HIV and AIDS among African Americans
To date, over 225,000 African Americans have died of AIDS - nearly 40% of total deaths - and of the more than 1 million people living with HIV in the United States of America today, around half are black. And yet, as a racial group, African Americans represent just 13% of the US population. The estimated lifetime risk of becoming infected with HIV is 1 in 16 for black males, and 1 in 30 for black females, a far higher risk than for white males (1 in 104) and white females (1 in 588).1 In Washington D.C, which has the nation's highest district HIV prevalence (3%), 76 % of those infected are African American. 2
So why are black Americans so disproportionately affected by AIDS in America and how do black Americans themselves view the epidemic? And what is being done to limit the number of new cases of AIDS being identified in clinics across the country?
AIDS among African Americans
The first cases of AIDS among African Americans were identified in the early 1980s. Initially HIV and AIDS mainly affected gay men and intravenous drug users (IDUs) within the black community, much as it did in the rest of the population. However in 1983 the US Centers for Disease Control and Prevention (CDC) documented the first two cases of AIDS in women. Both women had acquired HIV through sex with an intravenous drug user. One of these women was Latina; the other was black.
From this point on, the AIDS epidemic began spreading rapidly amongst the African American population. Women were particularly affected and by 1988, African Americans accounted for half of all AIDS cases identified in females in the US.3 Today, over 60% of women with AIDS are black.4
Magic Johnson, who announced he was HIV positive in 1991
Much of the problem in the early years, was the American media's portrayal of AIDS as a disease of white gay men. Black Americans were given few reasons to believe that AIDS could affect them, even though black men made up a large proportion of the early cases of AIDS in the gay and bisexual community, and from the outset, black heterosexual adults and children were significantly more likely to be infected than white heterosexuals.5
One of the first groups to address this lack of awareness, and the general problems created by the AIDS epidemic among African Americans was the San Franciscan gay community group, Black and White Men Together (BWMT). BWMT was significant not only for giving rise to America's first official black AIDS organisation, the National Task Force on AIDS Prevention, but for counting Reggie Williams as one of its members. Williams was one of the first gay black AIDS activists, and worked for many years to document deaths and raise awareness of AIDS in the black homosexual community. It was his successful lobbying that eventually led the CDC to issue its first ever grant for HIV prevention targeted at black gay men in 1988.6
The seriousness of the AIDS epidemic among African Americans in the 1980s and 1990s was also highlighted by a number of well known African Americans who became infected with HIV or died of AIDS. Max Robinson, the first black US news anchorman, was one of the first African American celebrities to openly admit his status shortly before he died in 1988. His death was followed by that of tennis star Arthur Ashe, who died from AIDS in 1993, and the rapper Eazy-E, who died in 1995.
Perhaps the most famous HIV-positive black American still alive today is former basketball player Earvin "Magic" Johnson, who announced he had HIV in 1991. Magic Johnson's assertion that HIV "can happen to anyone" represented a greater understanding that AIDS was not just a 'gay' disease.
Others to have helped raise the profile of HIV in the black community include the Reverend Jesse Jackson, who in 2000 joined a number of other well-known African Americans in taking an oral HIV test to demonstrate the importance of HIV testing.
