HIV/AIDS in Communities of Color

By Bill Valenti M.D.

While white MSM still make up almost half the cases of AIDS in the US, people of color have passed the 50% mark

Men of color now account for a greater proportion of AIDS cases than do white men among men who have sex with men. A recent report from the Centers for Disease Control and Prevention (CDC) shows that among men who have sex with men (MSM), non-Hispanic black and Hispanic men accounted for an increasing proportion of AIDS cases. These groups also had smaller proportionate declines in AIDS incidence and deaths from 1996 to 1998, compared to white MSM during the same time period.

Based on a review of US AIDS cases over the past decade, a CDC study found that men of color represent an increasing proportion of AIDS cases among gay and bisexual men, rising from 31 percent in 1989 to 52 percent in 1998. African American men comprised one-third of AIDS cases among men who have sex with men, while Latino men represented 18 percent of cases. While declining from 69 percent in 1989, white men in 1998 continued to represent 48 percent of AIDS cases among men who have sex with men.

Data from the report also suggest that the stigma of homosexuality may be playing a key role in the disease's spread, and point to the early age at which gay and bisexual men are becoming infected. Of HIV and AIDS diagnoses among racial/ethnic minority MSM, the proportion who are young (aged 13-24 years) is higher than among white MSM.

Trends in AIDS incidence during among MSM aged :13 years from the 50 states, the District of Columbia, and US territories were analyzed by race/ethnicity, age, and geographic area of residence. In 1989, racial/ethnic minority men who have sex with men (MSM) accounted for 7609 (31%) of 24,444 AIDS cases among MSM, and by 1998, racial/ethnic minority MSM accounted for 9429 (52%) of 18,153 such cases.

The proportion of Asian men and Asian/Pacific Island groups remained unchanged at <2% for both periods of comparison. The report notes that the disproportionate impact of HIV/AIDS on racial or ethnic minority MSM indicated in this report is probably a minimum estimate, due to reporting biases, misclassification of race/ethnicity, and other factors. The CDC investigators also looked at new HIV infections diagnosed from 1996 to 1998 in the 25 states that have required reporting of HIV infection. In these states, the proportion of HIV-positive gay/bisexual men who are men of color and young (13-24 years) is much more broadly distributed. Among those diagnosed with HIV ages 13-24 years, 16% occurred among African Americans, while 15% each occurred among Asian-Pacific Islanders and Alaskan Natives and Natives American. Hispanics represented 13%, while Caucasians represented 9%. (The remaining 32% with new HIV infection were older than age 24.) These percentages among racial or ethnic minorities are higher than their reported proportional representation in the US population.

States with large numbers of AIDS cases such as California, New York, Florida, and Texas are not part of the HIV statistics because they do not report HIV infection. The report went on to say that even these numbers may be an underestimate.

The report points out accurately that race and ethnicity are not, by themselves, risk factors for HIV. However, among racial or ethnic minority MSM, social and economic factors, such as homophobia, high rates of poverty and unemployment, and lack of access to health care are associated with high rates of HIV-risk behavior. These factors also may be barriers to receiving HIV prevention information or to accessing HIV testing, diagnosis, and treatment. A major barrier to reaching men of color includes the stigma attached to acknowledging homosexual and bisexual activity. This stigma may inhibit racial/ethnic minority MSM from identifying themselves as homosexual or bisexual, and they may be more likely to identify with their racial/ethnic minority community than with the MSM community.

One might also expect that because of this stigma, even MSM who know their HIV status may not seek medical care; this has made HIV disease a chronic ambulatory illness for many people today. In the meantime, this emerging problem is not confined just to men. These same bisexual men fuel the epidemic in women and their offspring via mother-infant transmission. The response to this emerging epidemic in people of color requires a multidisciplinary effort that involves more than just government funding. The goal of this community effort should be to identify people at risk and encourage and facilitate HIV testing and other prevention strategies. For for those who are HIV-positive, medical care by experienced HIV providers can lead to better outcomes.

Summarized below are a variety of projects in various communities in the US, taken from the CDC's daily report concerning HIV/STDs and TB. (See HIV News in this issue for information about subscribing to this electronic list).

As part of the CDC effort, the National Prevention Information Network (NPIN) provides the Pathfinder African Americans & HIV/AIDS: A Guide to Selected Resources. This resource is designed to help users locate HIV/AIDS information, resources, and services as well as prevention information for African Americans. Go here. In Houston, health officials announced on World AIDS Day, 1999, that HIV-prevention efforts in the area will focus on African Americans. Between 1994 and 1998, African Americans accounted for 40 percent of new AIDS cases in Houston and Harris Countyup from 24 percent between 1981 and 1993. Mayor Lee Brown noted that African Americans now account for 61 percent of HIV cases in Houston and Harris County, calling it an alarming, undeniable increase. Brown detailed a new effort to encourage safe sex and to reduce needle sharing in several at-risk communities. The program, estimated to cost about $3 million, will focus on African American women, gay and bisexual African American men, and African Americans in jail. From: Blacks to be focus of area AIDS battle; Alarming jump in rate of HIV Iinfection cited. Houston Chronicle, December 2, 1999.

