Emergency Response Plan to HIV/AIDS in the African American Community

African Americans and HIV/AIDS

Overview

HIV disease disproportionately affects African Americans in Missouri. African Americans make up only 11% of Missouri’s population, they accounted for 55.3% of HIV cases and 52.6% of AIDS cases reported in 2002. The rate for HIV cases reported in African Americans in 2003 (33.8) was almost 10 times (9.9) of whites (3.4) and 4.9 times than the state case rate (6.9).

In 2003 150 African American males and 63 African American females where initially diagnosed with HIV. The case rates for African American males (51.2) was 4.7 times higher than the average for all males in Missouri (11.0). The case rates for African American females (18.9) was (6.3) times higher than state case rate (3.0) for all females.

Magnitude of the Problem and General Trends

Since 1982, 14,840* HIV-infected Missouri residents (i.e., persons with HIV Disease) have been diagnosed and reported to the Missouri Department of Health and Senior Services. Of these 14,840 HIV Disease cases, 9,902* (66.7%) are subcategorized as AIDS cases, and the remaining 4,938* (33.3%) are subcategorized as HIV cases.

The annual number of HIV Disease cases (i.e., diagnosed and initially reported for the first time to public health officials) had decreased each year from 1990 through 2000. However, the 578 HIV Disease cases diagnosed in Missouri residents in 2001 represented a 7.4% increase from the 538 cases diagnosed in 2000 and the 580 new HIV Disease Cases diagnosed in 2002 represented a 0.3% increase from the 578 cases diagnosed in the previous year. The number of cases diagnosed in 2003 (510) decreased 12.1% from 2002.

The 385* HIV cases diagnosed in Missouri residents in 2003 represented a slight increase (1.9%) over the 378 cases diagnosed in 2002. This increase continued an upward trend that resumed after a decrease in the number of cases diagnosed in 1999. The 125* AIDS cases diagnosed in Missouri residents in 2003 represented a 38.1% decrease from the 202 cases diagnosed in 2002. The number of diagnosed HIV cases in Missouri increased dramatically from 1986 to 1988 and have increased gradually since then, while the number of diagnosed AIDS cases peaked in 1989, and have been declining since then. The numbers of cases for HIV and AIDS were approximately the same for the first time in the history of the epidemic from 1997 to 1999, with the number of HIV cases finally surpassing the number of AIDS cases in 2000. This divergent trend has continued since then. The total number of HIV Disease cases has, on the average, continued to decrease in 1989, except for a few years with minor upward moves (see Figure 15, “Reported HIV Disease Cases by Current Status and Year of Diagnosis, Missouri 1982-2003,” in the Missouri State Summary section of this document).

Of the 14,840 diagnosed HIV Disease cases, 9,495 (64%) are living, and 5,345 (36%) have died. The majority (5,147, or 96.3%) of these deaths have been in persons subcategorized as AIDS cases. The 5,147 AIDS cases who have died made up 52% of all diagnosed cases of AIDS in the state. During 2003, 124 HIV-related deaths in Missouri residents were reported on death certificates, an increase of 0.8% from the 123 HIV-related deaths reported in 2002.

Not all HIV-infected persons have been diagnosed nor are they aware of their infection status. It is estimated that the actual number of individuals infected with HIV (i.e., persons with HIV Disease) who are presently living in Missouri is in the approximate range of 9,500 to 13,500 persons. The Centers for Disease Control and Prevention (CDC) has stated that, nationwide, approximately 30% of HIV-infected persons are not aware that they are infected₁ (although a more recent CDC report has indicated that among young gay and bisexual men infected with HIV, the percentage who do not know their infection status may be much higher 21). An essential component of HIV prevention is to encourage and assist persons at risk for HIV infection to be tested so that, if infected, they can optimally benefit from available treatments, and be assisted in making behavioral changes to eliminate or reduce the risk of transmission to others.

