Avert, June 13, 2014
African Americans make up only 12 percent of the United States of America (USA) population, and yet accounted for over 46 percent of all HIV diagnoses in 2011. It is immediately clear that African Americans are the population group most affected by HIV and AIDS in the USA.
In this article, ‘African American’ refers to African American people, or black Americans, that are living in the United States of America (USA).
Key statistics–African American HIV epidemic
Between 2008-2011, African Americans accounted for:
- 64 percent of all HIV infections among women
- 67 percent of all HIV infections among children below 13 years old
- 42 percent of all HIV infections among adolescent and adult males
- 64 percent of all HIV infections among adolescent and adult females.
The estimated lifetime risk of becoming infected with HIV is 1 in 16 for African American men, and 1 in 32 for African American women, a far higher risk than for people of other ethnic backgrounds or races. The rate (per 100,000 population) of new HIV infections is 8 times larger among the African American community, than that among white people, based on population size.
Since the beginning of the HIV epidemic in the 1980s, over half of people who have died of AIDS-related illnesses were African American.
See our USA HIV & AIDS Statistics page for more statistics on the American HIV epidemic.
HIV transmission routes among African Americans
Sexual transmission of HIV
There are a myriad of social and economic factors that result in higher levels of sexual HIV transmission among African Americans. One predominant reason is that African Americans often only have sexual relations with others in their ethnic group. This concentrates the HIV epidemic among this community.
Also, higher levels of sexually transmitted infections (STIs) among African Americans facilitate sexual transmission of HIV. In fact, African Americans are the ethnic group most affected for every type of STI. For example, the prevalence of certain STIs among African Americans compared to white people was: 6.8 times higher for chlamydia, 15 times higher for gonorrhea, and 6 times higher for syphilis. Untreated STIs, especially those that cause sores, heighten the chance of HIV transmission.
19 percent of all HIV infections in 2011 among African American men were a result of heterosexual sex; and this figure is 89 percent for women. The low figure for men highlights the enormous proportion of HIV transmissions that were a result of sex between men.
African American men who have sex with men
Across the world, men who have sex with men (MSM) are disproportionately affected by HIV. This is also true among the African American population. Of all HIV infections in 2011 among male African Americans, 72 percent were transmitted via sex between men.
When comparing MSM infections between ethnic groups, African Americans accounted for 39 percent of MSM HIV infections in 2011, compared to 34 percent among whites. This difference does not seem too striking, until the huge population difference between African American MSM and white MSM is considered–2 percent of the USA population are MSM, and only 12 percent of the population are African American.
One study cited in the National HIV/AIDS Strategy revealed half of all African American MSM in five major US cities were HIV-positive. A larger study (conducted in 21 cities) concluded that almost a third of African American MSM were infected with HIV.
Young African American MSM
Of all population groups in the USA, young African American MSM (between the ages of 13 and 24) are the most affected by the HIV epidemic. They are more than twice as likely to be infected with HIV than young MSM of any other ethnic group.
One reason for this vulnerability is the already high HIV prevalence within this community, and the increased likelihood of African Americans to only have sexual relations with others in their community. The risk is heightened for young men who partner with older men because older MSM tend to have had more sexual encounters and therefore greater exposure to HIV.
“In the black gay community, very young black men tend to have their first sexual experiences and relationships with older black MSM . . . It’s a very resource-driven situation. For young black MSM from urban areas, their peers don’t have the resources that they need — a place to stay, food on the table, pay my cell phone bill.”
Young African American MSM are also the least likely to be aware that they are infected, which means they may be less likely to take steps to prevent transmission of HIV. 17 However, other research has shown how young African American MSM do not engage in risky behaviour to a greater extent than young white or Latino men.
One study conducted between 2005 and 2008, suggested that heightened HIV transmission in Mississippi among young African American MSM (age 16-25) compared to young MSM of other ethnicities was because young African American MSM:
- are less likely to disclose their sexuality than young MSM of other ethnicities. This meant they were less likely to access HIV prevention information that is specific to them.
