By addressing the underlying factors that create and maintain poor African-American communities, we can positively change the environment that fuels the black AIDS epidemic. • There is only one randomly controlled HIV prevention program, “Many Men, Many Voices”, The following policy recommendations would enable us to alleviate the root causes of speciﬁcally designed for black MSM. Investing in the African American HIV/AIDS epidemic, and improve the chances of survival for research to produce interventions that will work those living with HIV/AIDS: for a diverse population of black MSM is essential to a national prevention eﬀort that will reverse 1. Support the strengthening of stable African-American communities by addressing the need for more affordable housing. • Stabilizing housing is one of the most eﬀective methods for reducing HIV-related morbidity and mortality. Scarcity of aﬀordable housing is often at the root of residential segregation, school failure for children and a lack of access to health care. • Expanding federal programs such as Housing Opportunities for Persons With AIDS (HOPWA). These programs are critical in helping those with AIDS avoid homelessness, which in turn creates access to medical care and support services. 2. Reduce the impact of incarceration as a driver of new HIV infections within the African-American community by: • Providing voluntary, routine HIV testing to prisoners on entry and release. Policy reforms that establish voluntary, routine HIV testing upon prison entry and release will help connect those who are infected to treatment and also reduce risk behaviors that could put others – in prison and in the community – at risk. • Making HIV prevention education and condoms available in prison facilities. the course of the epidemic in this population. The CDC and the National Institutes of Health must aggressively establish a robust research portfolio to achieve this goal. • The empowerment of community leaders and organizations has been a critical element in our nation’s eﬀort to combat the HIV epidemic. More support must be leveraged to develop, promote and sustain leadership among black MSM and in organizations serving them. Additionally, sustained investment must be made to build the capacity of organizations developed to serve black MSM in order to eﬀectively change social networks, behavior and conditions contributing to HIV infections in this population. • Eﬀorts should be supported to address homophobia evidenced through stigma, discrimination and AIDS cases among the U.S. prison population are more than three times that violence that creates vulnerability to behaviors and of the general population (51 per 10,000 compared to 15 per 10,000 in 2003). conditions associated with risk for HIV infection Nonproﬁt organizations, government and public health agencies must be allowed among black MSM. to distribute condoms in prison facilities. Ensuring access to condoms in prisons would not only protect prisoners, but also the health and lives of the people in the communities to which they will return. 4. Expand HIV prevention education programs, promote the early identification of HIV through voluntary, routine testing, and • Expanding re-entry programs to help formerly incarcerated persons successfully transition back into society. connect those in need to treatment and care as early as possible. Prisons increasingly hold members of poor communities who are both under-educated and unemployable. Expanded access to employment training and educational programs • Far too many African Americans do not have accurate is necessary to improve their ability to function in society, and to address prisoners’ HIV information about how HIV is transmitted or can prevention, substance abuse, mental health and housing needs prior to their release. be prevented. Culturally relevant HIV prevention education programs are needed to help African Americans protect themselves and their partners. 8 African Americans, Health Disparities and HIV/AIDS: Recommendations for Confronting the Epidemic in Black America PLEASE NOTE: THE REPORT AND PRESS RELEASE ARE EMBARGOED UNTIL THURSDAY, NOVEMBER 16, 2006 AT 10:00 AM (ET) / 7:00 AM (PT). INTRODUCTION • Approximately 250,000 Americans are unaware Since the beginning of the HIV/AIDS epidemic, African Americans have been that they have HIV and may unknowingly transmit overrepresented among those living with and dying from AIDS. Today, the disease the virus to others. While proper safeguards must continues to aﬀect African Americans more than any other racial/ethnic group in the be in place to ensure that HIV testing is always United States. While African Americans represented 13% of the U.S. population, they voluntary, expanded HIV testing eﬀorts will help accounted for half of all Americans living with HIV/AIDS and made up half of new more people learn their HIV status, and allow HIV/AIDS diagnoses in 2004. The disease also continues to have a disproportionate those who test positive to seek early treatment and impact on subgroups of African Americans, especially young women and men who reduce their risk of transmitting HIV. have sex with men (CDC, 2005; Kaiser Family Foundation, 2006). The number of African Americans infected with HIV increased from 2001 to 2004, a trend consistent • One of the main factors contributing to with every surveillance report generated since eﬀorts to track the AIDS epidemic began disparate treatment outcomes for African in 1981 (CDC, 2006; Kaiser Family Foundation, 2006). Americans is that many are diagnosed at late stages of disease, when it is often too late for Why does AIDS strike America’s black community hardest? HIV/AIDS is one of a medications to be effective. host of other health conditions that disproportionately impacts African Americans. Access to treatment only partially explains this disparity. African Americans living with • Community health workers (e.g., lay health advisors, HIV/AIDS are more likely than whites to have no medical coverage (22% for Africans peer counselors, health aides) are critical bridges Americans compared to 17% for whites), and those who do have coverage are much between physicians and patients in communities where less likely to be privately insured than whites (14% compared to 44%) (Kaiser Family mistrust of the health care system exists. Community Foundation, 2006). But other factors are at work as well: homelessness, drug use, distrust health workers can serve as “interpreters” who can of the medical establishment and high rates of incarceration, to name some of the most eﬀectively communicate with patients about the signiﬁcant. Investigating how HIV/AIDS intersects with these other disparities can help care that is being provided. Such interventions have us understand why the disease is so prevalent – and so deadly – for African Americans. repeatedly been found to be eﬀective in clinical settings in which a multicultural, multiethnic patient In examining the causes of excess HIV-related morbidity and mortality among African population is being served. Americans, this report reviews the current literature on HIV/AIDS. The available body of research illuminates the relationship between structural forces in American society– 5. Reduce the number of HIV infections in the African- notably, the incarceration of African-American men and disparate health outcomes for American community caused by injection drug African Americans with HIV/AIDS. use through the expansion of substance abuse prevention programs, drug treatment and recovery The 16th volume of the HIV/AIDS Surveillance Report, published by the CDC in 2005, services, and clean needle exchange programs. provided a signiﬁcant portion of the data used in this report. The surveillance data were For active injection drug users, in particular, clean based on estimates of HIV infections from 35 areas – comprising 33 states, Guam and the needle exchange programs are needed to minimize U.S.Virgin Islands – that were, at the time of this writing, engaged in reporting both cases the risk of infection through needle sharing. of HIV infection as well as cases of AIDS1. These data provide the best available estimate of the current scope of the epidemic in the United States (CDC, 2005). • Because one in ﬁve (19%) new HIV infections among African Americans is from injection drug use, HIV AND AFRICAN AMERICANS: A CLOSE LOOK education programs are needed to prevent people from using drugs in the ﬁrst place, and substance abuse treatment programs are needed to help those The CDC estimates that 488,000–557,000 African Americans were living with HIV/AIDS currently using drugs to quit. For injection drug users in the United States in 2003. African Americans account for a growing share of AIDS who currently are addicted, clean needle exchange diagnoses over time, increasing from 25% of cases diagnosed in 1985 to 49% in 2004.This programs are needed to minimize the risk of infection translated into a 2004 AIDS case rate among African-American adults and adolescents that from sharing unclean needles. was more than 10 times that of whites (CDC, 2005; Kaiser Family Foundation, 2006). 