Though action is being taken, Rev Jackson is likely one of many who believe that current efforts to combat HIV in the black community are still not enough:
"AIDS has been allowed to stalk and murder Black America like a serial killer because we have been a compliant victim, submitting through inaction. It is now time for us to fight AIDS like the major civil rights issue it is," Reverend Jesse Jackson, 2006 7
Main risk factors among African Americans
For both black men and women, having unprotected sex with a man is the leading cause of HIV infection. Among black men living with AIDS, 46% were infected through male-to-male sexual contact. Among this group, the young are particularly affected. In 2006, more black men who have sex with men (MSM) between 13 and 29 were infected with HIV than any other age group, including of other races.8 Furthermore, the HIV epidemic among this group is rapidly growing as between 2001 and 2006 annual HIV diagnoses among black MSM aged 13-24 grew by 93%. Among black MSM of all ages the figure was 12%.9
There are several theories as to why young black men are so vulnerable to becoming infected through homosexual activity, though none are decisive. These include the fact that this group is more likely to have sex with older men compared to young men of other racial groups, and that sexual partners are likely to be chosen from a relatively small group of people allowing HIV to spread quickly when it is introduced. However, other research has shown young, black MSM do not engage in risky behaviour to a greater extent than young white or Latino men, making reasons behind why they are disproportionately affected largely unknown.10
Black women are hugely, and disproportionately, affected by AIDS, with the most likely transmission route being heterosexual sex. Three-quarters of African American women living with HIV were infected this way and account for nearly half of the country's entire female epidemic. Of black men living with HIV, 20% were infected through heterosexual contact; more than two-thirds of all men infected in this way.11
There are a myriad of social and economic factors that result in higher levels of sexual HIV transmission among black Americans. However, higher levels of STDs among African Americans, also shaped by social and economic factors, in turn facilitate sexual transmission of HIV. Black Americans have 8 times the level of chlamydia, and 18 times the level of gonorrhea compared to white Americans.12 An analysis by the U.S Centers for Disease Control and Prevention (CDC) found that 48% of black women and 39% of black men were infected by genital herpes in the U.S compared to 21% of women and 11.5% of men overall.13
Injecting drug use is the second most likely HIV transmission route for African Americans and by 2007 accounted for 27% of all African Americans living with AIDS. More black males and females living with AIDS were infected by injecting drug use compared to males and females of any other racial or ethnic group. African American injecting drug users (IDUs) have a high risk of acquiring HIV and for not surviving long after an AIDS diagnosis.14
A direct risk of transmission occurs when IDUs share needles with people of a different HIV status. Indirectly, drug users may also become involved in crime or prostitution to fund their habit. Sex workers who are desperate for a fix, or are high on drugs are less likely to insist their clients use a condom. Crack cocaine, along with drugs such as crystal methamphetamine, can also lower inhibitions and increase the likelihood that users will engage in high-risk sexual behaviour.
See our HIV & AIDS Statistics by race and age page for more information on the black AIDS epidemic
Social and economic context of the African American AIDS epidemic
As with the epidemic among other groups, a complex set of factors influences the course of HIV and AIDS among African Americans. No single cause explains why black Americans are disproportionately affected by AIDS though there are a series of reasons that no doubt play their part.
"Obama will continue to fight poverty and homelessness, key drivers of this epidemic."
- Obama for America presidential campaign
Poverty is a major contributor to the HIV and AIDS epidemic among African Americans. Poverty and a disadvantaged upbringing often cause young people to drop out of school early, preventing them gaining access to well-paid and stable employment or causing them to lose a sense of self-worth and be drawn into illegal or socially unacceptable activities (such as drug use) that may put them at direct risk of HIV. The symptoms of poverty also influence sexual relationship patterns that encourage the spread of HIV. The need to pay attention to the social and economic context in which HIV flourishes was recognised by Barack Obama who, in his presidential campaign literature pledged to 'tackle the scourge of poverty where HIV and AIDS proliferate'.15
Nearly a quarter of African American families live in poverty, with even higher poverty rates for single male-headed households (27%) and single female-headed households (40%).16
One focus group involving African Americans in North Carolina revealed a link between participants' social background and sexual networks in the community. These contextual factors included institutional racism leading to diminished employment prospects and the inability to get a mortgage; high rates of incarceration; and lack of community recreation.
It was found that skewed sexual ratios resulting from rates of imprisonment, death and drug use among men, influenced patterns of sexual networks conducive to the spread of HIV and other STDs. Women, especially those who were poor or had lower educational attainment, were believed to feel dependent on men and more likely to tolerate their partner having concurrent partners. Similarly, women with incarcerated partners were more likely to have other sexual partners.
Racial segregation is also believed to be a factor in that it concentrates social and economic influences. This increases the likelihood of risk factors such as drug abuse, and boosts the chances of an individual having an infected sexual partner.17
Jesse Jackson publicly taking an oral HIV test.
Poverty can also force people, particularly women, to use sex as a form of payment or as a way to earn money. A study by the National Campaign to Prevent Teen Pregnancy 18 found that a significant number of young black women partake in 'transactional sex' relationships with older men to secure gifts, money or greater financial security. Often a woman in such a relationship will not be in a position to dictate condom use, making it more likely she could become infected with HIV herself, or that she could pass HIV on to her partner if she already has it.
A poor sense of self-worth, due to fewer opportunities to better one's self also means some feel protecting themselves from HIV is simply not a priority when sex can bring much more instant gratification. This lack of self-worth was clearly evident in the fatalistic views of black LA gang members recorded in a 2006 study by the Minority AIDS Project 19. A quarter of respondents felt it didn't matter if they got HIV, because they believed they would probably die young anyway.
