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U.S. Blacks Seek Answers to AIDS Epidemic

25 years into crisis, research still lags as infection rates rise

FRIDAY, Dec. 1, 2006 (HealthDay News) -- By now, most Americans know the drill: Practice safer sex, and HIV should leave you and your community alone.

Except that it's not really working out that way for America's blacks. Study after study shows that HIV infections continue to escalate among this community -- especially among gay and bisexual black men -- even though they practice safe sex at rates that equal or exceed those of whites.

For example, a study published in time for World AIDS Day on Friday in the American Journal of Public Health found that young black adults who had engaged in no sex over the past year, didn't drink, and didn't abuse drugs were still 25 times more likely to test positive for a sexually transmitted disease or HIV than whites who practiced similar behaviors.

According to the U.S. Centers for Disease Control and Prevention, fully half of the nation's new HIV infections occur among blacks, who make up just 13 percent of the population. That rate continues to soar, despite the fact that condom use among blacks now tops 50 percent, compared to just one-third for young whites. According to the CDC, black women have 21 times the risk of white women of contracting HIV, while black males are eight times as likely to become infected as white men.

And, according to a recent five-city study conducted by the CDC, a staggering 46 percent of young gay black men in America now carry HIV -- a rate that equals or exceeds that of most nations in sub-Saharan Africa. By comparison, the infection rate among gay American white men hovers around 21 percent.

"However, black men who have sex with men (MSM) do not engage in higher rates of unsafe sexual behaviors compared to other MSM -- we found that in about 30 studies," said CDC HIV/AIDS investigator Gregorio Millet. He spoke at a Foundation for AIDS Research (amfAR) summit on the issue held earlier this week in New York City.

Millet noted that studies also show that gay and bisexual black men use illicit drugs at roughly the same rate as their white peers.

So, if black Americans are doing so much that is right, what is going wrong? Twenty-five years into the AIDS epidemic, no one really knows for sure.

Denise Hallfors, the author of the American Journal of Public Health paper, said that for too long, the CDC and other public health entities have looked upon HIV/AIDS from a solidly white perspective.

Since the beginning of the AIDS epidemic, most infections among whites were largely contained within specific groups, such as gay men and intravenous drug users. "The thinking was, you have to go after those very high-risk populations," said Hallfors, who is senior research scientist at the Pacific Institute for Research and Evaluation in Chapel Hill, N.C.

"So, those are the populations that the CDC focused on and did outreach with. And if you look at the data from our study, that makes perfect sense -- whites have very low rates of STDs if they are not in those risk categories. As soon as they enter those risk categories, their rates triple."

But the black community appears to work differently, with the borders between low- and high-risk groups much more blurred. "High-risk individuals can and often do cross over into low-risk groups," Hallfors said. "Once they cross over into the low-risk group, then they spread infection to the much larger community."

Because of the higher death and incarceration rate of black men, black women -- who tend to partner with black men -- have a smaller pool of potential mates to pick from compared to whites, Hallfors added.

"So, if you are a young black female adult and you go to church every Sunday, you have a pretty conservative lifestyle, you don't drink, smoke or do drugs, and you have even one or two partners in your lifetime, if one of them happens to be infected, you're sitting there with an STD," Hallfors said. And since this woman's apparently low-risk, church-going partner may have unknowingly contracted his infection from a prior high-risk contact, she believes she is "safe" and thus doesn't get tested for HIV, or gets tested far too late.

The same may hold true among gay black men, Millet said. "Black MSM are also less likely than other MSM to be tested for HIV," at least on a regular basis, he said. That leaves them more open to unknowingly pass the virus on to other partners.

There could be many other reasons for the virulent spread of HIV among gay black men, but the data just isn't out there, he said. Gay black men may be at higher risk because of their genetics, their lower rate of circumcision (circumcision reduces infectivity), reduced access to health care, their pattern of sexual partners, and their higher rates of incarceration -- one in four black men will serve jail time vs. one in 24 whites. "Unfortunately, there are all these hypotheses where we just don't have sufficient data," Millet said.

Until recently, there's also been little outreach to this hard-hit community, Millet added. "This epidemic has been raging among black MSM for well over 20 years and for some reason there have not been enough HIV prevention programs directed at blacks," Millet said.

Damon Dozier, director of government relations and public policy at the National Minority AIDS Council, said it's taken the recent release of shocking statistics to wake policymakers from their focus on whites.

"I think that no one really paid attention to what was going on, but that 46 percent infection rate is a huge number," he said. "Because of that, the wool has been pulled from people's eyes."

But Dozier said that the CDC, especially, is less able to tackle these issues now than it was in the past. "The CDC prevention budget has been slashed over the past few years," he said. "It would take a number of dollars just to get them back to baseline. Our hope is that with this new Congress, with Ms. Pelosi [incoming House Majority Leader Nancy Pelosi, a California Democrat] as leader, that we can devote more money to prevention and direct those prevention dollars to that 46 percent demographic."

There are signs of a real turnaround at the CDC. Late in 2005, the agency's head, Dr. Julie Gerberding, met with black activists who had pasted signs reading 46% is Unacceptable to the front of their desks. As reported by The Advocate at the time, Gerberding told them that, "Whatever we are doing right now, it is not enough."

Since then, the agency has launched a flotilla of HIV/AIDS education and prevention programs aimed at specific black communities -- many with proven track records in turning attitudes and behaviors around.

And, on Thursday, Gerderding issued a statement noting that the CDC has "recently issued new recommendations to make HIV screening a routine part of medical care for all patients between the ages of 13 and 64." Most experts who deal with minority communities say getting individuals acquainted with their HIV status is key to helping them get treated, protect their partners, and slow the epidemic.

CDC investigator Millet said he believes the situation "is getting better, in that we are now asking the right questions -- there are more people from these affected populations who are doing the needed research."

Hallfors agreed. She said that papers like hers, and new data coming out of the CDC and elsewhere, "is really important, because policymakers can start to think differently. Whites and blacks are different, the dynamics are different, and you can't just treat these diseases the same for both groups."

More information

Find out more about HIV/AIDS from the U.S. Department of Health and Human Services.

SOURCES: Denise Hallfors, Ph.D., senior research scientist, Pacific Institute for Research and Evaluation, Chapel Hill, N.C.; Nov. 27, 2006, Foundation for AIDS Research (amfAR) summit, HIV Prevention for Men Who Have Sex With Men, New York City, with Gregorio Millet, M.P.H., behavioral scientist, Division of HIV/AIDS Prevention, U.S. Centers for Disease Control and Prevention, Atlanta; Damon Dozier, director, government relations and public policy, National Minority AIDS Council; Nov. 30, 2006, online edition, American Journal of Public Health; Sept. 2, 2005, The Advocate
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