AIDS in America II: It’s not Black and White

As promised, more on the hideously neglected HIV epidemic in Black America, promoted by a truly admirable report from the Black AIDS Institute. Endless news reports seized on the clever “If Black America were a country it would be drowning in US-funded HIV programmes” angle. Yes, there are more Black Americans living with HIV than there are people infected in Botswana, Haiti, Rwanda — all places that suck in PEPFAR millions. But that’s in part because there are a lot more black Americans than there are Haitians or Rwandans. The real point of the report is not in the raw numbers, but in the percentages.

Here are the percentages: Around 13% of Americans are black, but 50% of Americans with HIV are black. Black Americans in any given risk group are far more likely to be infected than whites. Gay men who are black are more than twice as likely as gay whites to be infected with HIV, for example. More than half of infected drug injectors are black. Black people are more likely to be diagnosed late than whites are (especially if they live in the nation’s capital, funnily enough), and that contributes to a far higher death rate — in New York City, a black man with HIV is more than twice as likely to die than a while man with HIV.

The Black AIDS Institute report, Left Behind, draws attention to another hugely important risk for black men: being in jail. In Washington DC, three quarters of black men will be in jail at some time in their lives. Nationwide, black men are seven times more likely than white men to be in prison. What proportion of prisoners in the US have access to condoms while in jail? Less than one percent. For God’s sake.

The report is almost brutal in its honesty, and it is very well worth a read. (Sample: “In tackling its own epidemic, which has not ceased growing from year to year, the U.S. fails to follow the advice it energetically dispenses in developing countries”.) I take issue with only one thing (not counting the grisly graphics — a report of this calibre surely deserves better than Microsoft Excel’s ink-wasting and data-obscuring default styles). That is the confusion of epidemics that are generalised (“everyone is at risk”) and concentrated (“only gay men, people who inject drugs or buy and sell sex are at risk”). The report suggests that because absolute levels of infection top five percent in some areas, higher than the rates in some African countries, the HIV epidemic in Black America is an African-style “generalised” epidemic.

This from Phill Wilson, head of the Black AIDS Institute, in an interview with KFF:

Part of the problem in America is that we think of our epidemic as a targeted epidemic where the general population is not at risk but there are vulnerable populations that you need to focus on. In developing countries, we think of them as generalized epidemic, which means that the entire society is at risk. In Black America, for example, we have an epidemic that is closer to a generalized epidemic than we have one that is closer to a targeted epidemic.

Actually, it’s more complex than that. Black America is one of the rare countries, along with Brazil and a handful of West African countries and Caribbean islands, that has both a concentrated (targeted) epidemic and a generalised epidemic. Let’s be very clear what those terms mean. In a concentrated epidemic, most new HIV infections take place in well-defined high risk behaviours — almost always selling or buying sex, injecting drugs and having anal sex with lots of partners. People who do those things may pass HIV on to their regular sex partners, but if you take those groups out of the equation (for example by providing very effective prevention for everyone that needs it), the epidemic will die out in a generation. In a generalised epidemic, HIV gets passed between men and women who are linked in loose sexual networks — the town wife and the country wife, the rich but boring husband and the poor but dashing boyfriend. Commercial sex, sex between men and drug injection may boost the epidemic, but the virus will get passed on indefinitely even without those behaviours.

As I say, Black America probably has both. Half of all black men with HIV picked up the virus in anal sex with another man. A quarter injected it into their veins along with drugs. Over all, fewer than a quarter of black men got infected in sex with a woman, and infected men still far outnumber women — as is common in concentrated but not in generalised epidemics. About a quarter of infections in black women in the US are injected; that leaves three quarters infected in unprotected sex with a man. Black women are far more likely than white women to report several sex partners in a limited time frame, which is the critical issue in sending an epidemic “generalised”. Left Behind wants black men to get responsible when it comes to sex, giving Uganda as an example. Which is a shame, because it looks like multiple partnerships are on the rise again in that former paragon of HIV prevention in Africa.

The report chides US officials for falling back on gay activists when looking for solutions to HIV in the US:

“Blinded to potential international precedents, policy-makers in the U.S. almost instinctively look to previous experience in the urban gay communities in the 1980s when thinking about community mobilization to fight AIDS, even though tis unique history of gay AIDS activism has only limited relevance to the challenge confronting Black America.”

Since I’ve been known to rail about the dangers of exporting San Fracisco style activism to prevention efforts in Africa I ought to be pleased. But there’s a danger of throwing the baby out with the bath water (as the Left Behind report goes on to acknowledge). Yes, Black America needs community leadership on HIV. But it should focus that leadership on changing the behaviours that put most people at risk for HIV. And those behaviours continue to be dominated by anal sex between men (including in jail?) and drug injection.

A final quote from the report:
“In the final analysis, this epidemic isn’t terribly complicated. When we allow politics, subjective notions of morality and profit-driven health economics to reign over public health, the most vulnerable in our society are lfet behind.”
Hear, hear!

This post was published on 11/08/08 in Science.

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  1. Comment by scott cunningham, 11/08/08, 04:21:

    Elizabeth – It’s good to see that the disproportionate incidence of HIV/AIDS among Blacks getting the attention it deserves. I wanted to point you to some papers that I think you might find interesting, if you haven’t seen them already. First, there’s Johnson and Raphael’s forthcoming article that provides some evidence that the racial disparity in AIDS among women in the US is due to disparities in male incarceration rates. Chris Cornwell (University of Georgia) and me have two papers along those same lines. In the first paper, “Sex Ratios and Risky Sexual Behavior,” we provide some evidence that Black males have higher rates of concurrency with females due to an imbalanced sex ratio created by higher rates of Black male incarceration. We also find some evidence that this surplus of unattached Black women results in some men negotiating fewer condoms during sex. In a second paper (that’s currently being rewritten), we find results similar to Johnson and Raphael (click here). We focus on gonorrhea instead of HIV/AIDS, because we argue that gonorrhea is a better proxy for contemporaneous sexual behavior given its short incubation spells and better detection due to being more symptomatic than HIV. We find evidence that even controlling for large state/year specific shocks to sexual behavior (crack and AIDS mortality specifically) that male incarceration rates are associated with higher gonorrhea incidence, particularly among Black females. Adimora and Schoenbach at UNC-Chapel Hill have also done a great deal on this, too.

  2. Comment by Doreen, 11/08/08, 05:25:

    Since there is no clear surveillance of anal sex in women, could this behavioral variable get lost in the interpretation of the data? If anal sex was a more efficient means of transmission in women could it be an alternative explanation to women having high rates of multiple partners?

  3. Comment by elizabeth, 11/08/08, 06:45:

    Scott: Thanks and I look forward to reading more.

    Doreen: good point. This is the most under-researched area of sexual behaviour; keep an eye on IRMA for info about anal sex between heterosexuals.

  4. Comment by Roger, 14/08/08, 10:20:

    You may find that interesting:

    “The largest study to date on ethnic minority gay men and men who have sex with men (MSM) in the UK has found significant variations in rates of HIV infection between ethnic groups despite similar rates of sexual risk behaviour. Professor Jonathan Elford of City University, London presented his findings to the satellite conference on MSM and HIV preceding the International AIDS Conference in Mexico, and his team added more data in posters presented to the main conference.”


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