1 The 35 areas are Alabama, Alaska, Arizona, Arkansas, Colorado, Florida, Idaho, Indiana, Iowa, Kansas, Louisiana, Michigan, Minnesota, Mississippi, Missouri, Nebraska, Nevada, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, South Carolina, South Dakota,Tennessee,Texas, Utah,Virginia,West Virginia,Wisconsin,Wyoming, Guam and the U.S.Virgin Islands. African Americans, Health Disparities and HIV/AIDS: Recommendations for Confronting the Epidemic in Black America 9 PLEASE NOTE: THE REPORT AND PRESS RELEASE ARE EMBARGOED UNTIL THURSDAY, NOVEMBER 16, 2006 AT 10:00 AM (ET) / 7:00 AM (PT). Table 1 Racial Disparities and HIV/AIDS: Estimated New Cases of HIV/AIDS among Whites, Blacks, Hispanics, 2001-2004 Figure 1 Estimated AIDS Diagnoses & US Population by Race/Ethnicity, 2004 AIDS Cases 42,514 US Population 293,655,404 White N (%) Black N (%) Hispanic N (%) Total* N (%) Males 38,218 (34) 49,704 (44) 22,062 (20) 112,106 (100) Females 7,262 (16) 30,483 (68) 6,610 (15) 45,146 (100) Total 45,479 (29) 80,187 (51) 28,673 (18) 157,252 (100) White, non-Hispanic 28% 69% African American 49% 13% Latino 20% 14% Asian/Paciﬁc Islander American Indian/ <1% Alaska Native 1% 1% 4% * Cases from the states that have used name-based HIV reporting systems for at least four years. Total includes estimates for Asian/Paciﬁc Islanders and American Indians/Alaska Natives, which are not shown here. Source: CDC, MMWR, February 10, 2006 Source: Kaiser Family Foundation In its February 10, 2006 Morbidity and Mortality Weekly Report (MMWR), which examined racial/ethnic disparities in diagnoses of HIV/AIDS, the CDC reported: Although blacks accounted for approximately 13% of the population of the 33 states during 2001-2004, they accounted for the majority (80,187 [51%]) of HIV/ Figure 2 AIDS Case Rate per 100,000 Population by Race/Ethnicity for Adults/Adolescents, 2004 AIDS diagnoses. Blacks accounted for the greatest percentage of cases diagnosed among males (44%) and the majority of cases among females (68%). Among males, 36% of MSM cases, 54% of IDU cases, 39% of MSM/IDU cases, and 66% of high- 72.1 risk heterosexual contact cases were in blacks. Among females, 70% of high-risk U.S. Case Rate = 17.1 heterosexual contact cases and 60% of the IDU cases were in blacks. Moreover, 69% of cases of perinatal transmission were among 75.0 7.1 blacks (MMWR, vol. 55 no. 5, 2006). 4.4 9.9 Signiﬁcantly, African Americans were also dramatically overrepresented in every age group of diagnosed cases. African American White Source: Kaiser Family Foundation Latino Asian/Paciﬁc American Indian/ Islander Alaska Native African Americans comprised 55% of individuals ages 15-24 diagnosed during this time period (MMWR, vol. 55 no. 5, 2006). African-American women were also overrepresented. In every category of transmission they constituted the majority of cases among all women. The high rates of HIV/AIDS among African-American 10 African Americans, Health Disparities and HIV/AIDS: Recommendations for Confronting the Epidemic in Black America PLEASE NOTE: THE REPORT AND PRESS RELEASE ARE EMBARGOED UNTIL THURSDAY, NOVEMBER 16, 2006 AT 10:00 AM (ET) / 7:00 AM (PT). women constitute one of the most alarming trends AFRICAN AMERICANS, HEALTH DISPARITIES AND HIV/AIDS in the epidemic in recent years. This trend continues to be particularly visible in the South, where African- Understanding the signiﬁcance of the health disparities of minority communities is American women constituted 72% of all reported cases. essential for assessing the impact of the HIV/AIDS epidemic on African Americans. African-American MSM were also disproportionately more likely to be HIV-positive than white MSM (Millet, et al., 2006). Although the majority of men who were living with AIDS as a result of male-to-male sex in 2004 were white (52%), preliminary data from the National HIV Behavioral Surveillance survey of MSM in ﬁve cities showed an HIV prevalence that was signiﬁcantly higher among African-American men (46%) as compared with whites (21%) or Hispanics (17%). More signiﬁcantly, in this study 67% of African-American respondents were not aware of their infection, compared to 48% of Hispanic respondents and 18% of white In its 2002 report, Unequal Treatment, the Institute of Medicine (IOM) traced the dimensions of racial health disparities in the United States. In addition to having higher rates of morbidity and mortality for conditions such as diabetes, cardiovascular disease, some forms of cancer and HIV/AIDS (MMWR, 2005), health care received by African Americans and Hispanics was of lower quality and more diﬃcult to access than that received by whites (IOM, 2002). Turning back the U.S. AIDS epidemic, the IOM maintained, will require signiﬁcantly reducing the number of new infections through HIV prevention eﬀorts and, for those who are infected, ensuring access to combination antiretroviral drug treatment (often referred to as highly active antiretroviral therapy or “HAART”) and necessary social services. respondents (MMWR, vol. 54 no. 24, 2005). Researchers using mathematical modeling have suggested that, with HAART, the HIV/ Finally, African Americans were overrepresented among AIDS epidemic might be contained. In a 2002 study modeling the impact of AIDS the estimated deaths among persons living with AIDS drugs on the spread of the HIV/AIDS epidemic,Velasco-Hernandez and colleagues during 1999-2003 (Figure 3), a period in which they out- concluded that antiretroviral medications “can function as an eﬀective HIV-prevention numbered those in every racial/ethnic category each year. tool, even with high levels of drug resistance and risky sex…even a high-prevalence Figure 3 Estimated Deaths of Persons Living with AIDS by year: 1999-2003 HIV epidemic could be eradicated using current ARVs” (Velasco-Hernandez, Gershengorn and Blower, 2002). But the converse also appears to be true. Failure to make appropriate treatment and service resources available will likely contribute to the continued expansion of the epidemic. The CDC reported that in 2003 only about half (55%) of 15- to 49-year olds who should be on antiretroviral therapy – approximately 268,000 individuals – were actually receiving it because of late diagnosis or other factors (CDC, 2005). Still, between 1995 (when the use of combination antiretroviral treatment became common for HIV disease) and 2004, the overall U.S. AIDS death rate declined by 70% (51,297 deaths in 1995 to 15,798 in 2004) (Kaiser Family Foundation, 2006). With reduced mortality, and an estimated 40,000 new infections each year, the number of individuals living with HIV has increased. Currently, the CDC estimates that there are more than 1.1 million people living with HIV – more than at any time in the epidemic (CDC, 2005). As this pool of infected people increases, the odds will also increase that the epidemic will maintain itself and expand in scope and signiﬁcance (Wilson, Gore, Greenblatt, Cohen, et al., 2004; R. Wallace, D. Wallace and Andrews, 1995; Wallace, Fisher and Fullilove, 1997). Simply put, as more people become infected, the chances increase that some infected individuals – particularly those unaware that they have HIV– will transmit the virus to others. Thus, an already signiﬁcant epidemic among African Americans will, in all likelihood, increase in scope. Black, not Hispanic White, not Hispanic Hispanic Asian Paciﬁc Islander American/Indian/Alaska Native The burden that an ever-growing HIV epidemic will place on the health care resources of African-American communities is diﬃcult to calculate, particularly because that system is already reeling under the weight of the excess morbidity and mortality from other conditions such as cardiovascular disease and diabetes. The HIV/AIDS epidemic is Source: CDC, HIV/AIDS Surveillance Report, 2005 African Americans, Health Disparities and HIV/AIDS: Recommendations for Confronting the Epidemic in Black America 11 PLEASE NOTE: THE REPORT AND PRESS RELEASE ARE EMBARGOED UNTIL THURSDAY, NOVEMBER 16, 2006 AT 10:00 AM (ET) / 7:00 AM (PT). part of a group of health conditions that, together, create signiﬁcant disparities between Homophobia and Transmission of HIV the well-being of African Americans and that of the general public in the United States (MMWR, vol. 54 no. 1, 2005; MMWR, vol. 55 no. 5, 2006). African-American men have the highest overall rates of HIV diagnosis of any population. In 2004, the HIV rate Marginalized Social Status and Stigma Contribute to Disease among black men was more than seven times higher than white men and almost twice as high as black Medical diagnosis and care are essential for reducing morbidity and mortality in any women. From 2001-2004, black MSM accounted for community. When access to care is diﬃcult, the management of any health condition roughly half (49%) of HIV diagnoses among African- becomes more challenging. If the management of a health condition is further American men (CDC, 2005). complicated because the patient is a member of a marginalized group, then there is greater likelihood that his or her illness will be poorly controlled and lead to a greater Homophobia and stigma are important contributing risk of death. What marks poor communities of color more than any other set of factors to this disparity. Until recently, homosexual characteristics is the degree to which the poverty of their residents creates and enforces intercourse was deﬁned as a crime in the penal code marginalized social status (Wilson, 1987; Wilson, 1996). of many states before being struck down by the U.S. Supreme Court (Lawrence v. Texas). However, Scientiﬁc evidence supports the assertion that the overrepresentation of African it still remains legal to discriminate against gay, Americans among those infected with and aﬀected by HIV is linked to marginalized lesbian, bisexual and transgender people in housing, social status. Hence, in communities of already marginalized residents, it is the employment and public accommodations across much marginalized among the marginalized – gay men, drug users, prisoners and formerly of the United States. Against this legal framework, incarcerated persons, the homeless, those living in extreme poverty and those who community and religious beliefs often stigmatize suﬀer from a variety of mental health disabilities – who are most likely to experience homosexuality as both immoral but also as anti-black. high rates of HIV-related mortality. Due to these factors and those of racism, black men in the broader community face multiple societal Stigma is also a part of the pattern of marginalization that aﬀects and inﬂuences interactions that can aﬀect their health. patterns of morbidity and mortality among African Americans. The Kaiser Family Foundation conducts surveys of HIV/AIDS awareness among the general public Black MSM are less likely to identify as gay or disclose every two years. The results consistently show signiﬁcant levels of ignorance their sexual behavior to others, which can negatively about AIDS and how the disease is transmitted. For example, while many African aﬀect their experiences with the healthcare system. Americans know that HIV can be transmitted through unprotected intercourse (99%) Malebranche and colleagues took a close look at the and that increasing condom use is very important to HIV prevention eﬀorts (89%), role