What Are African-Americans’ HIV Prevention Needs?
Are African-Americans at risk for HIV?
Yes. Many African-Americans are at high risk for HIV infection, not because of their race or ethnicity, but because of the risk behaviors they may engage in. As with other ethnic/racial groups, HIV risk depends not on who you are, but on whether you engage in risk-taking behaviors with an HIV+ partner, and whether you have access to care, education and prevention services. The majority of AIDS cases among African-Americans occur among persons aged 25-44, and among men.
While African-Americans comprise 13% of the US population, they are disproportionately affected by HIV, accounting for 37% of total AIDS cases in the US. In 1998, almost two-thirds (62%) of AIDS cases among all women were among African-Americans. Likewise, African-Americans accounted for over half (53%) of all AIDS cases among injection drug users (IDUs). In 1998, 62% of all children with AIDS were African-American.
Who are African-Americans at risk?
African-Americans, like many ethnic/racial groups, represent a diverse population. Their diversity is evident in their immigrant status, religion, socioeconomic status, geographic locales and the languages they speak. For example, African-Americans are White collar and working class, Christians and Muslims. They reside in inner-city and rural neighborhoods, are the descendants of slaves and recent Caribbean immigrants. Current epidemiological surveillance data do not record these social, cultural, economic, geographic, religious and political identities that may more accurately predict risk.
HIV transmission in African-American communities is primarily viewed as a problem among heterosexual IDUs and their sexual partners. Among African-American men, however, the cumulative proportion of AIDS cases attributed to homosexual/bisexual activity (38%) is greater than that attributed to injection drug use (35%).
African-American adolescents have, with few exceptions, markedly higher seroprevalence rates compared to White adolescents. Some sexually-active young African-American women are at especially high risk for HIV infection, especially those from poorer neighborhoods. A study of disadvantaged out-of-school youth in the US Job Corps found that young African-American women had the highest rate of HIV infection in the study. Women 16-18 years old had 50% higher rates of infection than young men.
What puts African-Americans at risk?
Injection drug use has played a major role in HIV infection among African-Americans. Although the majority of IDUs in the US are White, HIV infection is higher for Black IDUs than White IDUs. Unemployment and poverty are significant co-factors which may have led to high rates of addiction and high rates of risk behaviors such as sharing needles. In fact, the HIV and drug use epidemic among African-Americans is focused in a small number of inner-city urban neighborhoods of color, an indication that the epidemic may have more to do with geography and poverty than race.
While attitudes in the African-American community are slowly changing, homophobia and negative attitudes toward gay men still exist. For young African-American men who have sex with men (MSM), these negative attitudes may cause low self-esteem , lack of community and psychological distress, all of which contribute to risk-taking behaviors.
Many African-American women, especially adolescent women, are at high risk for heterosexually acquired HIV. African-American women may not want to or may not be able to negotiate condom use because they may think it would interfere with physical and emotional intimacy, imply infidelity by themselves or their partner or result in physical abuse. Some women may also be in denial or be unaware of their own risk. Over one-third (35%) of AIDS cases among African-American women reported in 1998 were classified as “risk not reported or identified.” It is thought that a majority of these women are infected through heterosexual sex with IDUs and/or gay or bisexual partners.
What are obstacles to prevention?
Communities of color in this country, including African-Americans, have experienced persistent inequalities in social benefits, health care, education and job opportunities. Economic disparities continue to exacerbate the health status of African-Americans and other communities of color in the US. As a result, African-Americans report high rates of diseases and mortality. In addition, many African-Americans hold a distrust of government programs and health institutions. Some African-Americans believe that the effects of AIDS on the community are the results of deliberate efforts and omission of responsibility by the US government. Effective community-based prevention programs must address these concerns.
AIDS has been seen as a primarily gay issue in the African-American community. In addition, homophobia exists in the African-American family, church and community on both a personal and institutional level. Many homosexually active African-American men may have been reluctant to respond to the AIDS epidemic for fear of alienation.
What’s being done?
African-American adolescents in Philadelphia, PA were offered an HIV prevention program addressing both abstinence and safer sex. Abstinence intervention participants reported less sexual intercourse after 3 months, but not at 6- or 12- month follow-ups. For youth who reported prior sexual experience, those in the safer sex intervention reported less sexual intercourse than those in the abstinence intervention at 3-, 6- and 12-month follow-ups. Both safer sex and abstinence-only approaches reduced HIV sexual risk behaviors in the short-term, but safer sex interventions may have longer-lasting effects and may be more effective for sexually experienced youth.
Some faith communities are responding to HIV in innovative ways. In Tennessee, the Metropolitan Interdenominational Church began an outreach program to IDUs in four poor, predominantly African-American neighborhoods. The program provides sterile needles, condoms, case management and prevention education. They are developing a church-based harm reduction program model for use in other faith communities.
The Well is a community-based drop-in center for African-American women that promotes self-help and wellness in a low income housing project in Los Angeles, CA. The Well offers peer support “sister circles”, exercise classes, community health education, a lounge/library, a nurse practitioner’s office, and a partnerships with other community health organizations. The well incorporates HIV/STD education into general education that addresses all aspects of women’s lives.
In 1999, in response to the disproportionate impact of HIV on communities of color in the US, the Congressional Black Caucus (CBC) Initiative earmarked $186 million to be spent on community-based HIV prevention programs for communities of color.
What needs to be done?
Researchers and service providers need a better understanding of the role of cultural and socioeconomic factors in the transmission of HIV, as well as the effect of racial inequality on public health. In addition, public health officials should consider changing epidemiological surveillance to include other demographic information such as social, economic and cultural factors. These efforts need to influence the design of HIV prevention messages, services and programs.
In the second decade of the AIDS epidemic, homophobia and AIDS denial have yet to be fully countered. Public health institutions should seek out partnerships with African-American faith communities and incorporate spiritual teachings on compassion to ignite a community response. HIV prevention for African-Americans must occur at the community level. Comprehensive programs should link with other health services, such as substance abuse programs, family planning services and STD clinics.
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Prepared By John Peterson Phd*, Gina Wingood ScD, MPH**, Ralph Diclemente PhD**, Pamela Decarlo***, Kathleen Quirk MA***
*Department Of Psychology, Georgia State University, **Rollins School Of Public Health, Emory University, ***CAPS
September 1999. Fact Sheet #15ER
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