Improved antiretroviral therapies (introduced since the mid-nineties) have slowed the progress of HIV disease in many infected persons, an achievement especially reflected in the substantial decrease in diagnosed AIDS cases in Missouri from 1996 to 1997, and in HIV Disease deaths from 1995 to 1997. The annual number of HIV Disease deaths has remained almost the same over the past six years (See Figure 4, “HIV Disease Deaths by Race/Ethnicity and Year of Death, Missouri 1993-2003,” in the Missouri State Summary section of this document). This likely reflects, at least in part, the limitations associated with current treatment regimens. Other factors that could potentially play a role here include delayed test seeking among certain populations, and limited access to or use of health care services.₂

There is an obvious need for continued emphasis on prevention of new infections, and for trying to ensure that all infected persons can access needed care services. Everyone needs to clearly understand that “despite medical advances, HIV infection remains a serious, usually fatal disease that requires complex, costly, and difficult treatment regimens that do not work for everyone. As better treatment options are developed, we must not lose sight of the fact that preventing HIV infection in the first place precludes the need for people to undergo these difficult and expensive therapies.”₃

The ability of improved treatments to extend the life-span of AIDS patients is reflected in the consistent increase in the number of persons living with AIDS in recent years, even though the annual numbers of new AIDS cases have been decreasing. At the end of 2003, 4,755 persons who were Missouri residents at the time of diagnosis were living with AIDS; the corresponding numbers for 2002, 2001, 2000, 1999, 1998, 1997, and 1996 were 4,455, 4,262, 4,049, 3,784, 3,496, 3,235, and 3,055, respectively.

Where

Of the 4,938 diagnosed HIV cases: 1,480 (30%) were from St. Louis City, 1,223 (24.8%) were from outstate Missouri*, 1,199 (24.3%) were from Kansas City, and 683 (13.8%) were from St. Louis County.

Of the 9,905 diagnosed AIDS cases: 2,844 (28.7%) were from St. Louis City, 2,709 (27.3%) were from Kansas City, 2,573 (26%) were from Outstate Missouri, and 1,518 (15.3%) were from St. Louis County.

Cases of HIV Disease disproportionately occurred in the state’s two major metropolitan areas (St. Louis and Kansas City). The highest rates of both HIV and AIDS cases, as well as the largest numbers of cases, were found in these two areas. St. Louis City consistently has had the highest case rates, followed by Kansas City, St. Louis County, and Outstate Missouri*.

Of total diagnosed HIV cases, 68.1% were from St. Louis City, St. Louis County, or Kansas City (which together comprise 32.3% of the state’s population). However, 1,223 cases of HIV have been diagnosed in the Outstate Missouri area. The number of HIV cases per 100,000 population (case rate) was the highest in St. Louis City, followed by Kansas City, and St. Louis County. Of the total diagnosed AIDS cases, 71.4% were from St. Louis City, St. Louis County, or Kansas City. Yet, 2,573 AIDS cases have been diagnosed in the Outstate Missouri area. Again, the highest case rate was in St. Louis City, followed by Kansas City and then St. Louis County.

Within St. Louis City, St. Louis County and Kansas City, both HIV Disease cases and cases of bacterial STDs generally tend to occur in the same specific areas.** It is within these areas that the need for prevention and care services are the greatest.

*The term “outstate Missouri” refers to all of the areas of the state outside St. Louis City, St. Louis County, and Kansas City.
**See the zip code maps in the St. Louis and Kansas City HIV Regions sections of the Epidemiologic Profiles.

Who

Of the 385 HIV cases diagnosed in 2003: 300 (77.9%) were in males and 85 (22.1%) were in females. The rate per 100,000 population for males (11.0) was 3.7 times higher than the case rate for females (3.0).

Of the 125 AIDS cases initially diagnosed in 2003: 103 (82.4%) were in males and 22 (17.6%) were in females. The rate per 100,000 population for males (3.8) was 4.8 times higher than the case rate for females (0.8).

Of the 162 HIV cases that seroconverted to AIDS in 2003: 132 (81.5%) were in males and 30 (18.5%) were in females. The rate per 100,000 population for males (4.9) was 4.9 times higher than the case rate for females (1.0).

