Helene Gayle

Director, HIV, TB and Reproductive Health

Bill and Melinda Gates Foundation

HIV/AIDS in the African American Community:Confronting the Challenge

“Our lives begin to endthe day we become silentabout things that matter.”

Martin Luther King, Jr.

—

HIV/AIDS Challenges

• Continuing spread in Africa, Caribbean• Emerging epidemics• Possible resurgence in high income countries• Anticipated escalation of new infections

– 45 million new infections by 2010– 28 million infections are preventable

Western Europe

570 000570 000North Africa & Middle East

550 000550 000Sub-Saharan

Africa

29.4 29.4 millionmillion

Eastern Europe & Central Asia

1.2 million1.2 million

South & South-East Asia

6 million6 million

Australia & New Zealand

15 00015 000

North America

980 000980 000Caribbean

440 000440 000

Latin America

1.5 1.5 millionmillion

Total: 42 million

East Asia & Pacific

1.2 million1.2 million

Source: UNAIDS, December 2002

Adults and Children Estimated to be Living with HIV/AIDS, End 2002

HIV/AIDS IN AMERICA TODAY

AIDS Cases and Deaths Reported1981 – 2002, United States

DeathsCases

Adults/Adolescents 849,780 482,330

Children (<13 years) 9,220 5,342

Total 859,000 487,672

0

10

20

30

40

50

60

70

Pe

rce

nt o

f Cas

es

MSM & IDU

Men who have sex with men (MSM)

Injection drug use (IDU)

Heterosexual contact

Year of Diagnosis

Proportion of Estimated Adult/Adolescent AIDS Cases by Exposure Category and Year of Diagnosis,

1985 – 2002, United States

85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02

0

10

20

30

40

50

60

70

Pe

rce

nt o

f Cas

es

Year of Report

Proportion of AIDS Cases, by Race/Ethnicity and Year of Report, 1985 – 2002, United

States

White, not Hispanic

Black, not Hispanic

Hispanic

Asian/Pacific Islander American Indian/Alaska Native

85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02

• 1 in 50 African American and 1 in 160 African American women is infected with HIV

• African American men’s rates of AIDS is

8X higher than White men’s

• African American women’s rates of AIDS is

20X higher than White women’s

Source: CDC. HIV/AIDS Surveillance Report. Atlanta: US Department of Health and Human Services, Public Health Service, 2001 (Vol. 13, No. 2)

Impact on Families: Adults

Leading Causes of Death Among African Americans, 25- to 44-Years-Old,

United States, 2001*

0 500 1000 1500 2000 2500 3000 3500 4000 4500

Cancer

HIV infection

Diabetes mellitus

Unintentional injury

Homicide

Heart disease

Nephritis, nephrosis & nephrotic syndrome

SuicideCerebrovascular disease

Chronic liver disease10

123456789

* Preliminary death-certificate data for 2001

Deaths

African American Adult and Adolescent AIDS Cases By Exposure Group, 1993 to 2001

0

5

10

15

20

25

30

35

40

45

1993 1994 1995 1996 1997 1998 1999 2000 2001

MSM

Heterosexual

IDU

Source: U.S. Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report. Atlanta: Department of Health and Human Services, Public Health Service, 2002 (Vols. 7-13)

Year of Report

% o

f C

ases

African American Men and Womenwith AIDS

• AIDS case rate is more than 2X higher in men than women (109.2

vs. 47.8)

• MSM is the number one mode of transmission of HIV in men (37%)

• IDU and Heterosexual activity are the number one mode of

transmission in women (39% respectively)

Source: CDC. HIV/AIDS Surveillance Report. Atlanta: US Department of Health and Human Services, Public Health Service, 2001 (Vol. 13, No. 2)

37% - 61% reported

unprotected anal intercourse in the

past 6 months

40% - 43% reported

multiple sex partners

in past 12 months

MSM Risk Behaviors amongAfrican Americans

37% - 51% reported

exchanging sex for money

or drugs

HIV Prevalence and Incidence Among 2,942 YMSM (23-29 years) in Six Cities*, 1998-2000,

