Racism, poverty, sexism all play a role in epidemic’s spread among black women

New resource guide educates on problem

Black women in the United States had the highest new diagnosis rate of HIV/AIDS of any ethnic/gender group between 2001 and 2004, according to the latest data from the Centers for Disease Control and Prevention (CDC) in Atlanta, GA.1

Black women accounted for 68 percent of the new diagnoses among women in that period, while black men accounted for 44 percent of the new diagnoses among men.1

While white men and black men each have greater numbers of new infections, black women are not far behind them in total numbers, with 30,483 new diagnoses estimated in 33 states, compared with 38,218 for white men and 49,704 for black men.1

Public health officials and others who work to stem the epidemic say there are a variety of reasons why black women have been disproportionately impacted by AIDS.

"Among women the epidemic has always been overwhelmingly in blacks and Hispanics, as opposed to men where in the early days of the epidemic it was well-represented among white men," says Judy Sackoff, PhD, deputy director for HIV surveillance at the New York City Department of Health and Mental Hygiene in New York, NY.

There are places in New York City where the epidemic’s prevalence among blacks is comparable to parts of sub-Saharan Africa.

There’s a project in Brooklyn where some buildings don’t have a tenant who isn’t infected with HIV, says Diana Williamson, MD, MPH, a New York City-based volunteer chair of the scientific committee and co-founder of the Black AIDS Institute of Los Angeles, CA.

"What ends up happening is the suspicion of health providers and lack of access to care in the United States makes the epidemic among certain black people, but not all, as bad as it is in parts of Africa," Williamson says. "They may not have access to care or antiretrovirals, and if you give some patients a prescription, they’ll sell it because they need the food more than the drugs."

The Black AIDS Institute has produced a new report called, "Getting Real: Black Women Taking Charge in the Fight Against AIDS" as an educational tool for HIV providers and outreach workers. The report is available on-line at www.blackaids.org. (See excerpt from report.)

"Anyone can download the report," Williamson says. "I would hope there would be some government agency or someone who would take this report and put it in the hands of every medical student, doctor, psychologist, clinician, and anyone who does treatment of HIV."

One new study has found that African American women drug users were not discussing HIV status with the drug-using and sexual partners.

"One of the big public health messages now is to know your status and discuss this, so the message obviously hasn’t reached all parts of the population," says Caroline Korves, SD, postdoctoral research fellow, department of epidemiology, Mailman School of Public Health at Columbia University in New York, NY.

"We asked within the survey whether or not a person thought their partner has HIV and whether they had actually discussed it," Korves says. "Most people had not discussed HIV, so they didn’t suspect HIV status among partners."

Investigators interviewed women who used heroin, crack, cocaine, or marijuana daily, and they recruited risk network members, who were either sexual or drug-using partners. All participants were tested for HIV, and 18 percent were HIV positive.3

The participants reported knowing that 7 percent of their risk network partners were HIV positive, but actual testing of the risk network members showed that 18 percent were HIV positive.3

"The take-home message here is there are a lot of people who still are engaging in high risk behavior just due to the fact they’re having sex and doing drugs with people who have HIV," Korves says. "Their partners are infected, and still this message that people need to discuss their serostatus has not reached everyone within the population."

Most black women newly diagnosed with HIV were infected through heterosexual contact, with that accounting for 76 percent of reported transmission and injection drug use accounting for 21 percent.1

"Heterosexual HIV in the black community is driven by poverty, sexism, and racism, and unless we address the underlying issues here we won’t stem the epidemic," says Peter Leone, MD, associate professor of medicine at the University of North Carolina at Chapel Hill.

The HIV infection rate for black women in North Carolina is 14 times higher than it is for white women.2

Leone has studied the differences between black women, ages 18 to 40, who are HIV infected versus those of the same age group who are HIV negative to see what factors might play a role in HIV risk.

The case study looked at newly-diagnosed women in the state of North Carolina, who were diagnosed between January, 2003 and August, 2004, and who were infected through sex with a man. When comparing this group with black women of the same age group who were not infected, the chief difference was socioeconomics, Leone says.