Of the 385 HIV cases diagnosed in 2003: 161 (41.8%) were in Whites, 213 (55.3%) were in Blacks, three (0.8%) were in Hispanics, 1 (0.3%) was an Asian/Pacific Islander, and one (0.3%) was an American Indian. (Race/ethnicity was unknown for six cases.) The rate per 100,000 population for Blacks (33.8) was 9.9 times higher than the case rate for Whites (3.4).

Of the 125 AIDS cases initially diagnosed in 2003: 63 (50.4%) were in Whites, 59 (47.2%) were in Blacks, 2 (1.6%) were in Hispanics, and there were no new cases Asian/Pacific Islanders or American Indians. (Race/ethnicity was unknown for 1 case.) The rate per 100,000 population for Blacks (9.4) was 7.2 times higher than the case rate for Whites (1.3).

Of the 162 HIV cases that seroconverted to AIDS in 2003: 64 (39.5%) were in Whites, 92 (56.8%) were in Blacks, 4 (2.5%) were in Hispanics, 1 (0.6%) was an Asian/Pacific Islander, and 1 (0.6%) was an American Indian. The rate per 100,000 population for Blacks (14.6) was 11.2 times higher than the case rate for Whites (1.3).

In 2003, Blacks made up 55.3% of newly diagnosed HIV cases, 47.2% of newly diagnosed AIDS cases, and 56.8% of the HIV cases that seroconverted to AIDS. Given that Blacks make up only about 11.2% of the state’s population, this clearly indicates their very disproportionate representation among HIV-infected persons. The case rate for HIV cases diagnosed in 2003 in Blacks (33.8) was 9.9 times higher than the cases rate in Whites (3.4). The case rate for newly diagnosed AIDS cases and for HIV cases that seroconverted to AIDS in 2003 in Blacks (9.4 and 14.6 respectively) was 7.2 and 11.2 times higher than the case rate in Whites (1.3 in each category). Blacks were also highly disproportionately represented among reported cases of gonorrhea, chlamydia, and syphilis (see the discussion of these diseases later in the summary).

For Hispanics, the total numbers of cases diagnosed in 2003 for HIV and AIDS in Missouri was small. There are some reasons for concern that HIV Disease might be a more significant problem for Hispanics in Missourithan current numbers seem to indicate. First, it is possible that among diagnosed HIV and AIDS cases, because of incorrect information provided on the case report forms, a higher proportion may actually be of Hispanic ethnicity than is indicated by the current numbers. Second, the Hispanic population is increasing rapidly in Missouri. According to 2000 census data, Missouri’s Hispanic population grew by 92.2% during the period from 1990 to 2000 (from 61,698 in 1990 to 118,592 in 2000); in contrast, Missouri’s total population grew by only 9.3% during this time.₄ Another issue regarding persons identified as Hispanic, is that these individuals actually consist of a diverse mixture of ethnic groups and cultures. This indicates a need for specifically targeted prevention efforts.₅

In 2003, no AIDS cases and only 1 HIV case each were diagnosed in Asians and in American Indians within Missouri. Numbers of diagnosed HIV cases in Asians and American Indians have been very small; each of these two groups comprised less than 0.5% of newly diagnosed HIV cases.

It should be emphasized that race/ethnicity in itself is not a risk factor for HIV infection; however, among many racial/ethnic minority populations, social, economic and cultural factors are associated with high rates of HIV risk behavior. These factors also may be barriers to receiving HIV prevention information or accessing HIV testing, diagnosis, and treatment.₆

In 2003, case rates for new HIV infections in Whites were the highest among males 30 to 39 years of age, but in Blacks the case rates were highest in the 20 to 29 year old age group. Although relatively small in number, infections were also occurring in teenagers among Blacks in Missouri (see Figure 8, “HIV Incidence Rates for Selected Race/Ethnicity/Gender Groups, by Age Group, Missouri 2003,” in the Missouri State Summary section of this document). CDC estimates that, nationwide, about half of all new HIV infections are in young people under 25 years of age.₁