- are more likely than older African American MSM to primarily have sex with just men, and those of the same race. The younger generation reported feeling more open about their sexuality than older men, leading them to feel more free to only have homosexual sex.
There were also more accounts of transmitted drug resistance among this population, because of their increased likelihood of only having sex within their demographic group of young, African American, homosexual men. HIV prevention methods need to be targeted to this group in order to stop the chain of transmission.
African American women
Encouragingly, there has been a 21 percent decline in new HIV infections among African American women since 2008. However, among women living with HIV, African American women are disproportionately affected, comprising 64 percent of the country’s entire female epidemic. They also account for 29 percent of the country’s African American epidemic, behind MSM.
The most likely transmission route is heterosexual sex, with 89 percent of African American women living with HIV being infected this way. 11 percent of female HIV infections were a result of sharing unsterile needles for drug use.
‘Sister to sister’ is an HIV prevention initiative delivered to African American women in a culturally sensitive way when they attend certain medical appointments. Such targeted campaigns may be contributing to the decrease in HIV infections among this population.
African American people who inject drugs
The third most likely route of HIV transmission within African Americans is among people who inject drugs (PWID). In 2010, they accounted for 9 percent of all HIV diagnoses among African Americans.
Injecting drug use counts for more HIV infections among African Americans than any other ethnic group. African American PWID have a high risk of acquiring HIV and of not surviving long after an AIDS diagnosis.
A direct risk of transmission occurs when PWID share needles with people of a different HIV status. Indirectly, drug users may also become involved in crime or sex work to fund their habit. Crack cocaine, along with drugs such as crystal methamphetamine, can also lower inhibitions and increase the likelihood that users will engage in high-risk sexual behaviour.
HIV prevention for African Americans
Funding for HIV prevention
Between 2009 and 2012, state and local health departments benefitted from over $360 million from the Centers for Disease Control and Prevention (CDC) to fund HIV prevention initiatives, with the CDC stating that most of this will be spent targeting MSM and ethnic minorities (especially African Americans).
Roughly half of the CDC budget is directed towards African Americans, proportional to their share of annual HIV infections. For the 2009 financial year, the CDC said $1.6bn was needed for HIV prevention, far in excess of the $753m allocated in 2008.
There is also a CDC funding for HIV scheme, whereby HIV and AIDS organisations that work with African American MSM or transgender people can apply for grants. So far, 34 organisations have been awarded about $300,000 of funding.
CDC prevention projects
The CDC currently funds several campaigns around the United States that address the epidemic in African Americans. This is part of its high-impact prevention approach that seeks to target high HIV prevalent populations and areas. These projects include:
- Act Against AIDS – uses mass media to raise awareness of HIV among all populations
- Testing Makes Us Stronger – encourages African American MSM to test for HIV
- Take charge. Take the test – encourages African American women to test for HIV
- Let’s Stop HIV Together – reminds people that HIV does not discriminate on grounds of race, gender or age
Act Against AIDS was the nation’s first national public awareness campaign (2009), with African Americans the first vulnerable group to be targeted. As part of the initiative, the CDC has partnered with 14 African American civic organisations to integrate HIV prevention into their core work.
Working with faith groups
The CDC also runs a variety of social marketing and advertising campaigns, many of which target churches–the focal points of many African American communities.
Many churches have already been mobilised against HIV by groups such as The Balm, in Gilead, which helps faith institutions to design programmes to tackle the issue of HIV among their congregation.
“There is no doubt that the link between HIV/AIDS, drug abuse and sexual activity has been a stumbling block for churches who feel that such behavior is contrary to their tenets . . . Fortunately, increasing numbers of churches are realizing that providing AIDS education and social services is consistent with the teachings of Jesus Christ. Clearly, Jesus’ actions on behalf of the sick show us how we should behave during this age of AIDS.” – Pernessa C Seele founded The Balm in Gilead
HIV testing among African Americans
HIV testing uptake is greater among African Americans than any other ethnicity, and more than twice that of white Americans.
