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 end the day we become silent about 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 North Africa & Middle East Sub-Saharan Africa 29.4 million Eastern Europe & Central Asia 1.2 million South & South-East Asia 6 million Australia & New Zealand North America Caribbean Latin America 1.5 million Total: 42 million East Asia & Pacific 1.2 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 Reported 1981 – 2002, United States Deaths Cases Adults/Adolescents 849, ,330 Children (<13 years) 9,2205,342 Total 859, ,672

Percent of Cases 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

Percent of Cases 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

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* Cancer HIV infection Diabetes mellitus Unintentional injury Homicide Heart disease Nephritis, nephrosis & nephrotic syndrome Suicide Cerebrovascular disease Chronic liver disease * Preliminary death-certificate data for 2001 Deaths

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

African American Men and Women with 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 among African Americans 37% - 51% reported exchanging sex for money or drugs

HIV Prevalence and Incidence Among 2,942 YMSM (23-29 years) in Six Cities*, , United States TotalWhiteAALatino Percent 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: )

years yrs. Age Group Percent Unaware White Black Latino Mixed Proportion of HIV-Infected Young MSM Unaware of Their Infection, by Age-group and Race/Ethnicity* *n=206 HIV-infected MSM aged years; n=367 HIV-infected MSM aged 23-29; six US metropolitan areas, Source: U.S. Centers for Disease Control and Prevention. Morbidity and Mortality Review (MMWR) 2002, August 23: 51(33);

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 among African Americans 74% - 88% report inconsistent condom use 16% - 32% report multiple sex partners in the past 3 months 24% - 82% had been diagnosed with an STD

Impact on Families: Youth 44% of AIDS cases among 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 inconsistent condom 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

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 Empowerment for 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