In 2003, two infants born to HIV-infected mothers were also infected. The number of perinatal HIV cases dropped from four in 1996 to 2 in 2003, and the number of perinatal AIDS cases dropped from three in 1996 to zero in 2003, while the annual number of live births in Missouri remained fairly constant. This difference reflected the use, starting in mid-to late-1994, of zidovudine (AZT, ZDV) treatment to reduce the risk of perinatal HIV transmission. It remains vitally important for all pregnant women to receive adequate prenatal care, starting early in their pregnancy, and to know their HIV status so that, if infected, they can take advantage of antiretroviral treatment to significantly reduce the risk of HIV transmission to their child, and also receive optimal treatment for their own disease. Prenatal providers should encourage all pregnant women to undergo voluntary HIV testing. Such testing should be viewed as a routine part of prenatal care for all women who are pregnant.₇

Epidemiology

Epidemiology is the branch of medicine that studies rapidly spreading outbreak of contagious disease and communicable diseases. Missouri State Statute 19CSR20-20.020 mandates the study and tracking of HIV among diseases, disabilities, conditions and findings that must be reported to the local health authority or the Department of Health and Senior Services.

From the time a person is first infected with HIV until death, he/she has HIV Disease, and is termed an HIV Disease Case. An HIV Disease Case can be subclassified as either an HIV Case (if he/she is in the earlier stages of HIV Disease) or an AIDS Case (if he/she is in the later stages of HIV Disease and has met the case definition for AIDS. See the following diagram:

• Each HIV Disease Case can be subclassified as either an HIV Case or an AIDS Case (i.e., he/she cannot be both an HIV case and an AIDS case at the same time). Once a person progresses to the later stages of the disease and is diagnosed as an AIDS case (by meeting the CDC surveillance case definition), he/she will remain an AIDS case. This is true even if he/she met the AIDS case definition because of a CD4+ lymphocyte count, 200 cells/mm3³, and later (perhaps as a result of effective antiretroviral therapy) has a CD4+ count > 200 cells/mm3³.

• HIV cases generally represent people who, in comparison to AIDS cases, were infected more recently. Thus the characteristics of reported HIV cases (e.g., race, gender, exposure category) would be expected to more closely represent the characteristics of person who are currently at highest risk of being infected.

• AIDS cases represent persons in the later stages of HIV disease who are at risk for developing serious, potentially fatal, opportunistic diseases. Consequently, AIDS cases, as compared to HIV cases, are individuals who are likely to have relatively greater needs for medical and social services, as well as for service coordination assistance.

  Trends in newly diagnosed AIDS cases (AIDS incidence) reflect, in part, the effects of antiretroviral treatment, since effective treatment given to infected persons while they are still HIV cases will slow the disease process, and consequently slow the progression of AIDS.

• In order to understand the epidemiology of HIV disease in Missouri (i.e. who is being infected, where are these persons located, what are the trends over time), it is necessary to examine not only HIV Disease Cases, but also the subcategories of HIV Cases and AIDS Cases.

The following is an excerpt from the Executive Summary of the 2002 Epidemiologic Profiles of HIV Disease and STDs in Missouri considers the magnitude of HIV infection in the State of Missouri; where people are infected; and who is being infected. The Missouri Department of Health and Senior Services, Division of Environmental Health and Communicable Disease Prevention, Office of Surveillance, produces the Epidemiologic Profiles of HIV Disease and STDs in Missouri annually.

Magnitude of the Problem and General Trends

Since 1982, 14,135 HIV-infected Missouri residents (i.e., persons with HIV Disease) have been reported to the Missouri Department of Health and Senior Services. Of these 14,135 HIV Disease cases, 9,478 (67.1%) are subcategorized as AIDS cases, and the remaining 4,657 (32.9%) are subcategorized as HIV cases.

The annual number of newly reported (i.e., initially reported for the first time to public health officials) HIV Disease cases had decreased each year from 1992 through 2000. However, the 622 HIV Disease cases initially reported in Missouri residents in 2001 represented an 18.0% increase from the 527 cases reported in 2000; but the 487 new HIV Disease Cases reported in 2002 represents a 21.7% decrease from the 622 years reported in the previous year, and is consistent with the decreasing trend noted since 1992.