"The things that jump out at you is there wasn’t much difference in age at first intercourse and previous unprotected vaginal sex and HIV testing, both groups were similar," Leone says. "But the big driving difference was socioeconomics, where those who were positive were 7 to 8 times more likely to be on public assistance than were those who were negative."

The women who were HIV negative were similar in marital status and educational level, but they were less likely to be unemployed or to have received public assistance.2

Also, the HIV-positive women were more likely to have herpes, and were less likely to have discussed their sexual and behavioral history with their male sex partners.2

"The women we interviewed, both HIV positive and negative, felt very unempowered in their relationships and in their communities," Leone says. "They themselves felt they put themselves at risk for HIV based on their own low self-esteem and their need to feel connected in their community."

One complicated issue that it’s unique to the black community is the lack of available black male partners, partly because of an increased mortality rate due to cardiovascular and other diseases for African American men, increased death rate due to violence, and a higher incarceration rate, Leone explains.

Among the HIV-positive black women, 81 percent said their sexual partners included men who had been incarcerated, and 59 percent of the HIV-negative black women reported having a sexual partner who had been incarcerated.2

"One of the things that is still a fall-out of poverty and racism is the fact we have a very closed society in terms of sexual networks," Leone says. "For black women, the majority of their partners are going to be black, so when the prevalence rate goes up in a community, your likelihood of coming into contact with someone who is HIV positive increases."

In New York City, where an important part of a city-wide health plan includes knowing one’s HIV status, there has been an encouraging trend seen in new HIV diagnoses, including those among black women, Sackoff says.

"The good news is that the number of new HIV diagnoses has been declining for years," Sackoff says. "Since we started keeping track in 2000, the number of new diagnoses in New York City has declined about 500 every year, so we’re down to 3,653 new HIV diagnoses in total."

Women accounted for 31.5 percent of the new HIV diagnoses in 2004, and blacks accounted for 53.5 percent of new diagnoses that year.4

The bad news is that the proportion of concurrent HIV/AIDS diagnoses among black women has climbed from 22.5 percent in 2001 to 28.4 percent in 2004, Sackoff says.

"We know that at the time women are diagnosed with HIV, more than one-fourth also have AIDS," Sackoff says. "I would speculate that it is stigma that keeps people from being tested."

Concordant diagnoses of HIV and AIDS are a disturbing problem on the 10th anniversary of protease inhibitors and highly active antiretroviral therapy (HAART), Leone says.

"A study in our own UNC clinic has shown the CD4 cell count at the time of presentation has declined over the 10-year period," Leone says. "People are presenting with more advanced disease now than they did 10 years ago, so we have HAART and mortality has dropped, yet people are coming in later, and it’s more likely to occur in minorities."

Leone speculates that socioeconomic pressures make knowing one’s HIV status a low priority, and he says he’s concerned that some at-risk groups feel disenfranchised from the health care system and so are not convinced they would be helped even if they did know their HIV status.

"While testing is critical in terms of reducing ongoing transmission of HIV, we have to couple that with broader prevention messages, and the money is not being given to the main chain of prevention programs," Leone says. "And our AIDS Drugs Assistance Program in North Carolina is still the lowest in terms of eligibility in the country."

References

  1. CDC. Trends in HIV/AIDS Diagnoses—33 States, 2001-2004. MMWR Morb Mortal Wkly Rep. 2005;54:1149-1153.
  2. CDC. HIV Transmission Among Black Women—North Carolina, 2004. MMWR Morb Mortal Wkly Rep. 2005;54:89-94.
  3. Korves C, Miller M. HIV Serostatus Concordance Between African American Women Drug Users and Their Risk Network Members. Presented at the 45th Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC), held Dec. 16-20, 2005, in Washington, DC. Abstract: H-1886.
  4. HIV Epidemiology Program, 4th Quarter Report. New York City Department of Health and Mental Hygiene. 2005;3(4):1-4.