Discrimination and stigma make life exceedingly difficult for those living with HIV, and prevent open discussion about the behaviours that can result in infection, and the action that could be taken to prevent it. It also leaves people afraid to be tested, meaning many may not seek treatment until they are very sick, and will not take sufficient precautions to prevent onward transmission.
Homosexuality is highly stigmatised in many communities, and in one that is already discriminated against by society in general, few black men want to acquire the extra stigma of being gay. It is also decried by the majority of black churches (and by the wider Christian religion), who see homosexuality as a sin. A combination of these factors causes many black men to keep their sexuality a secret. Instead, some black men who have sex with men identify themselves as 'on the down low'. This is where black men, who identify as straight and have a female partner, have sex with other men in secret. In the vast majority of cases, the woman in the relationship will be unaware of her partner's activities. One man interviewed by the San Francisco Chronicle in 2005, told reporters that the terms 'homosexual' or 'gay' are rarely used by black men on the down low:
"Gays to me were white men. The brothers that I hung out with, we never called ourselves gay. We just liked men. One brother asked me where my girlfriend was. I told him I didn't have a girlfriend because I'm gay. Yet he was still like, 'so why don't you have a girlfriend?' He thought I should have a girlfriend as a front."20 - Blue Buddha, San Francisco Chronicle, 02 May 2006
African American men labelled or identified as being on the down low are often blamed for a large part of the epidemic in that they are believed to transmit HIV to their unwitting female partners. However, some have criticised depictions of black men on the down low and the undue attention this has garnered with regards to the black AIDS epidemic.21 Others say attention of men "on the down low" has overshadowed discussion of more important factors in the epidemic such as the high prevalence of STDs.22
"Gays to me were white men. The brothers that I hung out with, we never called ourselves gay. We just liked men."
- Blue Buddha, San Francisco Chronicle
"The lifestyle referenced by the term the DL [down low] is neither new nor limited to blacks and sufficient data linking it to HIV/AIDS currently are lacking."23
Though the contribution to the epidemic by black MSM who do not identify themselves as gay may be exaggerated, many may miss out on HIV prevention strategies that are aimed at openly gay, or indeed at straight black men.
Stigma towards people living with HIV is sometimes believed to find its root in misconceptions about the virus. In a survey of HIV knowledge and perception, a higher than average percentage of African Americans believed, falsely, that the virus could be transmitted via kissing or sharing a drinking glass. A greater percentage of African Americans, than any other racial group, believed there was 'A lot' of prejudice and discrimination against people living with HIV and AIDS in America. However, a greater proportion of African Americans than other racial groups said they would be 'Very comfortable' working with someone with HIV or AIDS.24
Lack of access to healthcare
Healthcare in the US is principally funded through private insurance payments. This either means that those who cannot afford insurance have to be insured by the government through state Medicare or Medicaid schemes (see our HIV treatment in America page for more details) or that they remain uninsured altogether and have to pay for every individual treatment or consultation they receive. In 2007, nearly a fifth of African Americans did not have health insurance, compared to just over 10% of whites.25
This inability to pay, accompanied by a general suspicion of the medical profession and hospitals, means a significant number of African Americans do not visit a hospital or doctor until they are seriously ill. This can have consequences for HIV prevention, because it means many will avoid taking an HIV test until it is clear that there is something seriously wrong. By this point, an individual may have had unprotected sex with numerous people, because they were unaware of their infection and the need to use condoms. HIV negative people may miss out on the information and advice provided by doctors about HIV if they never go to a clinic.