The decreases in recent years in annually reported HIV Disease cases and annually diagnosed HIV cases were believed to reflect, at least in part, a decrease in new HIV infections (i.e., a decrease in HIV Disease incidence), at least in some subpopulations. However, it was recognized that this decrease could also, to some extent, potentially reflect changes in the HIV testing behaviors of at-risk persons and/or changes in the HIV testing practices of providers.

Of the 14,135 reported HIV Disease cases, 8,918 (63.1%) are currently living, and 5,217 (36.9%) have died. The majority (5,023, or 96.3%) of these deaths have been in persons subcategorized as AIDS cases. The 5,023 AIDS cases who have died make up 53.0% of all reported cases of AIDS in the state. During 2002, 123 HIV-related deaths in Missouri residents were reported on death certificates, a decrease of 18.0% from the 150 HIV-related deaths reported in 2001.

Not all HIV-infected persons have been diagnosed and thus made aware of their infection status. It is estimated that the actual number of individuals infected with HIV (i.e., persons with HIV Disease) who are presently living in Missouri is in the approximate range of 9,500 to 13,500 persons. The Centers for Disease Control and Prevention (CDC) has stated that, nationwide, approximately 30% of HIV-infected persons are not aware that they are infected^iv (although a more recent CDC report has indicated that among young gay and bisexual men infected with HIV, the percentage who do not know their infection status may be much higher^v). An essential component of HIV prevention is to encourage and assist persons at risk for HIV infection to be tested so that, if infected, they can optimally benefit from available treatments, and be assisted in making behavioral changes to eliminate or reduce the risk of transmission to others.

Improved antiretroviral therapies (introduced since the mid-nineties) have slowed the progress of HIV disease in many infected persons, an achievement especially reflected in the substantial decrease in reported AIDS cases in Missouri from 1996 to 1997, and in HIV Disease deaths from 1995 to 1997. The annual number of HIV Disease deaths has remained generally plateaued during the past 5 years. This likely reflects, at least in part, the limitations associated with current treatment regimens. Other factors that could potentially play a role here include delayed test seeking among certain populations, and limited access to or use of health care services.^vi

There is an obvious need for continued emphasis on prevention of new infections, and for trying to ensure that all infected persons can access needed care services. Everyone needs to clearly understand that "despite medical advances, HIV infection remains a serious, usually fatal disease that requires complex, costly, and difficult treatment regimens that do not work for everyone. As better treatment options are developed, we must not lose sight of the fact that preventing HIV infection in the first place precludes the need for people to undergo these difficult and expensive therapies."^vii

The ability of improved treatments to extend the lifespan of AIDS patients is reflected in the consistent increase in the number of persons living with AIDS in recent years, even though the annual numbers of new AIDS cases have been decreasing. At the end of 2002, 4,455 persons who were Missouri residents at the time of diagnosis were living with AIDS; the corresponding numbers for 2001, 2000, 1999, 1998, 1997, and 1996 were 4,262, 4,049, 3,784, 3,496, 3,235, and 3,055, respectively.

Where

Of the 4,657 reported HIV cases: 1,340 (28.8%) were from St. Louis City, 1,190 (25.6%) were from Outstate Missouri,^vii 1,155 (24.8%) were from Kansas City, and 629 (13.5%) were from St. Louis County.

Of the 9,478 reported AIDS cases: 2,693 (28.4%) were from St. Louis City, 2,615 (27.6%) were from Kansas City, 2,475 (26.1%) were from Outstate Missouri, and 1,466 (15.5%) were from St. Louis County.

Cases of HIV Disease disproportionately occur in the state's two major metropolitan areas (St. Louis and Kansas City). The highest rates of both HIV and AIDS cases, as well as the largest numbers of cases, are found in these two areas. St. Louis City consistently has the highest case rates, followed by Kansas City, St. Louis County, and Outstate Missouri.

Of total reported HIV Disease cases, 70.0% come from St. Louis City, St. Louis County, or Kansas City (which together comprise 32.3% of the state's population). However, 3,665 cases of HIV Disease have been reported from Outstate Missouri, and only 5 (4.4%) Missouri counties have no reported HIV or AIDS cases. Clearly, HIV prevention efforts are needed throughout the whole state.

