Demographic shifts change national face of HIV/AIDS.

As the global HIV/AIDS pandemic enters its third decade, it is impacting people of color most dramatically. Despite the fact that the health of the U.S. population has improved significantly over the last 50 years, ethnic and racial minority groups still continue to lag behind the white population, experiencing substantial disparities in health outcomes.

Recently released figures from the U.S. Centers for Disease Control and Prevention (CDC) confirm that HIV/AIDS is continuing to strike disproportionately and devastatingly in the heart of minority communities. In fact, they are making up far greater percentages of new cases than their populations would otherwise suggest. (1)

While race and ethnicity themselves are not risk factors for HIV infection, they are associated with key factors in the United States that determine health status-factors such as poverty, access to quality health care, health care-seeking behaviors, illicit drug use, and high rates of sexually transmitted diseases (STDs).

INCREASED HIV PREVALENCE

Despite the advances in AIDS drug therapies that have led to dramatic drops in deaths since 1996, ethnic and racial minorities continue to lag behind Whites in those decreasing rates. Between 1996 and 1997, deaths due to AIDS dropped 45 percent overall. Comparatively, they dropped 54 percent for Whites, 44 percent for Latinos, and 38 percent for African Americans. (2)

Overall, however, the prevalence of people living with HIV infection continues to increase, the result of new cases being diagnosed coupled with improvements in treatment regimens that result in people living longer after diagnosis.

WOMEN

Minority and young women face increasing risks for HIV and AIDS, with heterosexual contact now posing the greatest threat. Together, African American women and Latinas make up less than one-quarter of the U.S. female population. Yet the CDC reported that they represented fully 80 percent of AIDS cases reported in women in 2000 alone (3)

Thirty-eight percent of women living with HIV were infected through heterosexual exposure, while transmission through injection drug use accounted for an additional 25 percent of cases. According to the CDC Surveillance Report: "In addition to the direct risks associated with drug injection (sharing needles)...a significant proportion of women infected heterosexually were infected through sex with an injection drug user." (4)

AFRICAN AMERICANS

As of December 2000, the CDC had received reports of 774,467 aggregate AIDS cases; of those, 292,522 affected African Americans. Representing only an estimated 12 percent of the total U.S. population, African Americans now make up a staggering 38 percent of all AIDS cases reported in this country. It is estimated that almost 129,000 African Americans were living with AIDS at the end of 1999, more than any other racial/ethnic group. African Americans have a rate of new infections more than two times the rate for Hispanics and eight times that of Whites. (5)

Among African American males, the CDC reports that "the leading exposure category for AIDS is men who have sex with men (38 percent of the cumulative cases and 31 percent of new AIDS cases reported in 1998)." In those AIDS cases where causal relationship could be established, another 35 percent was attributed to injection drug use and seven percent were attributed to heterosexual contact. Of the latter, 35 percent of those infections were due to sex with an injection drug-using female and 63 percent were attributable to sexual contact with an HIV-positive person whose status was either unknown or undisclosed. (6)

Of the cases of heterosexual transmission among African American women, 28 percent were related to having sex with an injection drug user; four percent were related to having sex with a bisexual man, and 35 percent did not report or identify the risk factor. The CDC has found that "historically, more than two-thirds of AIDS cases among women initially reported without identified risk were later reclassified as heterosexual transmission." (7)

STDs such as syphilis, gonorrhea, chlamydia, and herpes are fueling the sexual spread of HIV infection because those infected with any of these diseases are at increased risk of contracting HIV during sexual activity. By the late 1990s, African Americans accounted for over 80 percent of reported syphilis cases and nearly 80 percent of the cases of gonorrhea, rates that are, respectively, 44 and 32 times greater than rates for Whites. (8)

Further fueling expansion of the HIV/AIDS epidemic is the intersection of substance abuse and HIV. Over one-quarter of new AIDS cases are due to injecting drug use. The CDC says that "studies of HIV prevalence among patients in drug treatment centers and STD clinics find the rates of HIV infection among African Americans to be significantly higher than those among Whites. Sharing needles and trading sex for drugs are two ways that substance abuse can... [put] sex partners and children of drug users at risk as well." (9)

A variety of factors contribute to the disparities in AIDS incidence and mortality experienced by African Americans. These include late identification of HIV infection, less access to experienced HIV/AIDS physicians, less access to HIV therapy that meets the U.S. Public Health Service guidelines, and lack of health insurance to cover HIV care and medications. (10)

Since the beginning of the epidemic, African Americans have accounted for over a third of U.S. AIDS deaths. The latest trends indicate that the AIDS mortality rate is still declining, though far more slowly than among Whites. African American deaths fell 17 percent in 1998, compared to 35 percent in the previous year. Among Whites, AIDS deaths fell by 22 percent and 51 percent, respectively, in the same years."