that race and sexual identity have on the healthcare far too many still believe that HIV can be transmitted by kissing (38% of African experiences of HIV-positive and HIV-negative African Americans, compared to 33% of Hispanics and 26% of whites), sharing a drinking Americans. Researchers convened focus groups with glass with someone who has HIV (25% of African Americans, compared to 17% of 81 black MSM in New York and Atlanta. The group Hispanics and 15% of whites) or touching a toilet seat (13% of African Americans, was evenly divided between those who self-reported as compared to 14% of Latinos and 8% of whites). Kaiser concludes that such ignorance being HIV-negative or HIV-positive. The study found may well be at the core of much HIV-related stigma, inasmuch as a failure to fully that the social stigma the men felt in their daily lives for understand HIV contributes to both myths and misconceptions about the epidemic being both African American and MSM carried into (Kaiser Family Foundation, 2006). their experiences in the healthcare system, aﬀecting healthcare utilization, HIV testing, communication and In rural areas, as noted poignantly by Levenson in his landmark work The Secret adherence behaviors (Malebranche, Peterson, Fullilove Epidemic (2004), the generalized stigma associated with HIV infection, irrespective and Stackhouse, 2004). of the sex or sexual orientation of the patient, is also a major barrier to providing eﬀective treatment of HIV. Nonetheless, MSM – both those whose sexual orientation The study concluded that,“Issues around distrust, racial and behaviors are hidden from others (including men on the “Down Low”) and those and sexual orientation stigma, and fear of medical facilities, who are open about their sexual orientation – face particular challenges in their eﬀorts can serve as barriers to accessing services and open to live and function with HIV (Herek, 1999; Malebranche, Peterson, Fullilove and communication...This internalized displacement makes Stackhouse, 2004; Malebranche, 2005). healthcare access diﬃcult because BMSM [black MSM] do not feel comfortable within medical facilities themselves, 12 African Americans, Health Disparities and HIV/AIDS: Recommendations for Confronting the Epidemic in Black America PLEASE NOTE: THE REPORT AND PRESS RELEASE ARE EMBARGOED UNTIL THURSDAY, NOVEMBER 16, 2006 AT 10:00 AM (ET) / 7:00 AM (PT). not simply because of geographical, transportation, ﬁnancial also facilitate the transmission and acquisition of HIV (CDC, STD Surveillance, 2005). or insurance barriers” (Malebranche, Peterson, Fullilove Syphilis, like many other STDs, facilitates infection with HIV, increasing transmission of and Stackhouse, 2004).These ﬁndings have important the virus at least two-to-ﬁve fold (CDC, Syphilis & MSM, 2004). implications for containing the HIV epidemic. Over the past several years, increases in syphilis have been reported in several The considerable stigma and homophobia experienced major U.S. cities with large populations of MSM. In these recent outbreaks, high by many black MSM can also have an impact on their rates of HIV co-infection were documented, ranging from 20% to 70% (CDC, self-esteem and behaviors. One study found a reduction Syphilis & MSM, 2004). in self-esteem among black MSM who attended churches that fostered homophobia. For some black MSM, this Nationally, the rate of primary and secondary (P&S) syphilis among males increased loss of self-esteem “undermined the individual’s ability 81% between 2000 and 2004. Increasing cases of P&S syphilis among MSM are to practice safe sex, seek medical care in a timely fashion, believed to be largely responsible for the overall increase. The CDC estimates that MSM or follow other health practices essential to well-being” comprised 64% of P&S syphilis cases in 2004, up from just 5% in 1999. Among black (Fullilove and Fullilove, 1999). One of the study’s men, the syphilis rate increased 23% between 2003 and 2004, while the rate among conclusions was that “Rebuilding self-esteem is an black women rose only 2.4%, suggesting higher overall increases among black MSM important task for those involved with AIDS treatment (CDC, STD Surveillance, 2005). and prevention” (Fullilove and Fullilove, 1999). HIV TESTING AND THE AFRICAN-AMERICAN COMMUNITY Additionally, younger black MSM who do identify as gay are often subject to homelessness resulting from rejection With the 2003 launch of CDC’s “Advancing HIV Prevention” initiative, the federal in the family and violence which can contribute to sexual government’s focus on HIV prevention has placed an increased emphasis on testing. More risk-taking, survival sex, excessive alcohol or drug use and recently, in September 2006, the CDC issued guidelines recommending that all American behavior associated with depression. adolescents and adults (ages 13-64) be tested for HIV as part of their routine medical care. There is reason to believe that diﬀerence in HIV rates There are several reasons for the recent increased focus on testing. The ﬁrst is that for MSM of diﬀerent races/ethnicities may involve more one-quarter of the estimated 1.1 million people living with HIV in the United States– than risk behavior alone. In a 2006 review of the literature 180,000 to 280,000 individuals – are unaware of their HIV status and may transmit HIV over the past two decades, Millett et al. found that black without knowing that they are putting partners at risk. The CDC has found that once MSM were as, or less, likely than other MSM to engage people learn they are infected with HIV, most will take steps to reduce transmission to in unprotected anal intercourse, the single most important sex or drug-using partners. Another reason is the evidence that ﬁnding HIV-infected risk factor. They also have the same number or a smaller persons who are unaware of their status will facilitate their entry into treatment. To help number of male sexual partners than other MSM (Millett implement this guidance, the CDC is funding the availability of new rapid HIV tests to et al., 2006). So why are black MSM so much more ensure that those who are tested know their results as soon as possible. susceptible to HIV and its repercussions than their white or Latino counterparts? Compared to other racial groups, more African Americans believe that HIV testing should be treated just like routine screening for other diseases and should be included The data indicate that black MSM are tested less frequently as part of regular exams (71% of African Americans vs. 63% of Hispanics and 65% of and at later stages of their HIV infection, and are also less whites) (Kaiser Family Foundation, 2006). Nonetheless, data suggest that one-third likely to have been previously aware that they were HIV of African Americans have never been tested for HIV, with many believing that they positive than MSM of other racial/ethnic groups (Millett et are not at risk (Kaiser Family Foundation, 2004). A recent CDC study also found that al., 2006).This means many HIV-positive black MSM may more than two-thirds of HIV-positive African-American MSM were unaware of their not be accessing antiretroviral treatment, which can help infection (MMWR, 2006). them to remain healthy. Additionally, they may unknowingly transmit HIV to sexual and drug-using partners. The perception among some African Americans that they are not at risk has been cited as a major factor in the failure to be tested for HIV infection or seek treatment. For Black MSM – both HIV-positive and HIV-negative– example, in a survey of 5,750 MSM who were recruited from venues in seven major also have higher rates of sexually transmitted diseases urban centers in the United States and then tested for HIV infection, 91% of the such as syphilis, gonorrhea and chlamydia, which can African-American men in the sample who were HIV-positive were not aware that they African Americans, Health Disparities and HIV/AIDS: Recommendations for Confronting the Epidemic in Black America 13 PLEASE NOTE: THE REPORT AND PRESS RELEASE ARE EMBARGOED UNTIL THURSDAY, NOVEMBER 16, 2006 AT 10:00 AM (ET) / 7:00 AM (PT). were infected, compared to 60% of the white, HIV-infected respondents in the survey 1999) and are often unaware of the fact that they are HIV (XIV International AIDS Conference, 2002). The fact that 39% of African Americans infected (CDC, 2005; Smith, Brutus & Cathcart, 2003).The infected with HIV are diagnosed approximately one year before they develop AIDS CDC’s HIV/AIDS Surveillance Report for 2005 reports that suggests that timely awareness of infection status may save lives (CDC, 2005). 39% of HIV-infected African Americans were tested within one year of being diagnosed with AIDS.The prognosis for Challenges to Implementing Large-Scale HIV Testing survival for patients who initiate treatment at this stage is much less optimistic than for those who are diagnosed and A national strategy to increase the number of individuals who are tested for HIV treated early (McNaghten, Hanson, Dworkin, et al., 1999). infection and admitted to treatment is an important component of a national plan enough and large-scale testing eﬀorts are likely to face a number of challenges. Social and Environmental Factors That Diminish Treatment Success First, as noted in an IOM report on the Ryan White Comprehensive AIDS Resources Because the management of HIV disease is so complex, Emergency (CARE) Act – the comprehensive federal AIDS treatment program – if it is easy to understand why HIV care and research testing initiatives are successful in increasing the numbers of individuals who are has devoted considerable attention to identifying diagnosed and in need of treatment, there is no certainty that funding for new treatment individual-level risk factors that explain who is at risk, slots or for medications for low-income patients will be available (IOM, 2005; National who becomes infected, who is best served by HIV ADAP Monitoring Project, 2005). Thus, wide-scale HIV testing eﬀorts to make clinical care and who is most likely to experience Americans aware of their HIV status could create an ethical dilemma: a large number of treatment failure. The focus on individual patients is people who ﬁnd out they have HIV