A failure to access medical services and take an HIV test can also have a detrimental effect on the health of the individual concerned. Studies have found that the risk of death from AIDS is around seven times greater amongst HIV+ black people than amongst HIV+ whites, principally because black people are usually diagnosed with HIV much later and are less likely to receive antiretroviral treatment once they are diagnosed.26 AIDS is now the leading cause of death in black women aged 25 to 34.27
American HIV-positive activist Hydeia Broadbent
Access to HIV treatment is a significant issue. Two thirds of African Americans rely on publicly funded programmes such as Medicaid to be able to finance their treatment, compared to 50% of HIV+ people as a whole. African Americans also feature significantly in the Ryan White CARE Act 'ADAP' (AIDS Drugs Assistance Programme) which provides drugs to those who do not qualify for Medicaid or Medicare, but cannot afford private health insurance. Some 60% of people who receive drugs through ADAP are from an ethnic minority. However, funding for ADAP (and the Ryan White CARE act in general) has not kept up with demand, and in the past, several states have experienced substantial waiting lists for treatment. As of September 2007, there were no patients on waiting lists, but these had reemerged in three states by March 2009.28 It is feared that public health care systems, relied upon disproportionately by the poor and African Americans, will buckle under budgetary pressures due to the adverse financial situation.29
Access to drugs is also an issue for pregnant HIV+ women. With the correct antiretroviral treatment and care, the risk of mother to child transmission of HIV is less than 2%. However, if she does not access medical services during her pregnancy or labour or remains undiagnosed, the risk of her infecting her baby is much higher. Of the estimated 3,592 under-13s living with AIDS who were infected during pregnancy, labour or through breastfeeding around two-thirds were African American.30
Almost one in twenty black men is currently in prison31, and there is around a one-in-three chance that a black male will serve time in prison during their lifetime.32
In 2006, researchers at the University of California at Berkley published a study showing that the increasing rate of HIV in heterosexuals, particularly women, closely tracked the increasing rate of incarceration among black men during the 1980s and early 1990s.33 A variety of research has shown men in prison to be at high risk of HIV, so their theory was that many black men became infected in jail and then went on to infect their female partners upon release. So convinced were they by this research, that they claimed that it almost entirely explained the disproportionate rate of HIV in African Americans.
A recent CDC study has however found that the vast majority of men are actually infected before they are imprisoned, suggesting that the rate of transmission within prisons is perhaps not as great as the UC Berkley evidence implies. Nonetheless, it remains an important piece of research in helping to understand the epidemic.34
It is possible that genetic difference between people from European and non-European backgrounds may also have a small part to play. Various studies have discovered that some people of European descent have a small genetic mutation (know as CCR5 receptor mutation) that makes their immune T-cells partially or fully resistant to HIV infection.35 Nobody is entirely sure why this mutation occurs (most believe it was a result of past European pandemics, such as small pox or the bubonic plague), but it is thought to affect about 10% of Caucasians. This does not mean that an individual with African (or indeed other non-European) ancestry is any more likely to develop HIV than a European without this CCR5 mutation; but as an entire racial group (ignoring other factors), whites are at a slightly lower risk of HIV infection than others.
Genetic factors really cannot fully explain the entire disparity between black and white infections however. Native Americans are statistically far less seriously affected by HIV than African Americans, although they too entirely lack the CCR5 receptor mutation.
How do African Americans view the epidemic themselves?
'AIDS in the black community' poster.
A 2009 survey by the Kaiser Family Foundation discovered over a fifth of black Americans cite HIV/AIDS as the most urgent health problem facing the US, significantly higher than the 6% average. (It should be noted that both figures have declined dramatically since as recently as 2004.)36 In another survey, four-fifths of African Americans believed that government spending on the disease domestically was insufficient. They also reported experiencing the highest levels of HIV-related stigma, were the most aware about transmission routes, were the most likely to have been tested, and were the ethnic group that was the most likely to say that they knew someone who was living with HIV or had died of AIDS.37
The level of concern and awareness about HIV is perhaps unsurprising given the severity of the AIDS epidemic within the black population. Though such surveys reveal higher levels of awareness among African Americans about HIV and AIDS, there are troubling signs that this is decreasing. Between 2004 and 2009, the proportion of black Americans who said they had seen, heard or read a lot about AIDS in the past year declined by almost half from 62% to 33%.38
A significant proportion of African Americans do not blame the spread of HIV on risky sexual behaviour, but instead hold the government responsible. 48% of African-Americans surveyed by Oregon State University researchers between 2002 and 2003 believed that HIV was a man-made virus. Over half (53%) believed that there was a cure for AIDS that was being withheld from the poor, and 27% thought AIDS was produced in a government laboratory. 12% thought that HIV was created and spread by the CIA and 15% thought it was a form of genocide against blacks.39
Such beliefs are perhaps understandable given the context of prejudice and exploitation that many black Americans have grown up with. Indeed, those that were found to have the most extreme conspiracy theory views in the study were unsurprisingly those that had encountered the most racism in their lives. Some cited the infamous 'Tuskegee' experiment as the basis for their beliefs. Conducted by the US government between 1932 and 1972, the study aimed to investigate the natural course of the sexually transmitted disease syphilis in the black population. Over 600 black men were enrolled, many of whom were infected with syphilis, but none were ever offered treatment. Many died as a consequence, fuelling outrage throughout the black community, and beyond.40
Such unethical practices have left a scar on the African American population that may never fully disappear. The conspiracy theories that they have given rise to also pose a serious risk to HIV prevention strategies, as they place the blame for infection elsewhere, and can stop individuals from taking responsibility for their own actions.41
What is being done to combat HIV in African Americans?