Unfortunately, African Americans are under-represented in the HIV prevention community planning process. In a March 1998 report, the CDC indicated that African Americans represent 27 percent of the 1,064 members of community planning groups nationwide while accounting for 45 percent of the new AIDS cases reported in 1998. (12)

LATINOS

Among minority groups, the Latino population ranks second among those most heavily impacted by HI V/AIDS. According to projections made by the Harvard School of Public Health, the number of new AIDS cases among Latinos will surpass that of Whites by 2005. (13) These trends portend disaster for the Latino population in the new millennium.

With a large and growing population, numbers indicate that Latinos represented 13 percent of the total U.S. population in 2000 (including residents of Puerto Rico) while accounting for 19 percent of the total number of new infections. The CDC reports that the rate of new of infections for Latinos in 2000 was more than three times the rate for Whites, but still just over one-third the rate for African Americans. (14)

Within the Latino community, men account for about four out of every five reported cases, with men who have sex with men (MSMs) leading the exposure category with approximately 40 percent of the new infections. Thirty-six percent are attributed to injection drug use, seven percent to sex with men who inject drugs, and five percent through heterosexual contact. Among Latinas, heterosexual transmission accounts for 40 percent of new cases while nearly half of all new infections were due to unidentified or unreported risk factors. (15)

At any given time, at least three-quarters of the one to four million migrant farm workers in the United States are Latino, and migrant and mobile populations are among the most medically underserved populations. Among those workers, HIV prevalence is estimated at between three and 13 percent. (16) According to the Health Resources and Services Administration (HRSA), mobility among migrant farm workers and the high percentage of multiple health problems they experience make the delivery of consistent medical care very difficult. (17)

Under-representation in the health professions also has serious impact on access to care for Latinos, particularly since they comprise such a high proportion of the country's uninsured population and Latino physicians are the ones most likely to provide care to the uninsured. (18)

Language challenges also contribute significantly to the barriers to prevention and care, given that 64 percent of Latino adults feel most comfortable speaking in Spanish and 68 percent of Latino AIDS cases are among foreign-born individuals whose first language is Spanish. (19)

NATIVE AMERICANS

The Native American population-approximately one percent of the U.S. population-is disproportionately affected by many social and behavioral factors that contribute to disparities in health outcomes and increased vulnerability for HIV infection. The population is relatively young and has high rates of poverty, STDs, and drug and alcohol abuse. (20)

Moreover, the policy of forced relocation of Native Americans throughout the United States and attempts to relocate them to urban areas, coupled with the racism and discrimination they have encountered, have led to a legacy of high rates of poverty, unemployment, welfare dependency, obesity, diabetes, alcoholism, substance abuse, and family violence. (21)

The AIDS epidemic among Native Americans (American Indians and Alaskan Natives) continues to grow As of December 1996, the CDC had reported a cumulative total of 475 cases of HIV infection and 1,569 cases of AIDS among Native Americans. By December 1998-a two-year period-the cumulative HIV infection cases increased by 33 percent to 632, and the AIDS cases increased by 24 percent to 1,940. (22)

Males make up 80 percent of the AIDS cases reported among Native Americans, with MSMs leading the exposure categories by accounting for nearly 60 percent of those infections. Injection drug use comes in first for women, now accounting for over half of the newly diagnosed cases. In overall mortality, by the late 1990s Native Americans had accounted for .25 percent of the cumulative U.S. AIDS deaths. (23)

It is probable that the number of HIV and AIDS cases is higher than what has been reported to the CDC due to misclassification of the ethnicity of Native Americans by health care workers and officials as White, Latino, or Asian.