may have nowhere to turn for the medical care that understandable, since it is the individual who is treated can improve chances for survival. in the clinical setting. But the trends in the literature to prevent and ultimately eliminate HIV/AIDS. But testing alone clearly will not be on HIV care have made it clear that because treating In addition, there is the question of suﬃcient resources to undertake wide-scale HIV HIV disease is a complex enterprise for physicians, it testing. According to Cohen and colleagues (2005): is easy to overlook factors that arise from the patient’s social environment that limit the eﬀectiveness of HIV The new CDC strategy calls for increasing the percentage of people who know they clinical care. The following excerpt, taken from an article are infected from 75% to 95%. Achieving this goal would require that an additional published by Metsch and colleagues (2004), eloquently 160,000 HIV-positive people learn of their status. If the prevalence in the tested describes this challenge: population were 1-3%, then 5.3 -16 million people would need to be screened – more than could be screened by shifting the entire CDC HIV prevention budget Several real and perceived barriers exist to the four new prevention strategies (Cohen,Wu and Farley, 2005). that contribute to suboptimal provision of transmission reduction counseling to FACTORS THAT CAUSE POOR OUTCOMES FOR AFRICAN AMERICANS WITH HIV HIV-positive patients. For example, current antiretroviral therapy requires near perfect adherence, and thus providers may be spending The eﬃcacy of antiretroviral medications in treating HIV disease and in reducing HIV- a signiﬁcant amount of time counseling patients related mortality has been established since 1996 (Palella, Delaney, Moorman, et al., 1998; about the need to take their medications, leaving Palella, Chmiel, Moorman, et al., 2002). Conventional medical wisdom asserts that when little time for discussion of risk reduction. In appropriate treatment guidelines are followed and patients adhere to the regimens that addition, physicians place diﬀerent levels of have been prescribed, HIV/AIDS can be managed much like any other serious, chronic emphasis on provision of this information to disease. Why then, in the era of HAART, are African Americans at such elevated risk for newly diagnosed and established patients. In the HIV-related mortality? Some of the key factors are discussed below. case of newly diagnosed patients, our ﬁndings indicated that perceived time constraints, patient Diagnosis at Advanced Disease Stages load, and physicians’ perception that patients had psychosocial problems were barriers to the In general, the studies conﬁrm the assertion that African Americans are more likely to enter delivery of transmission reduction counseling. treatment with advanced HIV disease (CDC, 2005; Fleishman, Gebo, Reilly, et al., 2005; Consequently, physicians with larger patient loads Gebo, Kelly & Diener-West, 2001;Welch & Morse, 2001; Shapiro, Morton, McCaﬀrey, et al., and those with a higher proportion of patients 14 African Americans, Health Disparities and HIV/AIDS: Recommendations for Confronting the Epidemic in Black America PLEASE NOTE: THE REPORT AND PRESS RELEASE ARE EMBARGOED UNTIL THURSDAY, NOVEMBER 16, 2006 AT 10:00 AM (ET) / 7:00 AM (PT). with mental health or substance abuse problems Distrust of the Medical Establishment may have less time to address prevention issues. However, these patients are particularly in Bogart and Thorburn (2005) conducted one of the largest surveys of African Americans need of HIV prevention counseling, in that concerning their belief in conspiracy theories about the origins of HIV/AIDS and the mental health and substance use problems can manner in which the African-American community’s AIDS epidemic is being addressed. have negative eﬀects in terms of medication They found strong endorsement of many of these beliefs and reported a signiﬁcant adherence, viral load suppression, and HIV drug correlation between endorsing conspiracy beliefs and negative attitudes towards, and reported resistance (Metsch, Pereya, del Rio, et al., 2004). inconsistent use of, condoms among men in their survey. Fullilove (2001), in an analytic essay about belief in conspiracy theories among African Americans, suggested that attitudes toward The challenge of treating HIV is further complicated HIV testing and treatment may be aﬀected by a perception that AIDS is a plot to destroy the when the patient is impoverished and living in socially African-American community. Other authors have similarly observed a strong relationship marginal circumstances (Smith, Brutus, Cathcart, et between mistrust of institutions and participation in AIDS research (Sengupta, Strauss, al., 2003; Moss, Hahn, Perry, et al., 2004). Working to Ronald, et al., 2000). And in a widely cited paper,Thomas and Quinn (1991) suggested that change the factors that create marginalization must be the lingering memory of the Tuskegee Syphilis Study and other negative impressions held part of the solution. by African Americans of the U.S. health care system may have signiﬁcant impact on the eﬀectiveness of HIV prevention programs. Competing Financial Needs Nessel and Primm (2004) conducted opinion surveys on AIDS’ origins among men and The HIV Cost and Services Utilization Study reported women who work in the ﬁeld of HIV treatment and prevention at a variety of national that failure to have transportation or the means of and international medical conferences.The questions included items on the role of the U.S. meeting a variety of competing needs strongly predicted government in causing the HIV pandemic or in being responsible for withholding the access to and use of medical care (Cunningham, cure for AIDS. In their analysis of 1,440 completed surveys, the authors found high levels of Anderson, Katz, et al., 1999). As Cunningham and distrust in conventional explanations for the origins of AIDS.The authors concluded that such colleagues observed: levels of distrust could have an impact on the general willingness of African Americans to be tested for HIV or listen to a physician’s advice about adhering to HIV-related treatments. In this nationally representative sample of persons receiving care for HIV infection, Although it is possible that mistrust of institutions and the health care system account we found that competing subsistence for much of the failure of at-risk African Americans to be tested or treated, these beliefs needs and other barriers were commonly often stem from the general lack of access that African Americans have to medical reported: greater than one third of the sample care, as well as to the poor outcomes that they experience in many of their encounters (representing >83,000 persons nationally) with clinicians (IOM, 2002). In fact, it is possible that the mistrust described in studies went without or postponed care at least once of HIV conspiracy theories simply reﬂect African-American patients’ reactions to the in a 6-month period as a result of at least one manner in which they are treated by clinicians, many of whom are biased with regard of the four reasons we assessed. In addition, to their expectations of their African-American patients: an estimated 17,000 persons in the United In a study based on actual clinical encounters, researchers found that doctors States who were receiving regular care went rated black patients as less intelligent, less educated, more likely to abuse drugs without food, clothing, or housing because and alcohol, more likely to fail to comply with medical advice, more likely they needed the money for medical care. In to lack social support, and less likely to participate in cardiac rehabilitation general, non-whites, drug users, and persons than white patients, even after patients’ income, education, and personality in lower socioeconomic groups were more characteristics were taken into account (IOM, 2002). likely to report these problems than those in other groups. The Role of Injection Drug Use in HIV’s Spread The lack of money and access to a variety of daily As noted earlier in this report, African-American patients who are most likely to necessities has been consistently shown to inﬂuence experience higher rates of mortality are also more likely to be members of highly HIV risk behavior as well as use of HIV-related services marginalized groups. In all too many cases, being a member of any one marginalized (Messeri, Aidala, Lee, et al., 2002). group is a risk factor for becoming a member of one or more marginalized groups. This chain of marginalization often begins with drug use. African Americans, Health Disparities and HIV/AIDS: Recommendations for Confronting the Epidemic in Black America 15 PLEASE NOTE: THE REPORT AND PRESS RELEASE ARE EMBARGOED UNTIL THURSDAY, NOVEMBER 16, 2006 AT 10:00 AM (ET) / 7:00 AM (PT). Drug use is a particularly important risk factor for HIV infection among African Americans and Hispanics. Injection drug use (IDU) accounts for more than 19% of Inadequate Government Funding for HIV/AIDS Services new African-American HIV infections in this country (CDC, 2006). HIV infection associated with injection drug use was 2.4 times and 2.6 times more prevalent among While lack of health insurance is certainly a major African Americans and Hispanics, respectively, than whites living with HIV/AIDS in barrier in African Americans’ access to HIV services the United States in 2004. (IOM, 2002), lack of government funding to provide services through legislation such as the Ryan White IDU is associated with high rates of hospitalization for HIV disease as well as poor CARE Act remains an obstacle. The CARE Act is the treatment outcomes (Betz, Gebo and Barber, 2005: Fleishman, Gebo, Reilly, et al., 2005; comprehensive federal funding program designed to Welch and Morse, 2001). The HIV Research Network, a federally funded network promote access to treatment, appropriate medications of HIV providers, has yielded a number of important studies of those seeking in- through the AIDS Drug Assistance Program (ADAP) patient and out-patient care for HIV disease. In a study of more than 8,000 patients and ancillary social services, such as housing through in