As with the epidemic among other groups, a complex set of socioeconomic factors influence the course of HIV and AIDS among African Americans. No single cause explains why black Americans are disproportionately affected by AIDS although there are a number of overlapping factors that no doubt play their part. Addressing the ‘social determinants of health’ 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 black population.
Poverty is a major contributor to the HIV and AIDS epidemic among African Americans. Poverty and a disadvantaged upbringing often cause young people to drop out of school early, preventing them from gaining access to well-paid and stable employment or causing them to lose a sense of self-worth and be drawn into illegal or socially unacceptable 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. The need to pay attention to the social and economic context in which HIV flourishes was recognized by Barack Obama who, in his presidential campaign literature pledged to ‘tackle the scourge of poverty where HIV and AIDS proliferate’.
Nearly a quarter of African American families live in poverty, with even higher poverty rates for single male-headed households (27 percent) and single female-headed households (40 percent).
One focus group involving African Americans in North Carolina revealed a link between participants’ social background and sexual networks in the community. These contextual factors included institutional racism leading to diminished employment prospects and the inability to get a mortgage; high rates of incarceration; and lack of community recreation.
It was found that skewed sexual ratios resulting from rates of imprisonment and death and drug use among men influenced patterns of sexual networks conducive to the spread of HIV and other STDs. 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. 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 likelihood of engaging in risk factors such as drug abuse and having sex with an infected sexual partner are increased if a person lives in an area where those risk factors are concentrated. According to the CDC, this situation, otherwise referred to as ‘residential segregation’ partly explains the disproportionately high level of STDs among African Americans.
Poverty can also force people, particularly women, to use sex as a form of payment or as a way to earn money. A study by the National Campaign to Prevent Teen Pregnancy found that significant number of young black women partake in ‘transactional sex’ relationships with older men to secure gifts, money or greater financial security. Often a woman in such a relationship will not be in a position to dictate condom use, making it more likely she could become infected with HIV herself, or that she could pass HIV on to her partner if she already has it.
A poor sense of self-worth, due to fewer opportunities to better one’s self also means some feel protecting themselves from HIV is simply not a priority when sex can bring more instant gratification. This lack of self-worth was clearly evident in the fatalistic views of black LA gang members recorded in a 2006 study by the Minority AIDS Project. A quarter of respondents felt it didn’t matter if they got HIV, because they believed they would probably die young anyway.
Discrimination and stigma make life exceedingly difficult for those living with HIV, and prevent open discussion about the behaviors 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, and will not take sufficient precautions to prevent onward transmission.
Homosexuality is highly stigmatized in many communities and is also decried by the majority of black churches, who see homosexuality as a sin. As a result, black men may prefer to keep their sexuality a secret. Instead, some black men who have sex with men identify themselves as ‘on the down low’. This is where black men, who identify as straight and have a female partner, have sex with other men in secret. In the vast 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 black 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 labeled 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. However, some have criticized depictions of black men on the down low and the undue attention this has garnered with regards to the black AIDS epidemic. Others say attention of men “on the down low” has overshadowed discussion of more important factors in the epidemic such as the high prevalence of STDs.
“Gays to me were white men. The brothers that I hung out with, we never called ourselves gay. We just liked men.”
“The lifestyle referenced by the term the DL [down low] is neither new nor limited to blacks and sufficient data linking it to HIV/AIDS currently are lacking.”
Though the contribution to the epidemic by black MSM who do not identify themselves as gay may be exaggerated, many may miss out on HIV prevention strategies that are aimed at openly gay, or at straight black men.
Stigma towards people living with HIV is sometimes believed to have its root in misconceptions about the virus. In a 2004 survey of HIV knowledge and perception, a higher than average percentage of African Americans believed, falsely, that the virus could be transmitted via kissing or sharing a drinking glass. A greater percentage of African Americans, than any other racial group, believed there was ‘a lot’ of prejudice and discrimination against people living with HIV and AIDS in America. However, a greater proportion of African Americans than other racial groups said they would be ‘Very comfortable’ working with someone with HIV or AIDS.