The common perception among African Americans is that the government is not doing enough to protect African Americans from AIDS. Roughly half of the Centers for Disease Control and Prevention's (CDC) budget is directed towards African Americans, proportional to their share of annual HIV infections. However, it is argued directing the CDC's entire HIV budget towards the black AIDS epidemic would not be sufficient. What could be improved, therefore, is the size of the HIV budget itself. For the 2009 financial year the CDC said $1.6bn was needed for HIV prevention, far in excess of the $753m allocated for 2008, indicating how financial need has so far been greatly unmet.42 In fact, although Obama's 2011 budget shows a 4% increase in funding for HIV prevention to the CDC, some leaders from the HIV/AIDS community see the new budget as a setback, stating that
"With the growing number of new infections and people needing lifesaving treatment and services, we are disappointed in the level of spending proposed by the government." - Carl Schmid, deputy executive director of the AIDS Institute 43
The "100 days to fight AIDS" march in Washington D.C. in November 2008
The CDC currently funds several projects around the United States that address the epidemic in African Americans.44 These include rapid HIV testing programmes in traditionally black universities and colleges across the country, a variety of epidemiological research programmes and the 'Minority AIDS Initiative' which aims to address health disparities and provide prevention programmes to ethnic minority groups at high risk of HIV. The CDC also runs a variety of social marketing and advertising campaigns, many of which target black churches - the focal points of many African American communities (around 80% of African Americans are thought to belong to a church). And in 2007, they provided $35 million to facilitate HIV testing and improve early HIV diagnoses in areas with high levels of HIV within local black communities.45
In 2006, a wide range of black politicians, senior clergy members, civil rights icons and community leaders signed a National Call to Action and Declaration of Commitment to End the AIDS Epidemic in Black America in which they promised to do everything in their power to address the epidemic in their communities.47 This was followed by a meeting of eight high profile African American organisations at the 16th AIDS conference in Toronto, where leaders pledged to work together to reverse the spread of HIV in the black community by 2011, and to openly discuss homosexuality, drug use and sex within prisons.48
The CDC's Heightened National Response to the HIV/AIDS Crisis Among African Americans was intended to intensify efforts to tackle the black AIDS epidemic focusing on four different areas: Expanding the reach of prevention services; increasing opportunities for diagnosing and treating HIV; developing new prevention interventions; and mobilising broader community action.49 By 2009, Dr Kevin Fenton, the CDC's director of HIV prevention, believed good progress was being made on all four focus areas.50 The nation's first national public awareness campaign, Act Against Aids, was also launched in 2009, with African Americans the first vulnerable group to be targeted. As part of the initiative, the CDC is partnering with 14 African American civic organisations to integrate HIV prevention into their core work.51 One of the first steps of the campaign - a social media effort called 'I know' - was launched in March 2010.52
"If we are to survive the AIDS epidemic, we are going to have to gather all of our resources and marshal them for the political struggles that lay ahead. "
- Activist and actor, Danny Glover53
Any effective, sustained effort to tackle AIDS in the US should have positive outcomes on African Americans seeing as they constitute such a large proportion of the overall epidemic. The CDC's acknowledgment of and research into entrenched social factors, such as poverty, which are a major contributor to the ongoing HIV transmission rate, is a positive step and should be reflected in all concrete action taken to reverse the trend of transmission in the African American community.
President Obama has made several gestures that indicate he is prepared to give the domestic epidemic the attention it deserves. Many of these were outlined during his election campaign. These included promises to implement a National AIDS strategy within a year of being elected and specifically address the epidemic in minority communities.54 To this end, Obama launched a series of National HIV/AIDS community discussions, the first held on the 25th August 2009, in Atlanta, Georgia in order to include the public in the formation of a National AIDS strategy.55 Although Obama has not met his promise to create a National AIDS Strategy within a year of taking office it is certain that only a collective effort will make progress in tackling HIV and AIDS among African Americans.