In Arizona, an increasing number of African Americans, Hispanics, and women are becoming infected with HIV, which has taken the lives of some 4,000 people in the state in the past 20 years. Phoenix Body Positive, an AIDS support group, is helping minorities and women find treatment for HIV/AIDS. The groupwhich is trying to help more than the gay white men who began the organization over 10 years agois working with churches, doctors, and testing centers to spread its message. Phoenix Body Positive offers HIV prevention counseling, support services like day care, and respite services. The agency's 1200 clients include approximately 400 women, 380 Hispanics, and 330 African Americans. From: More blacks, Latinos, women seeking help. Arizona Republic Online. January 1, 2000. The Health Resources and Services Administration (HRSA) has given $21.7 million to fund 51 grants for early HIV intervention care and services for underserved persons. The grants are funded under the Ryan White Comprehensive AIDS Resources Emergency Act. Programs under the act help communities determine HIV-related priorities and fund programs for them, according to HRSA's Dr. Joseph O'Neill.

From: HRSA announces $21.7 million to fund HIV/AIDS programs in underserved Areas. Reuters Health Information Services, January 17, 2000. See also the HRSA website links to CARE Act funding and grant opportunities: Here

The US Conference of Mayors (USCM), working with the Centers for Disease Control and Prevention (CDC), has announced that it will award $915,000 for HIV prevention efforts pertaining to three groups: women at high risk, gay and bisexual men of color, and Native American tribes/nations. Organizations must apply for the grants by April 17, 2000. USCM executive director J. Thomas Cochran noted that this year's award total is the second highest in the 16 years the program has been operating. The grants are one-time awards, and the recipients of them will be announced in the summer of 2000. From: U.S. mayors announce $915,000 in HIV prevention grants. U.S. Newswire, February 11, 2000.

Sisters and Daughters of Sheba is a program that to stem the increasing rate of HIV infection among African American women. In Michigan, where the program is based, African American women have an HIV rate 19 times higher than that for white women. The free program provides basic information on HIV and other sexually transmitted diseases and discusses self-esteem issues with the women. It also teaches women to care about themselves and their health, and teaches teenagers to practice safe sex, using peer mentors. Founder Debra Ann Brodie, a Detroit psychologist, started Sheba in 1996, and since that time nearly 400 women and girls have participated. The program is supported by a three-year, $210,000 grant from the Centers for Disease Control and Prevention, and $30,000 from the Michigan AIDS Fund. From: Program aims to reduce the rate of AIDS for black women. Detroit Free Press Online. February 15, 2000.

New research suggests that a behavioral intervention that promotes both male and female condoms can help effect increases in such condom use. The researchers studied more than 1000 women who were patients at sexually transmitted disease (STD) clinics in Birmingham and Huntsville, Alabama. The women, whose median age was 23, agreed to an initial visit and to six planned monthly followup visits, and were told to keep a sexual activity diary. More than four-fifths of the women were African American, and nearly two-thirds had children. At the beginning of the study, 65 percent of the women reported having an STD previously, and most used male condoms infrequently or not at all. The women watched a ten-minute video about the female condom, were counseled by a nurse about using the female condom, and were given items to take home, including brochures and samples.

Results after the followup visits show that 1023 women took place in at least one followup visit. After the intervention and counseling, 782 more than at the start of the programor 79 percent of the womenhad used the female condom at least once, usually soon after a session. Most women used it multiple times, but not exclusively. The researchers noted that many clients of public STD clinics will try, and some will continue, to use female condoms when the product is promoted positively and when women are trained to use it correctly and to promote it to their partners. See: Artz L, et al. Effectiveness of an intervention promoting the female condom to patients at sexually transmitted disease clinics. American Journal of Public Health. 2000, Vol. 90, No. 2, Page 237.

HIV is now epidemic among people of color. While white MSM still make up almost half the cases of AIDS in the US, people of color have passed the 50% mark, in contrast to the situation earlier in the epidemic. The response to this shift in HIV demographics requires strong involvement and leadership from all segments of the communitues infected. The response should include churches, community organizations, schools, health departments, government and private philanthropy.

In order for interventions to be effective, it is important for communities to mobilize quickly and efficiently. The goal of these initiatives should be to focus on reaching people at risk to prevent HIV in those who are not infected. Equally important is to help infected patients to get tested and to access life-saving medical care.

Bill Valenti, MD, is Clinical Associate Professor of Medicine at the University of Rochester School of Medicine and has been involved in AIDS treatment, research, and policy since the early 1980s. Dr. Valenti is also co-founder of Community Health Network, Rochester, New York, where he continues to see patients.

1. Centers for Disease Control and Prevention (CDC). HIV/AIDS among racial/ethnic minority men who have sex with menUnited States, 1989-1998. Morbidity and Mortality Weekly Report. 2000 Vol. 49, No. 1, Pages 4-11. Full article here.

2. Kitahata MM, Koepsell TD, Deyo RA, et al. Physicians' experience with the acquired immunodeficiency syndrome as a factor in patients' survival. New England Journal of Medicine. 1996, Vol. 344, Pages 701-706. Abstract here.