Lack of access to healthcare
Healthcare in the US 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 or that they remain uninsured altogether and have to pay for every individual treatment or consultation they receive. In 2007, nearly a fifth of African Americans did not have health insurance, compared to just over 10 percent of whites. The National HIV/AIDS Strategy, released in July 2010, places a strong emphasis on the impact of the health care reform bill, or the Affordable Care Act, on the future provision of HIV treatment. The changes due to 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.
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 it is clear that 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 recognized that blacks 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 if the racial disparities of the HIV and AIDS epidemic in America are to be overcome.
Access to HIV treatment is a significant issue. Two thirds of African Americans rely on publicly funded programs such as Medicaid to be able to finance their treatment, compared to half of HIV positive people as a whole. African Americans also feature significantly in the Ryan White CARE Act ‘ADAP’ (AIDS Drugs Assistance Program) which provides drugs to those who do not qualify for Medicaid or Medicare, but cannot afford private health insurance. However, funding for ADAP (and the Ryan White CARE act in general) has not kept up with demand, and in the past, several states have experienced substantial waiting lists for treatment. As of September 2007, there were no patients on waiting lists, but these had reemerged in three states by March 2009. It is feared that public health care systems, relied upon disproportionately by the poor and African Americans, will buckle under budgetary pressures due to the adverse financial situation.
Poor access to quality healthcare means that the risk of death and the survival rate of African Americans after an AIDS diagnosis are worse compared to most other racial and ethnic groups. HIV is now the third leading cause of death in black men and women aged 35 to 44.
Access to drugs is also an issue for pregnant HIV positive women. With the correct antiretroviral treatment and care, the risk of mother to child transmission of HIV is less than 2 percent. However, if she does not access medical services during her pregnancy or labor or remains undiagnosed, the risk of her infecting her baby is much higher. Of the estimated 3,833 under-13s living with AIDS in 2008 who were infected during pregnancy, labor or through breastfeeding almost two-thirds were Black/African American.
Almost one in twenty black men is currently in prison, and there is around a one-in-three chance that a black male will serve time in prison during their lifetime.
In 2006, researchers at the University of California at Berkeley published a study showing that the increasing rate of HIV in heterosexuals, particularly women, closely tracked the increasing rate of incarceration among black men during the 1980s and early 1990s. A variety of research has shown men in prison to be at high risk of HIV, so their theory was that many black men became infected in jail and then went on to infect their female partners upon release. So convinced were they by this research that they claimed that it almost entirely explained the disproportionate rate of HIV in African Americans.
A recent CDC study has however found that the vast majority of men are actually infected before they are imprisoned, suggesting that the rate of transmission within prisons is perhaps not as great as the UC Berkeley evidence implies. Nonetheless, it remains an important piece of research in helping to understand the epidemic. The National HIV/AIDS Strategy cites a number of studies which link the difficulties faced by men upon leaving jail in accessing treatment to a deterioration in their health and increased chance of onward transmission of HIV.
It is possible that genetic difference between people from European and non-European backgrounds may also have a small part to play. Various studies have discovered that some people of European descent have a small genetic mutation (known as CCR5 receptor mutation) that makes their immune T-cells partially or fully resistant to HIV infection. Nobody is entirely sure why this mutation occurs (most believe it was a result of past European pandemics, such as small pox or the bubonic plague), but it is thought to affect about 10 percent of Caucasians. This does not mean that an individual with African (or indeed other non-European) ancestry is any more likely to develop HIV than a European without this CCR5 mutation; but as an entire racial group (ignoring other factors); whites are at a slightly lower risk of HIV infection than others.
Genetic factors really cannot fully explain the entire disparity between black and white infections however. Native Americans are statistically far less seriously affected by HIV than African Americans, although they too entirely lack the CCR5 receptor mutation.