ASIAN AND PACIFIC ISLANDERS 

Strong deterrents contributing to the under-reporting of REV/AIDS cases among APIs include the fact that many are non-citizens who fear that their residence in the United States may be placed in jeopardy if they test positive for HIV as well as the shame and loss of face that accompanies having contracted a socially stigmatized disease. (24)

Few states collect or report HIV/AIDS surveillance data by Asian and Pacific Islander (API) national origin/ethnicity, and several do not separately report any data on APIs. Instead, these states subsume any data on APIs in an "Other" category. In addition, anonymous HIV testing data is not included in the national surveillance reports on HIV cases. Yet APIs have high rates of utilization of anonymous HIV counseling and testing sites.

The cumulative number of AIDS cases reported among APIs through the late 1990s was approximately .8 percent of the total U.S. infections, with API males accounting for nearly 90 percent of the population's infections. MSMs experience the most severe impact of HIV and AIDS among this group, accounting for 56 percent of the reported AIDS cases among adult and adolescent males. Injection drug use accounted for five percent of the AIDS cases, while heterosexual contact accounted for less than 10 percent of infections. In at least one-third of the cases, a risk factor was not identified. Among females, half of HIV infections were due to heterosexual contact and nearly 20 percent to injection drug use, leaving large numbers of cases not attributed to an identified risk factor. (25)

RECOMMENDATIONS

Anecdotal information from many organizations providing prevention services in minority communities indicates that they are under-funded and may not receive sufficient resources to do the job.

There is an evident need for more education and prevention efforts across the board--efforts that must focus on high-risk behaviors, be sustained for MSMs, target women who expose themselves to unknown risks, enable female-controlled prevention methods, address the intersection of drug use and sexual contact, and culturally focus on specific populations.

These organizations that provide prevention services need to reach out not only to those infected and/or affected by HIV/AIDS in communities of color but also to those community institutions--such as religious groups--that might help them. Such institutions are uniquely positioned to bridge cultural barriers that often stand in the way.

With more than 3,000 AIDS service organizations nationwide amassed under its umbrella, the National Minority AIDS Council (NMAC) has made it a priority to develop local resources and build leadership to fight and win the battle against this disease in communities of color. For more information on NMAC and its work contact Sherri Watkins at 1931 13th Street, N W, Washington, DC 20009. Phone: [phone]. Fax: [phone]. E-mail: [e-mail]

REFERENCES

(1.) M. Maldonado, HIV/AIDS: African Americans (Washington, DC: National Minority AIDS Council, 1999), p. 3.

(2.) Ibid.

(3.) "HIV/AIDS Among U.S. Women: Minority and Young Women at Continuing Risk," Fact Sheet of the US. Centers for Disease Control and Prevention, National Center for HIV, STD, and TB Prevention (Atlanta: CDC, March 2002).

(4.) Ibid.

(5.) "HIV/AIDS Among African Americans," Fact Sheet of the US. Centers for Disease Control and Prevention, National Center for HIV, STD, and TB Prevention (Atlanta: CDC, March 2002).

(6.) M. Maldonado, HIV/AIDS: African Americans, p. 5.

(7.) Ibid., p. 6.

(8.) Ibid., p. 10.

(9.) "HIV/AIDS Among African Americans," Fact Sheet of the US. Centers for Disease Control and Prevention, National Center for HIV, STD, and TB Prevention (Atlanta: CDC, March 2002).

(10.) M. Maldonado, HIV/AIDS: African Americans, p. 11.

(11.) Ibid., p. 5.

(12.) Ibid., p. 11.

(13.) M. Maldonado, HIV/AIDS: Latinos (Washington, DC: National Minority AIDS Council, 1999), p. 3.

(14.) "HIV/AIDS Among Hispanics in the United States," Fact Sheet of the US. Centers for Disease Control and Prevention, National Center for HIV, STD, and TB Prevention (Atlanta: CDC, March 2002).

(15.) Ibid.

(16.) M. Maldonado, HIV/AIDS: Latinos, p. 8.

(17.) Latinos Living with HIV Disease: Barriers to Care (Washington, DC: U.S. Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau, April 1999), pp. 1-4.

(18.) M. Maldonado, HIV/AIDS: Latinos, p. 12.

(19.) Ibid., p. 13.

(20.) M. Maldonado, HIV/AIDS: Native Americans (Washington, DC: National Minority AIDS Council, 1999), p. 2.

(21.) Ibid.

(22.) Ibid., p. 6.

(23.) Ibid., pp. 7-8.

(24.) M. Maldonado, HIV/AIDS: Asians and Pacific Islanders (Washington, DC: National Minority AIDS Council, 1999), p. 9.

(25.) Ibid., pp. 3-6.