Within St. Louis City/County and Kansas City, both HIV Disease cases and cases of bacterial STDs generally tend to occur in the same specific areas. It is within these areas that the needs for prevention and care services are the greatest.

Who

Of the 4,657 reported HIV cases: 3,848 (82.6%) were in males and 809 (17.4%) were in females.

Of the 9,478 reported AIDS cases: 8,520 (89.9%) were in males and 958 (10.1%) were in females.

Of the 4,657 reported HIV cases: 2,504 (53.8%) were in whites, 1,981 (42.5%) were in blacks, 114 (2.4%) were in Hispanics, 16 (0.3%) were in Asian/Pacific Islanders, and 15 (0.3%) were in American Indians.

Of the 9,478 reported AIDS cases: 6,098 (64.3%) were in whites, 3,125 (33.0%) were in blacks, 197 (2.1%) were in Hispanics, 32 (0.3%) were in American Indians, and 26 (0.3%) were in Asian/Pacific Islanders.

Males continue to make up the largest numbers of reported HIV Disease cases, but certain populations of females appear to be increasingly affected by HIV Disease. Of AIDS cases reported in 2002, females made up 20.9%; by comparison, of AIDS cases reported six years previously (in 1996), only 12.1% were in females.

In 2002, blacks made up 43.0% of reported HIV cases and 44.4% of reported AIDS cases. Given that blacks make up only about 11% of the state's population, this clearly indicates their very disproportionate representation among HIV-infected persons. The rate for HIV cases reported in 2002 in blacks (21.6) was 6.5 times the rates in whites (3.3). Also, 57% of AIDS-related deaths in 2002 were in blacks. Blacks are also highly disproportionately represented among reported cases of gonorrhea, chlamydia, and syphilis.

For Hispanics, although the total numbers of cases reported for HIV and AIDS in Missouri is small (14 HIV cases and 14 AIDS cases in 2002), the rates for HIV and AIDS cases reported were 3.6 times those seen in whites. There are some reasons for concern that HIV Disease might be a more significant problem for Hispanics in Missouri than current numbers seem to indicate. First, it is possible that among reported HIV and AIDS cases, because of incorrect information provided on the case report forms, a higher proportion may actually be of Hispanic ethnicity than is indicated by the current numbers. Second, the Hispanic population is increasing rapidly in Missouri. According to 2000 census data, Missouri's Hispanic population grew by 92.2% during the period from 1990 to 2000 (from 61,698 in 1990 to 118,592 in 2000); in contrast, Missouri's total population grew by only 9.3% during this time.^ix Another point with regard to persons identified as Hispanics is that these individuals actually consist of a diverse mixture of ethnic groups and cultures. This points to the need for specifically targeted prevention efforts.^x

Numbers of reported HIV and AIDS cases in Asians and American Indians have been very small; each of these two groups comprises less than 0.5% of total reported HIV and AIDS cases. In 2002, no AIDS cases and only 2 HIV cases each were reported in Asians and in American Indians in Missouri.

It should be emphasized that race/ethnicity in itself is not a risk factor for HIV infection; however, among many racial/ethnic minority populations, social, economic and cultural factors are associated with high rates of HIV risk behavior. These factors also may be barriers to receiving HIV prevention information or accessing HIV testing, diagnosis, and treatment.^xi

The majority of new HIV infections (71.5% in 2002) are acquired by persons 20-39 years of age. Although relatively small in number, infections are also occurring in teenagers (4.4% in 2002) in Missouri. CDC estimates that, nationwide, about half of all new HIV infections are in young people under 25 years of age.ⁱ

In 2002, no infants were born to HIV-infected mothers. More generally, the proportion of HIV-exposed infants who became infected was noticeably less for those born during the period from 1995-2002 compared to those born during the earlier period from 1993-1994 (6.9% vs. 26.4%). This difference reflects the use, starting in mid-to late-1994, of zidovudine (AZT, ZDV) treatment to reduce the risk of perinatal HIV transmission. It remains vitally important for all pregnant women to receive adequate prenatal care, starting early in their pregnancy, and to know their HIV status so that, if infected, they can take advantage of antiretroviral treatment to significantly reduce the risk of HIV transmission to their child, and also receive optimal treatment for their own disease. Prenatal providers should encourage all pregnant women to undergo voluntary HIV testing. Such testing should be viewed as a routine part of prenatal care for all women who are pregnant.^xii