six cities, Betz and colleagues found that African-American women accounted for the Housing Opportunities for Persons With AIDS a disproportionately high percentage of AIDS-deﬁning illness hospitalizations among (HOPWA) program. women. Moreover, African Americans were more likely to be hospitalized with comorbid mental health conditions than whites. They conclude: “These results emphasize While essential, the CARE Act has not proven to be the signiﬁcant burden of co-morbid disease resulting from drug and alcohol use by a panacea for meeting the needs of those living with adults infected with HIV, and support previous ﬁndings of an increased prevalence of HIV disease. A 2005 IOM study, “Public Financing substance abuse and psychiatric disorders among individuals with HIV” (Betz, Gabo and Delivery of HIV/AIDS Care: Securing the and Barber, 2005). Legacy of Ryan White,” concluded that current public funding of HIV/AIDS care under the CARE Increased access to quality drug prevention and treatment programs is needed to Act was, at best, a patchwork of services and access to reduce the number of African Americans who put themselves at risk of acquiring necessary medications: HIV by sharing contaminated needles. For those currently addicted, needle exchange programs have been shown to be an eﬀective HIV prevention method. However, Current public ﬁnancing strategies for a federal ban in place since 1989 prohibits the use of federal funds to support such HIV care have provided care and extended programs. Opponents of needle exchange programs argue that such eﬀorts endorse or the lives of many low-income individuals. could encourage injection drug use.Yet seven federally funded reports agree that access Signiﬁcant disparities remain, however, in to sterile syringes does not encourage people to increase or initiate drug use (Harm assuring access to the standard of care for Reduction Coalition, 2001). HIV across geographic and demographic populations. The current federal-state A study of HIV cases in Baltimore, a city with a large African-American and IDU partnership for ﬁnancing HIV care has been population, found that the percentage of HIV cases attributed to IDU decreased from unresponsive to the fact that HIV/AIDS 60% of all cases in 1994 to 41% in 2003 after the city instituted a needle-exchange is a national epidemic with consequences program. Nationally, a study by the National Institutes of Health and the Institute of that spill across state borders. State Medicaid Medicine demonstrated that needle exchange programs contribute to 80% reductions programs that provide a signiﬁcant in risk behaviors among IDUs and at least a 30% reduction in HIV transmission proportion of coverage for HIV care have (AIDS Action, 2001). been widely varying resources and priorities, which in turn produce an uneven and Despite the ban on federal funds, all states except New Jersey currently allow legal therefore ineﬀective approach to managing access to syringes. The percentage of New Jersey’s AIDS cases attributed to IDU is the epidemic (IOM, 2005). almost double the national average (44% compared to 24% nationally). As of October 2006, a bill was pending in the New Jersey legislature that would sanction state funding for needle exchange programs (Kaiser Family Foundation, State Health Facts, 2005). EPIDEMIOLOGICAL IMPACT OF POVERTY AND SEGREGATION Even today, the United States remains in many ways a racially and economically segregated country in which poverty is disproportionately concentrated in African- 16 African Americans, Health Disparities and HIV/AIDS: Recommendations for Confronting the Epidemic in Black America PLEASE NOTE: THE REPORT AND PRESS RELEASE ARE EMBARGOED UNTIL THURSDAY, NOVEMBER 16, 2006 AT 10:00 AM (ET) / 7:00 AM (PT). American and Hispanic neighborhoods (U.S. Census, Figure 4 2005). In a 2003 study by Anderson, et al., the authors describe this phenomenon: Social, political, and economic forces have historically concentrated large numbers of lower-income African Americans in central cities, and continued racial discrimination in housing markets impedes their movement out of these areas. Despite a reduction in racial segregation over recent decades, African Americans remain highly over-represented within the populations of impoverished neighborhoods. In 1990, 17.4% of all African American residents of the country’s metropolitan areas lived in extreme poverty neighborhoods, compared with only 1.4% of Source: New York City Department of Health and Mental Hygiene, Health Disparities in New York City, 2004. all white residents. At the same time, within the 100 largest central cities, 24.2% of all The same concentration of poverty and HIV can be seen in neighborhoods in other parts of African Americans, but only 3.2% of whites, the country.The District of Columbia, which has the nation’s highest AIDS case rate – lived in extreme poverty neighborhoods, 162.4 per 100,000 in 2002, compared to 14.8 per 100,000 nationwide, and 60% of whose with African Americans representing more residents are African American – is another example.The District is heavily segregated, with than 50% of the population in these areas. 57% of its black residents living in just three of its eight wards,Wards 5, 7 and 8 – the city’s (Anderson, et al., 2003) poorest. In Wards 7 and 8, more than 90% of the population is African American (District of Columbia DOH, 2004).The AIDS case rate among black women in Ward 8 is 83 per 10,000, Although health and disease are characteristics of individuals, compared to 63 per 10,000 for District women overall. health disparities are seen in those areas, both urban and rural, where many African Americans live.This can be seen Other cities with large, geographically and economically segregated African-American when patterns of health disparities are aggregated by race/ populations are similarly hard hit by HIV/AIDS. Los Angeles County has more ethnic group and by community. residents living in poverty than any other large metropolitan area in the United States, and is also home to the nation’s largest county jail (LAC Department of Health Services Cancers, cardiovascular disease, sexually transmitted and Public Health, 2004). In Los Angeles County, HIV infection rates are also highest diseases, homicides and violent victimizations are more for African Americans (81 cases per 100,000 for blacks compared to 36, 33 and 11 per prevalent in poor neighborhoods of color than they are 100,000, respectively, for Hispanics, whites and Asians). Baltimore, whose population is in more aﬄuent communities (Task Force, 2003; New 64% African American, follows Washington, DC in terms of AIDS death rate York City Department of Health [NYC DOH], 2004). (117 and 162.4 per 100,000, respectively). And in Chicago, where African Americans accounted for 60% of new AIDS diagnoses in 2004, the AIDS diagnosis rate was more New York City, the epicenter of the U.S. HIV epidemic than three times that of whites and twice that of Hispanics (Chicago Department of and the nation’s largest city, is a prime example. New Health, 2005). York has more cases of persons living with HIV/AIDS and more AIDS-related mortality than any other urban The Rural HIV Epidemic area in the United States (CDC, 2006; NYC DOH, 2006). Figure 4 contains two maps illustrating deaths Poverty, segregation and disease burden aren’t conﬁned to urban areas, of course, and HIV from AIDS and diabetes, both common causes of disproportionately strikes African Americans in rural areas, particularly in the Southeast. death among the poor. These maps show that the city’s poorest neighborhoods, which are heavily populated by In 1999, 22% of new AIDS cases in the Deep South (Alabama, Georgia, Louisiana, African Americans, have the highest rates of AIDS- and Mississippi, North Carolina and South Carolina) were in non-metropolitan areas– diabetes-related deaths (NYC DOH, 2004). nearly three times the percentage in other Southern states and the North Central African Americans, Health Disparities and HIV/AIDS: Recommendations for Confronting the Epidemic in Black America 17 PLEASE NOTE: THE REPORT AND PRESS RELEASE ARE EMBARGOED UNTIL THURSDAY, NOVEMBER 16, 2006 AT 10:00 AM (ET) / 7:00 AM (PT). region, more than ﬁve times the percentage in the West and more than seven times that Perhaps most important of all, with a reduction in drug in the Northeast. In these Southern states, where the percentage of African Americans use and criminal activity, the risks of incarceration for in the population is the highest in the country, half of African Americans live below community residents would also decrease. As will be 200% of the poverty line and they have signiﬁcantly less access to healthcare than described, incarceration is a driving force in maintaining people of other races and ethnicities (Reif, Geonnotti, Whetten, 2006). the HIV/AIDS epidemic in these communities; therefore, stabilizing housing and stabilizing neighborhoods so that In a landmark study of rural, HIV-positive African Americans ages 18-59 in North they have less crime becomes one of the most eﬀective Carolina with heterosexually acquired HIV infection, study participants were methods for reducing HIV-related morbidity and mortality. substantially more likely than control groups to be poor, undereducated, have been homeless in the past 10 years, report concerns about having enough food for themselves and their families in the past month and have been incarcerated. They Impact of Affordable Housing on Community Desegregation also reported more lifetime sex partners, higher rates of exchanged sex, higher rates of STD diagnosis, more drug use, more partners who were injection drug users and The disproportionate impact of HIV/AIDS in urban more concurrent sexual relationships in the past ﬁve years (Adimora, Schoenbach, African-American communities is, as has been suggested Martinson, Coyne-Beasley, et al., 2006). in this report, a function of the same set of forces that create residential segregation, the concentration of THE EPIDEMIOLOGICAL CONSEQUENCES OF UNSTABLE HOUSING poverty in segregated communities and the geographical concentration of health disparities. New York City, one Homelessness is the most extreme form of a growing