Special Report: AIDS and Minorities

Among men who have sex with men, more minorities have AIDS than whites

Activists: Funds needed for targeted prevention

The Atlanta-based Centers for Disease Control and Prevention now confirms what HIV clinicians in large cities have known for the past few years: There are more AIDS cases among black and Latino men who have sex with men (MSM) than among white MSM.

Experts on AIDS say more money should be spent on prevention efforts targeting these groups and that the African-American and Latino communities need to provide greater tolerance and acceptance for men in their ranks who have sex with men.

The rate of AIDS cases among African-American MSM is five times higher than the AIDS rate among white MSM, and the rate of AIDS among Latino MSM is twice as high as among whites, according to CDC statistics.

In 1989, men of color represented 31% of AIDS cases among gay and bisexual men. This number climbed to 52% in 1998. About one-third of the AIDS cases among MSM involve African-Americans, and 18% involve Latino men.1

The CDC also reports that a significant percentage of black and Latino MSM who have AIDS do not identify themselves as homosexual or bisexual, which means traditional prevention programs that target gay populations may not work as well among ethnic minority men.

"This epidemic is by no means over in white gay men, but we’re seeing reversals in the trends among gay men of color," says Helene Gayle, MD, MPH, director of the National Center for HIV, STD, and TB Prevention at the CDC. (See Q&A, p. 29.)

"This will surprise many across the nation," Gayle says. "Although consistently gay men have represented a major category [of AIDS cases], the tendency to equate gay with white still persists."

Gayle spoke at a recent CDC press teleconference on the CDC’s report, which was published in the Jan. 18, 2000, issue of the Morbidity and Mortality Weekly Report. The conference also featured Phill Wilson, executive director of the African-American AIDS Policy & Training Insti tute at the University of Southern California in Los Angeles, and Rafael Campo, MD, a physician at Harvard Medical School and Beth Israel Deaconess Medical Center in Boston.

All three speakers emphasized the importance of focusing prevention programs on at-risk minority groups.

"The significance of the report is not the statistics, I think, because the trends have been obvious for years," Wilson says. "The tragedy is that this didn’t have to happen; we could have prevented it."

The CDC has long had evidence of this demographic trend because it’s been evident in large cities, like New York City, for years, says Colin Robinson, policy associate with the Gay Men’s Health Crisis in New York.

"The CDC’s own report in 1997 did a special issue of MMWR highlighting the fact that in cities like New York, this was already the case," Robinson says.

Large cities have biggest problem

Cities with populations greater than 500,000 are hardest hit by AIDS, with 85% of AIDS cases among gay and bisexual men of color located in these areas.1

New York state’s African-American and AIDS organizations in recent years have recognized the need for special attention to the problem of African-American gay and bisexual men who are at risk for HIV. A coalition of 11 organizations that have black gay services, HIV prevention services, and African-American community services formed the New York State Black Gay Network at the end of 1998 to seek solutions to the problem, says Nguru Karugu, MPH, the network’s coordinator.

"One thing that is very clear to us when we read this [CDC] report is that we have known and screamed about this problem for many years," Karugu says. "Our question to the CDC is: Why do you keep saying this and not providing the resources to get the work done?’"

The problem is that federal funding, including CDC grants, have not provided nearly enough money for prevention programs, Karugu and Robinson say.

"We hope the CDC and Dr. Gayle will build political support for policy changes and funding changes that need to happen," Robinson says.

Gayle agrees that the CDC needs to direct more resources toward prevention efforts. "This report reveals we need HIV prevention now more than ever," she says. "Expanding our HIV prevention is urgent not only for Latino and African-American communities whose risk is increased, but also renewing efforts among white communities where the risk hasn’t gone away by any means."

In October, the CDC announced that it had increased minority prevention funding by 50% by awarding $39 million to more than 100 organizations nationwide to expand HIV prevention efforts in African-American and Latino communities. The increased funds resulted in part from the concerted effort by African-American community leaders and the Congressional Black Caucus to get Congress to increase funding.

