The United States leads the global response to HIV/AIDS, but fails to mobilize the same commitment to address the large and growing epidemic within its own borders, according to a report released last week by the Black AIDS Institute.
"Left Behind! Black America: A Neglected Priority in the Global AIDS Epidemic," praises the President's Emergency Plan for AIDS Relief, championed for the past several years by President George Bush, for its efforts to address HIV outside the United States.
However the report issues a stinging criticism of the government's "profoundly inadequate response" to the epidemic within its own borders, where Black Americans are most severely affected by the disease.
"More Black Americans are infected with HIV than the total populations of people living with HIV in seven of the 15 countries served by PEPFAR," said Phill Wilson, CEO of the Black AIDS Institute and one of the authors of the report.
"Were Black America a separate country, it would elicit major concern and extensive assistance from the U.S. government," Wilson told reporters. "Instead, the national response to AIDS among Black Americans has been lethargic and often neglectful."
When it comes to AIDS treatment, the report shows that many of the same factors that contribute to excessive rates of HIV illness and deaths in developing countries also apply to Black America – including late initiation of treatment, a high prevalence of multiple medical conditions, and the inability of patients to stick with their treatment regimens.
King County — a Model
In Seattle, the Metro King County Health Department – unlike the federal government—has developed an HIV/AIDS strategic initiative designed to diminish the epidemic by the year 2015.
"My guess is that we may have one of the lowest disparity rates in the country, " said Dr. Bob Wood, director of HIV/AIDS Control for the county public health department. "That's not to discount the disparity – there is still a disparity."
King County statistics show that as of June 30, 2007, 6,188 persons in King County are living with HIV or AIDS, with new infections "holding steady" at 350 to 400 per year.
County studies indicate most of those affected are men who have sex with men, injection drug users and foreign-born Blacks, who together make up 86 percent of reported cases.
Yet King County has one of the lowest percentages in the nation of people with HIV who are not receiving regular care, 17.9 percent. King County also claims one of the lowest HIV infection rates among injection drug users in major urban areas, at 2 to 3 percent.
Meanwhile, health workers say their HIV-prevention program funding has decreased 18 percent in the last decade. Nevertheless, the county's strategic plan includes the goal of reducing new HIV infections by 25 percent by 2015.
The Metro King County website provides hundreds of resources for information, counseling, testing and care, at www.metrokc.gov/health/apu/resources.
Black AIDS Report
While the U.S. government requires countries receiving international AIDS program support to have a national AIDS strategy in place, the United States itself has no strategy for its own epidemic, and was one of 40 countries that failed to fulfill its commitment to report to the Joint United Nations program on HIV/AIDS on its response to AIDS at home.
At the same time that the United States has dramatically, and appropriately scaled up funding for AIDS overseas, it has simultaneously cut real spending for domestic HIV prevention and care initiatives – even as HIV caseloads in Black America have risen sharply.
According to the Black AIDS report, the Federal government is taking a fundamentally flawed approach to the epidemic.
"The 'concentrated epidemic' approach reflects a fundamental misunderstanding of the social networks of Blacks in America," Wilson said. "We are experiencing an epidemic with significant transmission beyond vulnerable populations."
According to Wilson, a more effective approach for the Black community would include a mix of targeted programs for high-risk populations; broad-based initiatives that mobilize entire communities; and efforts to address the role of concurrent partnerships and the rapid spread of HIV transmission in social networks.
Women, Children Increasingly Affected
Wood said that foreign-born Black residents have higher infection rates in King County, as do men who have sex with men. However the number of infected native-born Black women is slowly rising, comprising 12 percent of new cases.
"We don't have a lot of programs targeting Black women because they're very hard to reach," he said. "Many don't know they're at risk — through the behavior of their partners."
"Black women are particularly affected by the domestic AIDS response and attention to their needs are inadequate. Lives are lost as a result," said Dr. Helene Gayle, president and CEO of CARE. "As in other parts of the world, Black women in the U.S. often face increased vulnerability to HIV due to lack of a perception of power in sexual relationships and low self-esteem.
"Many cannot insist on abstinence or the use of condoms because of fear of emotional or physical abuse by their partners," Gayle said. "Development of female-initiated prevention methods is not only a critical priority for Black women overseas, but also for Black women here at home."
The report illustrates that young people in Black America, as in other parts of the world, are often at highest risk of infection because of inadequate knowledge of HIV infection, a high prevalence of inter-generational relationships, and a shortage of youth-tailored HIV prevention programs.
The report also says the taboos around men who have sex with men in Africa and other heavily impacted regions also exacerbates AIDS in Black America. "Among men who have sex with men worldwide, Blacks in the U.S. may have the highest HIV prevalence," said Jesse Milan, vice president of the non-profit health management consultancy Altarum.
"America has claimed a leadership role in the fight against the global HIV epidemic," said Wilson. "Yet, America's failure to respond to its own epidemic among its Black citizens undermines its credibility in addressing AIDS epidemic worldwide. For the U.S. to truly be a global AIDS leader, it must put its own house in order, too."
State of the Union
According to the Black AIDS Institute report:
• Standing on its own, Black America would constitute the world's 35th most populous country, but would rank 16th in the world in the number of people living with HIV.
• Outside of sub-Saharan Africa, only four countries – and only two in the Western Hemisphere – have adult HIV prevalence as high as the conservative estimate ( 2 percent among adults) for Black America. Blacks represent about one in eight Americans, but account for one in two people living with HIV
• Despite extraordinary improvements in HIV treatment, AIDS remains the leading cause of death among Black women between 25-34 years and the second leading cause of death in Black men between 35-44 years.
• Black women in the U.S. are 23 times more likely than White women to be diagnosed with AIDS.
• Blacks make up 70 percent of new HIV diagnoses among teenagers and 65 percent of HIV-infected newborns.