However, around 20 percent of African American people living with HIV are still unaware of their status. Those who do test and are diagnosed positive, but present for HIV testing late, are at increased risk of transmitting HIV to others during this period. Young African Americans are most likely to be unaware of their status.
Various campaigns have been running to encourage African Americans to test for HIV, including ‘Testing Makes Us Stronger’, and ‘Take charge. Take the test’.
HIV treatment among African Americans
A CDC study found that only 46 percent of African Americans living with HIV were on antiretroviral treatment (ART). Moreover, only 35 percent had achieved viral suppression, where HIV is reduced to a low level in the body, meaning onwards HIV transmission is less likely.
A University of Michigan study, published in 2012, found that less than 30 percent of African Americans living with HIV on antiretroviral therapy (ART) were adhering to it, compared to 40 percent of people of other races. Over half of the African American study patients reported depression, with untreated depression noted as a cause of non-adherence among any racial group. Positively, prescribing anti-depressants doubled the number of patients adhering to ART.
It is important that access to healthcare is increased for African Americans, with regards to other health conditions and opportunistic infections.
See our HIV Treatment in the USA page for more information.
Social and economic factors in the African American HIV epidemic
A complex set of socioeconomic factors influence the transmission of HIV among African Americans. Addressing issues such as poverty, poor access to healthcare, and unemployment is now seen as an integral part of tackling the disproportionate impact of HIV on the African American population.
28 percent of African American families live in poverty, with similar poverty rates for single male-headed households (24.9 percent) and even higher poverty rates for single female-headed households (42.3 percent).
Often, African Americans live in concentrated residential areas, where risk factors such as drug abuse and risky sexual behaviour are common. This is known as ‘residential segregation’, which fuels the concentration of the HIV epidemic within the community.
Poverty and a disadvantaged upbringing may cause young people to drop out of school early, preventing them from gaining access to stable employment. It may also increase the likelihood of them being drawn into illegal activities (such as drug use) that may put them at direct risk of HIV.
The symptoms of poverty also influence sexual relationship patterns that encourage the spread of HIV, such as young women with older men. One focus group involving African Americans in North Carolina found that women, especially those who were poor or had lower educational attainment, were believed to feel dependent on men and more likely to tolerate their partner having concurrent partners. Similarly, women with incarcerated partners were more likely to have other sexual partners.
Poverty can also force people, particularly women, to use sex as a form of payment or as a way to earn money; often this is without a condom. A study by the National Campaign to Prevent Teen Pregnancy found that a significant number of young African American women partake in ‘transactional sex’ relationships with older men to secure gifts, money or greater financial security.
Stigma and discrimination
HIV and AIDS stigma:
Stigma and discrimination make life exceedingly difficult for those living with HIV, and prevent open discussion about the behaviours that can result in infection, and the action that could be taken to prevent it. It also leaves people afraid to be tested, meaning many may not seek treatment until they are very sick. Stigma towards people living with HIV is also believed to have its root in misconceptions about the virus, such as how HIV can and cannot be transmitted.The widespread perception of high HIV prevalence among the African American community increases the stigma and discrimination that members of the community who are living with HIV experience.
Homosexuality is highly stigmatised in many communities, with the majority of African American churches seeing homosexuality as a sin. As a result, African American men may prefer to keep their sexuality a secret to avoid homophobia. Instead, some African American men who have sex with men identify themselves as ‘on the down low’. This is where African American men, who identify as straight and have a female partner, have sex with other men in secret.
