Poverty — not race — driving HIV epidemics in urban communities

Heterosexual HIV rate is 2.1% in some communities

Perhaps the most surprising news in the Centers for Disease Control and Prevention's (CDC's) recent report linking poverty to a generalized HIV epidemic in urban communities across the United States was that race played far less of a role than many people would imagine. The biggest factor was poverty in an urban community.

The CDC's analysis of epidemiological data from 23 U.S. cities found that the HIV infection rate was 2.1% for heterosexuals, which is 10 to 20 times greater than the HIV infection rate among heterosexuals nationwide, says Paul Denning, MD, MPH, medical epidemiologist at the CDC's National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention in Atlanta, GA.

The analysis excluded men who have sex with men (MSM), injection drug users (IDUs), sex workers, and sexual partners of sex workers.

When the cohort studied was divided by race, the results were similar: the HIV infection rate for blacks was 2.1%; for Hispanics it also was 2.1%, and for whites it was 1.7%. All groups were well above the 1% cut-off that UNAIDS uses to indicate a generalized epidemic.1

By comparison, Haiti has an HIV infection rate of 2.2% and Ethiopia's infection rate is 2.1%, Denning says.

The similarity between the HIV infection rates found in some urban and poor U.S. communities and in some poor nations is shocking, says Wesley Tahsir-Rodriguez, MPH, senior policy manager for the National Minority AIDS Council in Washington, DC.

"Those countries don't have the types of resources we do," he adds. "You don't expect a country like the United States with its resources to have those kinds of HIV numbers."

Like Haiti and Ethiopia, these poor urban domestic areas have a primary heterosexual transmission cycle occurring where HIV is spreading from one heterosexual to another, Denning says.

"Within these groups there is a sufficient number of heterosexuals who don't have those additional risk factors of MSM, IDU, and sex work that they can maintain a sustainable epidemic among heterosexual to heterosexual," he says. "The infections are not just transmitted among high-risk individuals."

The study highlights the key and often overlooked issue in HIV infection — its strong tie to poverty and social injustice, AIDS advocates say.

The CDC's study is not a surprise, but it's fuel for outrage, says Carole S. Treston, RN, MPH, executive director of AIDS Alliance for Children, Youth & Families in Washington, DC.

"The study points out that much of this epidemic is very localized, and it really hits urban tracts of urban poor neighborhoods very disproportionately," Treston says. "It was very remarkable to see there was little racial difference in HIV infection among the urban poor, but that wasn't a surprise for those of us who work in the urban areas."

The study also casts a spotlight on how HIV is a heterosexual disease. Heterosexual transmission of HIV infection has remained stable, accounting for 31% of overall infections nationwide, Denning says.

But this population often is overlooked as people associate HIV with MSM and IDUs, Tahsir-Rodgriguez says.

"Nobody talks about heterosexual contact when we talk about HIV," he says. "Still to this day it's seen as a gay disease or an injection drug user disease, but heterosexual contact definitely is a mode of transmission, and women are seeing increases in those numbers."

Poverty increases multiple risks

While minorities have been impacted more greatly than their counterparts, poverty is the greatest indicator for HIV infection, as well as an indicator for other health issues, Tahsir-Rodriguez says.

"People living in poverty have less access to the medical system in general, and this causes a huge risk for contracting HIV," he explains. "First, there's a lack of education and medical information about the importance of staying HIV negative among people living in poverty."

Also, poor people with less medical insurance are less inclined to see a doctor and will use the emergency room for acute and routine care, he adds.

Many emergency rooms do not offer routine HIV testing, and ER doctors have little time to discuss HIV prevention strategies.

Plus, poor communities have higher prevalence of sexually transmitted diseases (STDs), which can make people more susceptive to HIV infection, Tahsir-Rodriguez says.

Researchers also theorize that these communities have high rates of HIV infection because their social and sexual networks are insulated.

"So any sexual act that occurs is at much greater risk of HIV infection," Denning says. Incarceration can play a role, and people living in poverty have unstable lives in terms of income, housing, and relationships, which also can play a role, he says.

"But really the big role is they live in areas that have high levels of infection," Denning says.

"You could have a 20-year-old, upper middle income individual who is in college and engages in the same sexual behavior as a similar woman in these communities," he explains. "But the woman in these areas is at much greater risk because of the high HIV prevalence in her community."

National surveys have shown that young African American women are much more likely than their white peers to use condoms, and yet they have higher rates of HIV infection, Denning says.

"If you're swimming in shark-infested waters, you're much more likely to get bitten," says Adam Tenner, executive director of Metro TeenAIDS of Washington, DC.

"We need to figure out how to get the sharks out of the pool," he adds.

Metro TeenAIDS educates Washington, DC, youth about HIV and how to prevent infection.

The organization's goal is to better understand how peer norms are formed. Peer norms are a big predictor of adolescent behavior, and the organization wants to understand how to change them.

"What can we do to create a tipping point and interrupt the epidemic in DC, so we can create an HIV-free generation," Tenner says.

The long-term solution to ridding poor urban micro-communities of the epidemic involves addressing education and housing problems, gender inequalities, and sexual vulnerability in those communities, Treston says.

"We need to shore up our education system and allow people to have a better opportunity for the future, provide decent housing so the most vulnerable wouldn't have to trade sex to have a place to spend the night," she says. But those are the ideal solutions that likely will remain unattainable.

"In our imperfect world with limited resources, we should have focused efforts in the hardest hit communities," Treston says. "These would involve using peers who are HIV positive delivering community-based prevention and linkage to care programs."

The public health system could examine the current health care delivery system in these communities to ensure they are accessible, responsive, client-friendly, and free of stigma and judgment in order to engage poor and marginalized people, she adds.

The CDC continues to promote HIV testing and funds programs that make it readily available at the community level, Denning says.

There also is need for more social marketing campaigns in the hardest hit communities. These could be conducted through hair salons in some African American communities, churches, and other faith-based organizations, he adds.

Some of the health care access disparity issues might be addressed through the health care reform bill's focus on funding free and reduced cost health clinics and shoring up Medicaid, but its impact remains to be seen.

"The amount of resources coming out of federal programs is not keeping up with the times," Tahsir-Rodriguez says. "The HIV strategy from the White House mentions targeting inner cities and poor communities because that's where we see more infection, but the dollars have to follow the plan."


  1. Denning P, DiNenno E. Communities in crisis: is there a generalized HIV epidemic in impoverished urban areas of the United States? Presented at the 18th International AIDS Conference. Vienna; July 2010.