United States

14

3.5

13

7

32

2.54.4

14.7

0

510

15

20

2530

35

Total White AA Latino

Per

cen

t

HIV Prevalence

HIV Incidence

* Baltimore, Dallas, Los Angeles, Miami, NYC, Seattle

Source: U.S. Centers for Disease Control and Prevention. Morbidity and Mortality Review (MMWR) 2001, 50:440-443)

74

55

93 91

7566

7871

0

20

40

60

80

100

15-22 years 23 - 29 yrs.Age Group

Per

cen

t U

naw

are

White

BlackLatino

Mixed

Proportion of HIV-Infected Young MSM Unaware of Their Infection, by Age-group and Race/Ethnicity*

*n=206 HIV-infected MSM aged 15-22 years; n=367 HIV-infected MSM aged 23-29; six US metropolitan areas, 1994-2000.

Source: U.S. Centers for Disease Control and Prevention. Morbidity and Mortality Review (MMWR) 2002, August 23: 51(33); 733-736

Up to 85% reported

inconsistent condom use

12% - 32% reported multiple

sex partners

IDU Risk Behaviors among African Americans

21%-80% reported sharing needles

Heterosexual Risk Behaviors amongAfrican Americans

74% - 88% report inconsistentcondom use

16% - 32% report multiple sex

partners in thepast 3 months

24% - 82% had been diagnosed

with an STD

Impact on Families: Youth

• 44% of AIDS cases among 13-24 year olds are African American

• 59% of cases among young men

- MSM is the number one mode of transmission in young men (60%)

• 41% of cases among young women

- Heterosexual activity is the number one mode of transmission in young women (56%)

Source: U.S. Centers for Disease Control and Prevention. National Center for HIV, STD and TB Prevention. Division of Sexually Transmitted Diseases. 2001

25% - 56% of adolescents

are sexually active

30% - 86% of adolescents

report inconsistentcondom use

High Risk Behaviors Among African American Youth

50% - 71% of adolescents report

drug or alcohol use

• Prevalence of HIV infection is 5 times greater in incarcerated populations vs. general public

(Rapposelli, et al., 2002)

• CDC cross sectional surveillance study revealed that 12% of HIV infected persons were diagnosed while incarcerated (Nakashima et al., 2002)

HIV Testing in Correctional Settings

21

HIV Prevention is Challenging…

But it isn’t any harder than living with HIV.

Focus on Prevention

Effective Prevention Tools

• Mass media• Voluntary counseling

and testing• Targeted peer

counseling • School-based

programs• Programs for out-of-

school youth• Workplace programs

• Condom social marketing

• Public sector condom distribution

• Harm reduction programs and drug treatment

• STD treatment• Prevention of mother to

child transmission

VCT – A Key Element in Integrating

Prevention and Care

• Gateway to care and treatment

• Has independent efficacy as prevention intervention especially in HIV-infected people

• Broader knowledge of serostatus permits the development of prevention programs that specifically target people living with HIV/AIDS

• Potential of anti retroviral therapy to reduce infectiousness

Structural Interventions

• Interventions that operate at the environmental or structural level and alter the context for individual action

• Examples:– 100% condom brothels– Closing of gay bathhouses in San Francisco– Legalizing over the counter sales of needle and

syringes in pharmacies– Increased alcohol taxes

Factors Affecting HIV Prevention

Individual micro-level factors

Structural intermediate-level factors

Structural macro-level factors

Individual level knowledge of HIV risk and prevention

Area-based treatment center and neighborhood characteristics; poverty and deprivation

Socio-economic status of populations

Individual characteristics targeted in prevention programs

Personal vulnerabilities such as knowledge and skills

Structural level laws, policies, standard operating procedures; environmental conditions and resources of individuals

Economic conditions or policies

Programmatic vulnerabilities such as education and services

Economic underdevelopment, gender inequality

Societal vulnerabilities such as discrimination of HIV-positive

Class, race, gender, sexuality inequalities

Source: Sunartojo, 2000.

Prevention Framework

Enabling Environment

Service and Commodities

Empowermentfor Prevention

Decrease in Risky Behavior

Modify Biologic Factors

Decrease in HIV

Incidence

The best way to predict the future is to invent it.

— Alan Kay

The best time to plant a tree is twenty years ago

The next best time is now

- African Proverb