In the majority of cases, the woman in the relationship will be unaware of her partner’s activities. One man interviewed by the San Francisco Chronicle in 2005 told reporters that the terms ‘homosexual’ or ‘gay’ are rarely used by African American men on the down low:
“Gays to me were white men. The brothers that I hung out with, we never called ourselves gay. We just liked men. One brother asked me where my girlfriend was. I told him I didn’t have a girlfriend because I’m gay. Yet he was still like, ‘so why don’t you have a girlfriend?’ He thought I should have a girlfriend as a front.” –Blue Buddha, San Francisco Chronicle, 02 May 2006
African American men labelled or identified as being on the down low are often blamed for a large part of the epidemic in that they are believed to transmit HIV to their unwitting female partners. Others say attention of men “on the down low” has overshadowed discussion of more important factors in the HIV epidemic such as the high prevalence of STIs.
Lack of access to healthcare
Healthcare in the USA is principally funded through private insurance payments. This either means that those who do not have health insurance may have to be insured by the government through state Medicare or Medicaid schemes (see our HIV treatment in the United States of America page) or they remain uninsured altogether and have to pay for every individual treatment or consultation they receive.
In 2012, around 19 percent of African Americans did not have health insurance, compared to 11 percent of whites. This is not surprising in a community where 28 percent of its members are living in poverty.
The National HIV/AIDS Strategy, started in July 2010, places a strong emphasis on the impact of the Affordable Care Act on the future provision of HIV treatment. The changes that come into force in 2014 include expanded Medicaid eligibility, protection for people with pre-existing condition or chronic illnesses (such as HIV/AIDS) that will allow them to access health insurance, and increased access to tax credits.
Access to HIV treatment:
Two thirds of African Americans rely on publicly funded programmes such as Medicaid to finance their treatment, compared to half of all HIV-positive people. African Americans also feature significantly in the Ryan White CARE Act ‘ADAP’ (AIDS Drugs Assistance Programme) which provides drugs to those who do not qualify for Medicaid or Medicare, but cannot afford private health insurance. 34 percent of ADAP’s patients are African American.
Poor access to quality healthcare means that the risk of death and the survival rate of African Americans after an AIDS diagnosis is worse compared to most other racial and ethnic groups. HIV is now the fifth leading cause of death in African American men and seventh among African American women aged 25 to 44.
High cost of HIV treatment:
The cost of treatment, as well as a number of other factors, means that African Americans may not visit a hospital or doctor until they are seriously ill. This can have consequences for HIV prevention, because it means many will avoid taking an HIV test until there is something seriously wrong. By this point, an individual may have had unprotected sex with numerous people, because they were unaware of their infection and the need to use condoms.
Although it should be recognised that African Americans are more than twice as likely than whites to report having had an HIV test in the last 12 months, sufficient coverage of HIV testing among this population is still lacking. It has been identified that ‘missed opportunities’ to diagnose HIV at health settings must be addressed to overcome the racial disparities of the American HIV epidemic.
In mid-2013, African Americans made up 36 percent of prison inmates. Considering they only make up 12 percent of the USA population, this shows the huge proportion of African Americans that are incarcerated. The figure for whites was 47 percent. 65 percent of the deaths in prisons from AIDS-related illnesses during 2007 were among African Americans.
Release from prison:
Alongside being more vulnerable to HIV infection within prisons, there is also a greater risk of onwards transmission upon release from prison. The National HIV/AIDS Strategy claims the gender imbalance that occurs in communities with high rates of incarceration also results in an “increased likelihood that the remaining men will have multiple, concurrent relationships with female sex partners” and therefore an increased risk that a single male will transmit HIV to multiple female partners.
The future of HIV among African Americans
Any effective, sustained effort to tackle HIV in the USA should have positive outcomes for African Americans seeing as they constitute such a large proportion of the overall epidemic.
The CDC’s acknowledgement of, and research into, entrenched social factors such as poverty, is a positive step and should be reflected in all concrete action taken to reverse the trend of HIV transmission in the African American community.
Increased efforts must be scaled up to encourage African Americans to prevent and test for HIV, to control the epidemic among this population.