Robinson says not only is more money needed for prevention, but also that it needs to be administered in a more efficient way. New York state, for example, received only about 4% of a $4 million national CDC grant, issued last year, for direct services relating to HIV prevention. "New York should have gotten around 10% of that grant," he says.

New York state has a greater number of HIV/ AIDS cases, and the state has additional challenges, such as high immigration and substance abuse concerns, he adds.

Target teens for HIV prevention

Prevention programs will have to focus on at-risk teenagers in the Latino and African-American communities because the recent CDC report shows that gay minority men who have sex with men often are infected at younger ages than white gay men are. CDC researchers examined HIV infection data collected from 1996 to 1998 in 25 states that report HIV infection. They found that 16% of blacks, 13% of Hispanics, and 9% of whites ages 13 to 24 were diagnosed with HIV.1

These types of statistics bode ill for efforts to stop the spread of the disease because youths often are more likely to engage in risky activities, including unsafe sex and sharing drug paraphernalia.2

"The unchecked spread of AIDS in our youngest and fastest-growing segment means that American society as a whole and our great promise of a future may soon be terribly blighted," Campo says.

The CDC’s report also confirmed anecdotal evidence collected by Audie Lemke, MSW, director of the HIV/AIDS Project Development and Evaluation Unit at the School of Social Work in the University of Washington in Seattle. "I’m not surprised by it," she says.

"I was doing surveys in gay bars in Seattle from 1991 to 1997, and we consistently showed that gay African-American men had higher rates of HIV infection and higher rates of unprotected anal intercourse than white gay men."

Before the nation’s health policy-makers can hope to reverse the trend and slow the spread of HIV among black and Latino communities, some major societal changes need to be made, Campo suggests.

"We must confront two key issues that erode American civil society: homophobia and racism. Both of these forms of intolerance have a particularly virulent effect in the Latino community," Campo says.

The CDC report notes that homophobia contributes to some minority MSM denying that they are homosexual or bisexual.

According to the report, about one in four black MSM who have AIDS and one in six Latino MSM who have AIDS still identify as heterosexual.1

"Clearly we know that homosexuality is stigmatized across all cultures, but it may even be greater in Latino and African-American communities," Gayle says.

"Fear continues to drive far too many young black and Latino men to die alone rather than to face the risk of being shunned by family and friends," Gayle adds. "Fear is what drives families to silently hope their son is a drug addict when they find out he has AIDS, as opposed to his being homosexual, and fear drives young men away from the people and prevention services that might help protect them from infection."

Gayle says the CDC hopes to break some of the silence around homosexuality in communities of color by highlighting this report’s findings.

Fear leaves gay blacks, Latinos isolated

Black gay and bisexual men face the stigma present in the greater white society and the more personal stigma within their African-American communities, and both affect how they identify themselves sexually, Wilson explains.

"I reject the notion that African-American communities are more biased against gay and bisexual men than are other communities," Wilson says. "But I do know from my experience that when that bias happens, it can impact us in a more dramatic way because often in core communities we depend on the sanctuary of our racial communities, and when you lose that sanctuary, the impact of homophobia and the impact of anti-homosexual bias can be overwhelming."

Latino homosexuals also have to cope with rejection from their church because most Latinos are Catholic, Campo says. The Catholic Church also hinders AIDS prevention efforts with its condemnation of the use of condoms, he states.

"I think because Latinos are so overwhelmingly Catholic, the church is a place where folks often get information that actually puts them at higher risk for HIV and AIDS," he says.

"I think the church has to do more and could learn a little bit from some of the initiatives that black churches have begun to undertake and discuss these issues around sexuality much more frankly," Campo adds. (See story on black church initiatives, p. 27.)

References

1. HIV/AIDS among racial/ethnic minority men who have sex with men — United States, 1989-1998. MMWR 2000; 49:4-11.

2. Diamond C, Buskin S. Continued risky behavior in HIV-infected youth. Am J Publ Health 2000; 90:115-118.