Changing Face of HIV Shows Disparities in Care, Outcomes

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http://www.medscape.com/viewarticle/733041

November 23, 2010 — The 2010 National Summit on HIV Diagnosis, Prevention, and Access to Care highlighted the persistent disparities that exist in HIV care and outcomes. Particular focus has been placed on the severe burden of HIV among blacks in the United States. The Centers for Disease Control and Prevention report that at the end of 2007, blacks accounted for almost half of all people living with HIV infection in the 37 states and 5 dependent areas that have long-term, confidential, name-based HIV reporting.

According to Kimberly Smith, MD, from Rush Medical College in Chicago, Illinois, the AIDS epidemic began as early as the 1980s in the black community. At that time, AIDS rates were 3 times higher in blacks than in whites. Dr. Smith pointed out that from the beginning of the epidemic, AIDS was perceived as a "gay white disease," which prompted a delayed response from black communities and community leaders. HIV-positive members of the black community were also marginalized, contributing to the stigma and delayed response. In the United States in 1996, rates of HIV infection were highest among blacks.

A recent article published in the Washington Post reported that 3% of the general population of Washington, DC was infected with the HIV virus. It is considered a "severe epidemic of HIV in DC, transmitted via every route of transmission."

Nnemdi Kamanu Elias, MD, interim director of the District of Columbia Health Department HIV/AIDS, Hepatitis, STD, and TB Administration, reported in an open panel discussion that black men account for 7% of those living with HIV in Washington, DC; 70% of those living with AIDS were older than 40 years of age; and more black men who have sex with men (MSM) were infected than their counterparts in other racial and ethnic groups.

Dr. Smith reported that "the HIV epidemic in some US populations rivals that of some sub-Saharan African countries." A study by H. Irene Hall, PhD, and colleagues, published in the Journal of the American Medical Association (2008;300:520-529), provided the first direct estimates of HIV in the United States. That study found that new HIV infection remains concentrated among MSM and blacks. The study highlights "the urgent need to acknowledge that HIV remains a major health concern in the US," the authors write.

According to Dr. Smith, the focus of this epidemic should be to discern exactly "how we got to this point." She highlighted 2 issues in particular: behavior and environment.

Behavioral factors include high-risk environments, concurrent partnerships, the mixing of high- and low-risk individuals, disassortative mating, substance abuse, and mental illness. Environmental factors include poverty, poor access to care, low health literacy, incarceration, high prevalence of sexually transmitted infections, and misunderstandings about how HIV is contracted and who is at risk.

A study by Manya Magnus, PhD, MPH, and colleagues from the George Washington University School of Public Health and Health Services, in Washington, DC (AIDS. 2009;23:1277-1284), examined the risk factors driving the emergence of the epidemic of HIV infection by heterosexual transmission and the disproportionate rates of infection among heterosexual black women. Of the 750 participants, 61.4% were older than 30 years, 92.3% were black, 60% had an annual household income of less than $10,000, and 5.2% screened positive for HIV. Women were more likely to screen positive than men, and of those who screened positive, 47.4% did not know their status before the study. Nearly 45% reported concurrent sex partners, and nearly 46% suspected concurrency in their partners. According to Dr. Smith, the study suggests that "the primary risk of HIV in heterosexual African Americans may simply be engaging in normal heterosexual behavior in a high-risk environment."

Other risk factors for black women include intravenous drug use, a history of incarceration, symptoms of depression, and not using a condom during the most recent sexual encounter. Black men older than 35 years have higher rates of HIV infection. Dr. Smith also reported that black youth with low-risk behavior are 25 times more likely than whites to acquire a sexually transmitted infection. Blacks also use condoms more than any other ethnic group — approximately 30% in the 10 most recent sexual encounters, compared with 25% among whites and 20% among Hispanics. Black MSM also engaged in high-risk behavior less frequently than white MSM. According to Dr. Smith, this means that there is "no room for error — the condom cannot break, must use a condom, can't get drunk, etc." This has led Dr. Smith to believe that it is "a behavioral issue rather than an environmental issue that is driving the epidemic."

Incarceration rates can also help account for the HIV epidemic among blacks. Rates of incarceration are highest among black men in the United States. According to Dr. Smith, "an African American male 30 to 34 years has a 27% chance of spending time in jail or in prison in his lifetime." That rate increases to 68% if he is a high school dropout. The higher rates of incarceration among black men affect the partners left behind. Those left behind may choose another partner or participate in concurrency, and the incarcerated partner is more likely to have sex in a pool of individuals with high HIV prevalence.

According to Dr. Smith, blacks experience higher HIV-related death rates, and life expectancy is only marginally improved, despite the advent of antiretroviral therapy (ART). Higher death rates are associated with delayed entry into care and late initiation of ART. Even with the initiation of ART, clinical trials have consistently shown that blacks have lower response rates to therapy.

The conference highlighted several modalities to improve disparities and control the epidemic. Dr. Smith encouraged more media campaigns to talk about HIV in the community. She also feels there should be "decreased focus on high-risk behavior, because it is not required for HIV infection in the black community." The representation of black MSM in the mainstream media also needs to be improved, and condoms should be made readily available in the prison system. Finally, Dr. Smith cited the need for improved patient–provider relationships and greater diversity among providers. In the fight to prevent the growing HIV epidemic among blacks, " are more likely to make individuals more comfortable, and they are more likely to come back