national problem: the of the nation’s most racially segregated urban centers, increasingly inadequate supply of aﬀordable housing. Increasing the availability of also has one of the most segregated HIV epidemics. aﬀordable housing, reducing residential segregation and decreasing the number of As noted in Table 2, rates of persons living with HIV/ households living in extreme poverty are key goals of the Department of Housing and AIDS in selected, largely African-American/Latino Urban Development’s (HUD) 2000-2006 Strategic Plan (HUD, 2000). neighborhoods of New York City can be represented as a percent of the community’s total population. When families need to spend too much of their income on rent and food, medical care and other basic necessities may be sacriﬁced (Freeman, 2002). Family residential instability is associated with school failure for children, a lack of access to preventive health care and the aggravation of a host of chronic health conditions ranging from Table 2 HIV/AIDS Prevalence in Select New York City Neighborhoods, 2004 cardiovascular disease to HIV/AIDS (Anderson, St. Charles and Fullilove, 2003). Population Diagnosed with HIV (%) Unstable housing and extreme poverty exert enormous pressures on the social Bronx 1.2 functioning of neighborhoods. Crime tends to ﬂourish, particularly drug-related oﬀenses. Crotona-Tremont 2.1 These trends are particularly evident among young men (Fagan, 2004). The prevalence Morrisania 2.4 of violent crime has an enormous eﬀect on the perceptions of residents that it is safe to Mott Haven 2.3 walk, shop and interact with their neighbors (Klinenberg, 2004). Moreover, the prospect of traveling long distances through unsafe neighborhoods to seek clinical services is a factor in the failure to seek medical care for a variety of health conditions (Fullilove, Fullilove, Stevens and Green, 2001). Hence, increasing the conﬁdence of residents of poor neighborhoods that they can move about freely and can interact freely with their neighbors will increase the social cohesion of the community (Fullilove, 1998). One obvious impact of increased social cohesion will be increased “social capital” available to children and their families (Fullilove, Green and Fullilove, 2000). In this Brooklyn 1.0 Bedford-Stuyvesant 1.8 East New York 1.4 Manhattan 2.0 Central Harlem 2.6 East Harlem 2.6 Source: New York City Department of Health and Mental Hygiene, 2006 context, social capital refers to beneﬁts that result from membership in social networks It is impossible to conceive of eﬀective HIV prevention that are often intangible (e.g., advice about how to get a job, providing a referral to a and treatment interventions that do not also target the person or a service, etc.). As the quality of neighborhood life improves, many of the environmental forces that drive the epidemic and that risks associated with adolescent drug use and sexual risk behaviors are also reduced comprise eﬀorts to treat it eﬀectively. Thus, a focus on (Leventhal and Brooks-Gunn, 2000). reducing neighborhood segregation, increasing the pool 18 African Americans, Health Disparities and HIV/AIDS: Recommendations for Confronting the Epidemic in Black America PLEASE NOTE: THE REPORT AND PRESS RELEASE ARE EMBARGOED UNTIL THURSDAY, NOVEMBER 16, 2006 AT 10:00 AM (ET) / 7:00 AM (PT). of aﬀordable housing, and intervening to assist residents There have also been studies that speciﬁcally address race and treatment outcomes to make their communities safer will signiﬁcantly and adherence to HIV treatment regimens, which is crucial to the eﬀectiveness of improve the health of community residents: antiretroviral treatment. Moss and colleagues (2004) examined adherence to HAART in a 12-month prospective study of 148 homeless or unstably housed individuals in San The importance of housing policy that attempts Francisco. They found that “African-American ethnicity predicted both discontinuation to deconcentrate neighborhood poverty while of therapy and low adherence in those who continued to receive therapy. Adherence in providing aﬀordable housing to low-income African-American subjects was 60%, compared with 81% in all other subjects” (Moss, families can be seen in the strong emphasis Hahn, Perry, et al., 2004). placed on income mixing within the HOPE VI Urban Revitalization Demonstration Program Given the social and environmental forces that drive the HIV/AIDS epidemic as well (Salama, 1999), the federal government’s program as a host of other health disparities, working to improve housing and neighborhood for the physical and social revitalization of quality of life will have obvious beneﬁts for improving both community and overall distressed public housing. Such an emphasis is in public health. As the National AIDS Housing Coalition states, “Stable, aﬀordable sharp contrast to the public housing program’s housing oﬀers the best opportunity for persons living with HIV/AIDS to access record of concentrating poverty by routinely drug therapies and treatments and supportive services that will enhance the quality constructing developments in impoverished of life for themselves and their families. When people are housed, they can access and areas and reserving units for the poorest of adhere to drug treatments and therapies and require fewer hospitalizations and less households, practices which are believed to be emergency room care” (National AIDS Housing Coalition, 2006). Stable housing is, largely responsible for many of public housing’s therefore, a cornerstone of HIV prevention and care. Policies that improve the ability most recognized failures: environments of of individuals to acquire stable housing will, in turn, stabilize the communities in violence, substance abuse, welfare dependency, which they live. teen pregnancy, unemployment, and lowered educational achievement among youth IMPACT OF INCARCERATION ON HIV/AIDS IN BLACK AMERICA (Anderson, et al., 2003). America’s prison population – 2.13 million in 2004 – is larger today than ever before, An examination of HIV treatment outcomes for the and incarceration rates among ethnic minorities continue to be disproportionately homeless, conducted by the National Housing and high. Nationwide, 41% of prisoners are African American (Golembeski and Fullilove, HIV/AIDS Research Summit, highlights the linkage 2005). For these reasons, America’s prisons play a central role in the social, economic between marginal social status and health (Gelberg, and health disparities experienced by the African-American community, and the HIV/ Gallager and Anderson, 1997): AIDS epidemic is merely one consequence of the close connection between prisons and poor communities of color (Lemmelle, 2003). Indeed, research shows that housing is a matter of life and death for persons living with HIV/ Some 90% of prisoners are male. In 2004, African-American males were seven times more AIDS. The all-cause death rate among homeless likely than white males and three times more likely than Hispanic males to be imprisoned HIV-positive persons is ﬁve times the rate of (4,919 prisoners per 100,000 black males compared to 1,717 prisoners per 100,000 Hispanic death among housed persons with HIV/AIDS: males and 717 prisoners per 100,000 white males, respectively) (U.S. Dept. of Justice, Bureau 5.3 to 8 deaths per 100 person years for HIV- of Statistics, 2005). In addition, African Americans are signiﬁcantly more likely to go to positive homeless persons, compared to 1 to 2 prison if arrested than whites (Bureau of Justice Statistics, 2004; Mauer, 1999;The Sentencing deaths per 100 person years for HIV-positive Project, 2005).The federal government’s “War on Drugs,” which led to dramatic increases persons who are housed (National AIDS in the U.S. prison and jail population, also contributed to higher rates of imprisonment of Housing Coalition, 2005). African Americans (Mauer, 1999). More recently, a study presented at the XVI International Hammett and colleagues examined data on infectious diseases among prisoners in 1997 AIDS Conference found that homeless individuals suﬀering and estimated that between 150,000 and 200,000 people living with HIV infection passed from HIV/AIDS were in urgent need of additional social through a U.S. correctional facility - approximately one-quarter of all people living with support and better care in order to achieve improved HIV in the country (Hammett, Harmon and Rhodes, 2002).They also estimated that other treatment outcomes (Kidder, et al, 2006). African Americans infectious diseases such as tuberculosis (TB) and hepatitis C, which are often co-morbid with comprised 70% of study subjects. HIV, were overrepresented within correctional institution populations. Some 29-43% of African Americans, Health Disparities and HIV/AIDS: Recommendations for Confronting the Epidemic in Black America 19 PLEASE NOTE: THE REPORT AND PRESS RELEASE ARE EMBARGOED UNTIL THURSDAY, NOVEMBER 16, 2006 AT 10:00 AM (ET) / 7:00 AM (PT). people in the United States living with hepatitis C and 40% of the persons living with TB facility. Over a 16-year period (July 1988 through disease passed through correctional facilities in 1997 (Hammett, Harmon and Rhodes, 2002). February 2006), a total of 88 male prisoners who Hammet et al. further note: were known to have negative HIV tests upon entry into prison subsequently tested HIV positive. While Prevalence statistics for prisoners by race and ethnicity are generally lacking, so the 88 men who seroconverted during the time they it was not possible to develop estimates of disease burden by racial and ethnic were incarcerated accounted for only 10% of all HIV- group. However, the disproportionate incarceration rates experienced by African positive prisoners in Georgia prisons during the same Americans and Latinos and the already disproportionate burden of diseases under 1988-2005 time frame, the study was signiﬁcant in study among the same groups combine to produce a situation in which the that it conﬁrmed that HIV risk behaviors do indeed vast majority of prisoners and releasees with these infectious diseases are African occur in at least one of the nation’s largest state prison American or Latino. In New York State correctional facilities, 48% of prisoners