Access to Treatment and Care Services

HIV Disease is still a terminal illness, however with proper medical treatment and support services, it can be a manageable chronic disease. African Americans living with HIV/AIDS in the state of Missouri appear to fair worse than the rest of Missourians living with HIV/AIDS. This indicated by epidemiological data that states that, although blacks make up only about 11% of Missouri's population, they accounted for 43.0% of HIV cases and 44.4% of AIDS cases in 2002. The rate for HIV cases reported in 2002 in blacks (21.6) was 6.5 times the rates in whites (3.3). Also, 57% of AIDS-related deaths in 2002 were in blacks.

Nationally, African Americans are also disproportionately impacted by HIV/AIDS.
The following excerpts come from the Fact sheet - HIV/AIDS Among African Americans: http://www.cdc.gov/hiv/topics/aa/resources/factsheets/aa.htm

• According to the 2000 Census, African Americans make up 12.3% of the population of the United States. However, they have accounted for 39% - more than 347,000 - of the more than 886,000 estimated AIDS cases diagnosed since the beginning of the epidemic. By the end of December 2002, more than 185,000 African Americans had died with AIDS.

• For people diagnosed with AIDS since 1994, African Americans had the poorest survival rates of all racial and ethnic groups, with 55% surviving after 9 years compared to 61% of Hispanics, 64% of whites, and 69% of Asian/ Pacific Islanders.

• In 2000, HIV/AIDS was among the top three causes of death for African-American men ages 25-54 and African-American women ages 35-44.

• The AIDS diagnosis rate among African Americans was almost 11 times the rate among whites. African-American women had a 23 times greater diagnoses rate than white women. African- American men had almost a 9 times greater rate of AIDS diagnosis than white men.

•  A study of people diagnosed with HIV found that 56% of "late testers," i.e., those that were diagnosed with AIDS within one year of their HIV diagnosis, were African American. Late testing represents missed opportunities in prevention and treatment of HIV.

These higher HIV and AIDS incidence rates and evidence of poorer quality of life among African Americans, suggest critical problems in accessing a broad range of health services, including different types of therapeutic and preventive interventions, in a timely fashion.

A good overview of the issues related to treatment and access issues among African Americans living with HIV, can be found on the Kaiser Family Foundation website. The Kaiser Family Foundation is a non-profit, private operating foundation dedicated to providing information and analysis on health care issues to policymakers, the media, the health care community, and the general public. The Foundation is not associated with Kaiser Permanente or Kaiser Industries.

Click on the following link: http://www.kff.org/hivaids/1620-index.cfm and download the Minority Health Today Journal Supplement. In this journal supplement there is an article entitled: African Americans and AIDS: Issues in Access to Care by Kevin C. Heslin and William E. Cunningham, MD. The authors discuss specifically: Use of Health Services, Financial Barriers, and Nonfinancial Barriers; as themes related to the access and treatment issues among African Americans living with HIV.

Stigma and Complacency among African Americans

The Two Silent Factors - Stigma & Complacency
By: Lawrence E. Lewis, MSW
HIV/AIDS Community Coordinator
Office of Minority Health
Missouri Department of Health and Senior Services
HIV/AIDS disproportionately impacts African Americans, both nationally and locally. According to the Center for Disease Control and Prevention (CDC), African Americans accounted for about 21,000, or 50 percent, of the more than 42,000 estimated AIDS cases diagnosed among adults in the United States. Despite evidence that antiretroviral therapy ("the cocktail") is very effective in the treatment of HIV, and delay in the onset of AIDS, the CDC reports "The AIDS diagnosis rate among African Americans was almost 11 times the rate among whites. African-American women had a 23 times greater diagnoses rate than white women. African- American men had almost a 9 times greater rate of AIDS diagnosis than white men."

As discouraging these figures are, what is more distressing is that two other factors that don't deal with individual behavior but community norms fuel HIV infection and AIDS-related deaths. These two silent factors are stigma and complacency.

