Our HIV crisis: All incidence is not equal

Our HIV crisis:
All incidence is not equal

Published on February 18, 2015


Despite representing only 13 percent of the U.S. population, African Americans account for nearly half of all new HIV infections each year. Rates of transmission among injecting drug users, black women and black infants born to seropositive mothers continue to decline, but HIV incidence among gay and bisexual men who are young and black has charted a steady rise.

Centers for Disease Control and Prevention estimates are jarring: Their numbers suggest that one in five black men who have sex with men (MSM) living in a major city already has HIV. Forty percent of these cases will progress to AIDS. This is all compounded by the fact that black MSM are the most likely demographic subgroup to date other members of their own race.

Yet, if we ask Americans where the virus destroys lives, a majority will point beyond our borders.

A very clear transitive relationship exists: Socioeconomic issues associated with poverty — limited access to health care, housing and HIV prevention education — undoubtedly increase the risk of infection. The poverty rate is higher among African Americans than other racial and ethnic groups. Therefore, we should expect baseline incidence of HIV among black Americans to be higher than for other groups.

But while nearly all accept this reality, sensationalized characterizations of the black community promote misconceptions about the primary reasons for high incidence.

Take for example the false claim that HIV/AIDS is a product of irresponsibly foregoing condom usage. Black MSM confront a great paradox in HIV incidence: Meta-analyses from researchers at the CDC showed in 2012 that black MSM reported fewer high-risk behaviors than MSM of other ethnic groups. Still, at the time the authors published their study, black MSM had three times the chances of testing HIV positive and six times the chances of having undiagnosed HIV. Disparities in condom usage on racial and ethnic grounds do not provide a real explanation for this crisis.

Incarceration due to the war on drugs has of course disproportionately affected people of color. But pointing the finger at male-to-male transmission in prisons to explain the crisis is similarly incorrect. From July 1988 to February 2005, Georgia implemented mandatory HIV testing upon prison entry and subsequent voluntary testing by request or by clinical indication. Of those found to be HIV positive in Georgia prisons and jails, 91 percent were positive upon entry. The real danger of living with HIV in prisons is not the risk of infecting another inmate, but the stigma and abuse that stems from a positive diagnosis.

HIV/AIDS in the black community, in many ways, is not an isolated crisis but rather the child of a more familiar one. It is the same American dilemma of historical racial subjugation. When considering America’s HIV crisis among African Americans, especially MSM, we must look back to that first relationship between socioeconomic status, HIV incidence and black Americans’ persistent struggle to overcome structural inequalities.

Years of discrimination in housing and other resources, inadequate sexual health education in our crumbling public schools and persistent racism are the primary culprits in this crisis. And while mass incarceration doesn’t cause HIV incidence to explode in prisons, it certainly affects those who are not jailed. The women and men left behind in society must encounter a numerically restricted sexual network, increasing the chances that they will come into contact with an HIV-positive individual in small, high-prevalence communities.

HIV will not disappear without an offensive strategy. There are many factors that contribute to the crisis, but expanding access to high-quality health care is the integral first step to decreasing the racial disparity in incidence. The concept of following through on the “treatment cascade” or “care continuum” is vastly important — individuals must be diagnosed, then linked to care, then remain in care, then eventually achieve viral suppression to prevent transmission. The problem is that far too many black MSM are unable to access medical care with the frequency that other groups do.


The first step in combatting the HIV/AIDS crisis begins with knowing one’s own status. If you or someone you know would like to receive free, confidential HIV testing, please call 203-936-8669.

The Affordable Care Act, in part, tried to address this crisis by eliminating discrimination practiced by insurance companies based on pre-existing conditions and by expanding Medicaid. But almost 20 states continue to deny Medicaid expansion, which would help those most vulnerable to HIV infection break into the care continuum and receive treatment. This is most potent in the South, where nine states have denied expansion, where African Americans are twice as likely to be uninsured and six times as likely to have HIV. And, according to a recent complaint filed with the Department of Health and Human Services, a number of insurance providers are actively discouraging HIV-positive individuals from enrolling in their plans through adverse tiering practices.

For many young black men who have sex with men, access to our health care networks is a question of life or death. We must confront this reality and take steps to ensure that they live.



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About the series

Our HIV Crisis is a series examining the HIV/AIDS epidemic. Focusing primarily on high-incidence communities in America, as well as on the landscape here at Yale, these columns seek to inform students about the most recent trends and challenges in combatting the crisis.