systems, providing empirical evidence that some diagnosed with AIDS in 1997 were Black and 45% were Hispanic, compared with prisoners engage in high-risk behaviors and become the proportions of these groups in the total population of the state of 18% and HIV positive while incarcerated. Nonetheless, the 14% respectively. study showed that the majority of new HIV infections among incarcerated individuals (90%) occurred The Connection Between Incarceration, Poverty and Homelessness outside of prison (MMWR, vol. 55 no. 15, 2006). If HIV-related morbidity and mortality are especially problematic among vulnerable Several caveats about the study should be noted. populations, it is reasonable to assume that a history of incarceration – and all of the Only one prison system and a small study sample personal and social chaos that it entails – contributes to increased vulnerability to HIV that did not include HIV-positive prisoners who did infection, disease progression and mortality. not volunteer to be tested were involved. Moreover, as MMWR authors note, “prisoners might have Prisons are a major factor in the continuing rates of poverty and social disadvantage in the inaccurately reported HIV risk behaviors because sex African-American community. Convicted felons in most states in the United States cannot between prisoners, sex with correctional staﬀ, injection vote and are often ineligible for federal housing or housing subsidies, federally ﬁnanced drug use, and tattooing are illegal or forbidden by student loans and many forms of employment (Iguchi, Bell, Ramchand and Fain, 2005). policy in this prison system” (MMWR, vol. 55 no. Formerly incarcerated persons are typically from poor, disadvantaged communities, and when 15, 2006, p. 425). But even interpreting these data they are discharged from prison they return to their old neighborhoods. As second-class conservatively, it is unlikely that Georgia is the only citizens in need of a great many social, economic and health services, their presence inevitably state prison system in which risky sex, injection drug adds to already high levels of social and economic disadvantage in the communities that use and seroconversions occur. house them (Golembeski and Fullilove, 2005). Formerly incarcerated persons are at higher risk for becoming homeless, and this risk is especially acute for those who have a mental Nonetheless, HIV risk reduction interventions such health disability and/or a history of mental illness (Kushel, Hahn, Evans, et al., 2005). as access to condoms, needle exchange and bleach for IV drug users are not available to the vast majority HIV Transmission in Prisons of prisoners. Policies on HIV testing and education vary widely between states and facilities. Condoms The U.S. Department of Justice found that in 2003 the AIDS rate among U.S. prisoners are banned or unavailable in 95% of the country’s was three times that of the general population.That year, 2% of state prisoners and 1.1% of prisons; only the state prison systems of Mississippi and Federal prisoners were known to be infected with HIV (U.S. Dept. of Justice, Bureau of Vermont make them available, as do the county jails Statistics, 2005). Given these facts, there has been and continues to be speculation that prisons systems of Philadelphia, New York City, Washington, are independent risk factors for HIV infection because prisoners engage in unsafe sex and DC, San Francisco and Los Angeles. There are no needle drug injection practices while “on the inside.” exchange programs in U.S. prisons or jails, and only jails in Houston and San Francisco are reported to provide In 2005, the Georgia Department of Corrections and the Georgia Division of bleach to prisoners to clean their needles (AIDS Policy Public Health, with assistance from the CDC, conducted a study to examine HIV and Law, 1997). In addition, prominent media coverage risk behaviors and patterns of HIV transmission within Georgia’s correctional over the past few years suggests that provision of medical system. This study was possible because in 1988 the Georgia Department of care is, at best, inconsistent in America’s prisons and jails. Corrections instituted mandatory HIV testing of prisoners upon entry to a prison In Alabama, prisoners with HIV are quarantined. 20 African Americans, Health Disparities and HIV/AIDS: Recommendations for Confronting the Epidemic in Black America PLEASE NOTE: THE REPORT AND PRESS RELEASE ARE EMBARGOED UNTIL THURSDAY, NOVEMBER 16, 2006 AT 10:00 AM (ET) / 7:00 AM (PT). Despite evidence showing that the proper and consistent lifetime number of sexual partners at any given age, which aﬀects the risk use of condoms greatly reduces HIV risk, the issue of sexual contact with an infected person….The dynamics of prison entry continues to be highly politicized – particularly in the and exit, coupled with a large increase in incarceration rates for men, are correctional context. In September 2006, California likely to impact the rate at which existing sexual relationships dissolve and Gov. Arnold Schwarzenegger vetoed legislation that form (Johnson and Raphael, 2005, p. 11). would have allowed nonproﬁts and public health agencies to distribute condoms to prisoners. With some In addition to aﬀecting the rate at which concurrent sexual relationships form and 160,000 prisoners, California has the nation’s largest break up, there is evidence that the loss of a signiﬁcant number of men to prisons also incarcerated population. aﬀects the degree to which women will insist on condom use and other safe sexual behaviors on the part of their sexual partners (Sampson, 1995). Finally, the impact Incarceration, HIV Infection and the African-American Community of missing fathers on families in general and on the delinquent behavior of their children is also considerable. Some data suggest one predictor for being imprisoned is having a family member who has been incarcerated. There are other reasons to believe that prisons make a signiﬁcant contribution to the level of HIV/AIDS For example, for children whose parents are imprisoned, feelings of shame, in poor, African-American communities. Two humiliation, and a loss of social status may result (Clear, 1996). Children begin to act investigators at the Goldman School of Public Policy out in school or distrust authority ﬁgures, who represent the people who removed at the University of California, Berkeley, modeled the parent from the home. Lowered economic circumstances in families experiencing the impact of incarceration on HIV/AIDS rates in imprisonment also lead to greater housing relocation, resulting in less cohesive the United States (Johnson and Raphael, 2005). They neighborhoods. In far too many cases, these children come to represent the next note: “Our results reveal that the higher incarceration generation of oﬀenders (Mauer, 1999). rates among black males over this period explain a substantial share of the racial disparity in AIDS Incarceration’s Impact on the Community’s Health infection between black women and women of other racial and ethnic groups” (Johnson and Raphael, 2005). The health consequences of incarceration have signiﬁcant impacts on prisoners and on the communities to which they will return.The intersection of drugs, HIV/AIDS, hepatitis C Such transmission would be aﬀected, the authors assert, and TB is particularly alarming in this regard. As MacNeil and colleagues (2005) reported in a from tattooing, drug use and high-risk sexual activity. study of the national TB surveillance system from 1993 through 2003,TB case rates in federal In the Georgia prison study (MMWR, vol. 55 no. 15, and state prisons were signiﬁcantly higher than in the general population (29.4 and 24.2 cases 2006), all of these behaviors were reported by cases as per 100,000, compared with 6.7 per 100,000 for the general population). HIV infection is well as controls, with the self-reported rates of having a major risk factor in having an active TB infection (MacNeil, Lobato and Moore, 2005). “received a tattoo in prison” emerging as a particularly The signiﬁcance of this study cannot be overemphasized. Unlike HIV, TB can be controlled, signiﬁcant risk factor for seroconversion in prison. The particularly in a setting in which patients are extremely constrained in their freedom of Johnson/Raphael model, however, is only partially movement. If treatment failures are signiﬁcantly elevated for this population, which is dependent on the assumption that the disparity disproportionately African American and Hispanic, it is reasonable to suppose that treatment between African-American and white HIV infection failures for prisoners with a variety of health conditions are likely as well. rates is a function of in-prison HIV risk behavior. The authors’ major focus was to test the degree to which “sexual relationship markets” – that is, the manner in which members of sexually active groups form and break up sexual relationships – are inﬂuenced by rates of incarceration: Of particular importance are the eﬀects of incarceration on the total lifetime number of sex partners and the likelihood of concurrent sexual relationships. The rates at which new relationships form and dissolve impacts the African Americans, Health Disparities and HIV/AIDS: Recommendations for Confronting the Epidemic in Black America 21 PLEASE NOTE: THE REPORT AND PRESS RELEASE ARE EMBARGOED UNTIL THURSDAY, NOVEMBER 16, 2006 AT 10:00 AM (ET) / 7:00 AM (PT). CONFRONTING THE EPIDEMIC IN BLACK AMERICA were already infected before they entered the correctional facility (MMWR, vol. 55 no. 15, Policy Recommendations 2006). Policy reforms that establish voluntary, routine HIV testing upon entry and release With an epidemic that continues to grow in size and scope, it is important to look beyond will help connect those who are infected to medical interventions as the sole solution to our nation’s problem with HIV/AIDS.The treatment and also reduce risk behaviors that United States may have already reached the outer limits of what can be done to prevent and could put others at risk. treat HIV by investing in interventions that are targeted to individuals. • Making HIV prevention education, substance abuse Given the social and economic characteristics