HIV-Related Stigma

HIV-related stigma refers to unfavorable attitudes, beliefs, and policies directed toward people perceived to have HIV/AIDS as well as their loved ones, associates, social groups, and communities. This stigma is deeply rooted in prejudices involving race, gender, sexuality (in general and homosexuality and bisexuality specifically), and illness. Resulting in a stigmatized individual who is "reduced in our minds from a whole and usual person to a tainted, discounted one." Many of us will struggle with being a stigmatized or "other" person at some point in our life whether that is based on race, gender, class, body image, sexual orientation, religious beliefs, or family construction; however as it relates to HIV infection, this stigma has the potential of further isolating an individual, who like the rest of us has already been "deemed other," from needed support networks (e.g. families, churches, social groups, etc.). This can result in the deterioration of interpersonal relationships, because a person feels the need to hide his/her infection, anxiety, depression, guilt, and even emotional or physical violence.

HIV-Related Complacency

Since the release of Highly Active Antiretroviral Therapy (HAART) in 1997 and people stop dying daily, many people developed the belief HIV is a manageable disease and once infected the medication will make everything better. While it is true that the quality of life of individuals living with HIV has greatly improved as a result of the medication HIV is not a disease that anyone should get. It is 100% preventable by practicing abstinence (no sex and no drugs) and one's risk can be greatly reduced by practicing safer sex (vaginal, anal, or oral sex with a latex condom) and not sharing needles.

The belief that HIV is a manageable disease is not as devastating as the belief, especially among youth, that HIV infection cannot happen to them. HIV does not discriminate based on age, race, gender, sexual orientation, class, or any other demographic. As a matter of fact youth age 13-24 have consistently made up at least 50% of the 40,000 annual infections since the late 1990's.

Closing

At this hour African Americans cannot afford to ignore HIV in our communities nor can we shun those members of our collective family that are living with the disease. We all need each other. If you have been touched by this or want to get involved contact your local health department or the Office of Minority Health to get more information. Get involved in awareness and prevention education or volunteer at a local AID service organization. Remember that every person touched by HIV/AIDS is someone's daughter, son, brother, sister, mother, father, or friend and they still need to feel connected and supported. Protect yourself from potential infection.

ⁱ Missouri Department of Health and Senior Services, Division of Environmental Health and Communicable Disease Prevention, Office of Surveillance (2003). 2002 Epidemiologic Profiles of HIV Disease and STDs in Missouri, p.44.
ⁱⁱ Ibid.
ⁱⁱⁱ Ibid.
^iv CDC. HIV Prevention Strategic Plan Through 2005; Jan. 2001. http://www.cdc.gov/hiv/resources/reports/psp/pdf/prev-strat-plan.pdf
^v CDC Press Release: New CDC Studies Shed Light on Factors Underlying High HIV Infection Rates Among Gay and Bisexual Men, July 2002. http://www.cdc.gov/od/oc/media/pressrel/r020710.htm
^vi CDC. HIV/AIDS Surveillance Report, 2001; 13(No. 1) http://www.cdc.gov/hiv/stats/hasr1301.htm
^vii CDC. Need for Sustained HIV Prevention Among Men who Have Sex with Men. http://www.cdc.gov/hiv/pubs/facts/msm.htm
^viii The term "Outstate Missouri" refers to all of Missouri outside of St. Louis City, St. Louis County, and Kansas City.
^ix MERIC. Missouri Hispanic Population - 2000 Census. http://www.missourieconomy.org/researchandplanning/indicators/population/hispanic2000.stm
^xCDC. HIV/AIDS Among Hispanics in the United States. http://www.cdc.gov/hiv/resources/factsheets/hispanic.htm
^xi CDC. HIV/AIDS among racial/ethnic minority men who have sex with men - United States, 1989-1998. MMWR 2000; 49(1):4-11. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4901a2.htm
^xii CDC. Revised guidelines for HIV counseling, testing, and referral and revised recommendations for HIV screening of pregnant women. MMWR 2001; 50(No. RR-19). http://www.cdc.gov/mmwr/pdf/rr/rr5019.pdf