of poor African-American communities, programs and condoms available in prison facilities. a more systemic approach is needed to help build stable communities. Without Every year since 1991, the rate of AIDS cases in addressing the underlying factors that create and maintain poor African-American prisons has been higher than that of the general communities, the conditions that fuel a growing AIDS epidemic will always outpace population. At the end of 2003, the most recent year the funding available to combat it. for which statistics are available, the rate of conﬁrmed AIDS cases among the U.S. prison population was Thus, managing homelessness, housing conditions, risk of incarceration and the more than three times that of the general population concentration of poverty in poor communities of color must also be addressed (Golembeski (51 per 10,000 compared to 15 per 10,000) (U.S. and Fullilove, 2005; Lemelle, 2003).These are more than just “complicating factors” Department of Justice, 2005). Nonproﬁt organizations, for people being treated for HIV/AIDS.They are the forces that produce marginalized government and public health agencies must be communities and marginalized people. Creating public policies that can change the risk allowed to discuss the relationship between substance environment of poor African-American communities will not only impact HIV, it will also abuse and HIV risk and to distribute condoms in aﬀect the conditions that generally contribute to health disparities there. prison facilities. Ensuring access to condoms in prisons would not only protect prisoners, but also the health The following policy recommendations will enable us to alleviate the root causes of the and lives of the people in the communities to which African American HIV/AIDS epidemic, and improve the chances of survival for those they will return. living with HIV/AIDS: • Expanding re-entry programs to help formerly 1. Support the strengthening of stable African-American communities by addressing the need for more affordable housing. incarcerated persons successfully transition back into society. Prisons increasingly hold members of poor • Stabilizing housing is one of the most eﬀective methods for reducing HIV-related communities who are both under-educated and morbidity and mortality. As noted earlier in this report, scarcity of aﬀordable housing is unemployable (Mauer, 1999; Golembeski and often at the root of residential segregation, school failure for children and a lack of access Fullilove, 2005). Expanded access to job training to health care because families spend too much of their income on rent and other and educational programs, including college-level housing needs. coursework, are necessary to improve their ability to function in society upon release. In addition, re- • Expanding federal programs such as Housing Opportunities for Persons With entry programs are needed that address prisoners’ AIDS (HOPWA) is critical in helping those with AIDS avoid homelessness, which HIV prevention, substance abuse, mental health and in turn creates access to medical care and support services. In 2006, the program housing needs prior to their release. provided rent, mortgage and utility payments, as well as other housing and support services, to 71,500 households (National AIDS Housing Coalition, 2006). 3. Eliminate the marginalization of, and reduce stigma and discrimination against, black gay and other men 2. Reduce the impact of incarceration as a driver of new HIV infections within who have sex with men. the African-American community by: • There is only one randomly controlled HIV • Providing voluntary, routine HIV testing of prisoners upon entry and release. prevention program, “Many Men, Many Voices”, While a recent CDC study established that HIV infection does occur in speciﬁcally designed for black MSM. Investing in at least one major state prison system (i.e., Georgia), 90% of prisoners research to produce interventions that will work 22 African Americans, Health Disparities and HIV/AIDS: Recommendations for Confronting the Epidemic in Black America PLEASE NOTE: THE REPORT AND PRESS RELEASE ARE EMBARGOED UNTIL THURSDAY, NOVEMBER 16, 2006 AT 10:00 AM (ET) / 7:00 AM (PT). for a diverse population of black MSM is essential • One of the main factors contributing to disparate treatment outcomes for African to a national prevention eﬀort that will reverse Americans is that many are diagnosed at late stages of disease, when it is often too late the course of the epidemic in this population. The for medications to be eﬀective. CDC and the National Institutes of Health must aggressively establish a robust research portfolio to achieve this goal. • The empowerment of community leaders and organizations has been a critical element in our nation’s eﬀort to combat the HIV epidemic. More support must be leveraged to develop, promote and sustain leadership among black MSM and in organizations serving them. Additionally, sustained investment must be made to build the capacity of organizations developed to serve black MSM in order to eﬀectively change social networks, behavior and conditions contributing to HIV infections in this population. • Eﬀorts should be supported to address homophobia evidenced through stigma, discrimination and violence that creates vulnerability to behaviors and conditions associated with risk for HIV infection among black MSM. 4. Expand HIV prevention education programs, promote the early identiﬁcation of HIV through • Community health workers (e.g., lay health advisors, peer counselors, health aides) are often critical bridges between physicians and patients in communities where mistrust of the health care system exists (IOM, 2002). They should be utilized as important resources for facilitating improved HIV/AIDS care. Many physicians lack the training and/or the life experience to understand the barriers that many HIV patients must overcome in order to maintain their health. Community health workers can serve as “interpreters” who can eﬀectively communicate with patients about the care that is being provided. Such interventions have repeatedly been found to be eﬀective in clinical settings in which a multicultural, multiethnic patient population is being served (IOM, 2002). 5. Reduce the number of HIV infections in the African-American community caused by injection drug use through the expansion of substance abuse prevention programs, drug treatment and recovery services, and clean needle exchange programs. For active injection drug users, in particular, clean needle exchange programs are needed to minimize the risk of infection through needle sharing. • About one in ﬁve (19%) new HIV infections among African Americans is from injection drug use (CDC, 2005). Education programs are needed to prevent people from using drugs in the ﬁrst place, and substance abuse treatment programs are needed to help those currently using drugs to quit. For injection drug users who currently are addicted, clean needle exchange programs are needed to minimize the risk of infection from sharing unclean needles. voluntary, routine testing and connect those in need to treatment and care as early as possible. • Knowledge is a critical ﬁrst step for stopping the spread of HIV, yet far too many African Americans do not have accurate information about how HIV is transmitted or can be prevented. Culturally relevant HIV prevention education programs are needed to help African Americans protect themselves and their partners. • Approximately one-quarter of the estimated 1.1 million Americans living with HIV/AIDS do not know that they are infected and may unknowingly transmit the virus to others. While proper safeguards must be in place to ensure that HIV testing is always voluntary, eﬀorts to expand HIV testing will help greater numbers of people learn their HIV status, allow those who test positive to seek early treatment and reduce their risk of transmitting HIV. African Americans, Health Disparities and HIV/AIDS: Recommendations for Confronting the Epidemic in Black America 23 PLEASE NOTE: THE REPORT AND PRESS RELEASE ARE EMBARGOED UNTIL THURSDAY, NOVEMBER 16, 2006 AT 10:00 AM (ET) / 7:00 AM (PT). LOOKING FORWARD This report was developed to examine the potential causes of excess HIV-related mortality in African Americans. In showing that HIV is one of a host of other health disparities that plague African Americans and by identifying social marginalization as a key cause of excess HIV-related mortality among African Americans, this report has made clear that policy and legislative reforms need to focus on structural interventions that will address the root causes of the overrepresentation of African Americans in the HIV/AIDS epidemic. Such reforms will not only improve eﬀorts to prevent HIV, they will improve the chances of survival for those African Americans already living with HIV/AIDS. The ﬁnancing of HIV care in particular, and health care in African-American communities in general, was beyond the scope of this report. The problems of a continually growing HIV epidemic at a time when resources to combat it have been reduced were partially addressed, but need to be considered more fully moving forward. In addition, the impact of stigma on HIV/AIDS among African Americans is an important area worthy of greater attention than was addressed herein. The development of interventions capable of creating tolerance, acceptance and compassion represents a signiﬁcant and vital challenge for behavioral intervention specialists. Finally, we feel that the recommendations in this report, if implemented, will further empower individuals to take personal responsibility for the prevention and spread of HIV/AIDS in the African-American community, even in diﬃcult life situations. 24 African Americans, Health Disparities and HIV/AIDS: Recommendations for Confronting the Epidemic in Black America PLEASE NOTE: THE REPORT AND PRESS RELEASE ARE EMBARGOED UNTIL THURSDAY, NOVEMBER 16, 2006 AT 10:00 AM (ET) / 7:00 AM (PT). REFERENCES: Adimora, A., Schoenbach,V.J., Martinson, F.E.A., Coyne- CDC. (2006). Racial ethnic disparities in diagnoses of HIV/AIDS – 33 states, 2001-2004. Beasley, T., et al. (2006). 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