Want to stop AIDS? Fight inequality

In February 2016, the CDC released striking new data projecting that half of black and a quarter of Latino gay and bi...

Posted: Dec 1, 2017 11:38 AM
Updated: Dec 1, 2017 11:38 AM

In February 2016, the CDC released striking new data projecting that half of black and a quarter of Latino gay and bisexual men in the United States will be diagnosed with HIV in their lifetimes.

As a public health researcher who has been working in HIV/STI prevention for over 10 years, my heart sank when I read this news. The findings forecasted one of the most significant racial and ethnic public health disparities in the United States, particularly for sexual and gender minority Americans.

More concerning is that the meaning of these findings is consistently oversimplified. The difficulty with racial and ethnic health disparities is that they are complex and often involve multiple systems, not just individuals experiencing a higher burden of disease. Too often, in order to explain disparities, their complexities get reduced to simple comparisons based on sociodemographic characteristics.

Understanding how sociodemographic characteristics intersect with the spread of HIV is critical to ending the epidemic. However, the flip side is that, as important as it is to inform the groups most affected by HIV, emphasizing racial and ethnic differences in infection have been found to increase stigma, and foster hopelessness and distress. In fact, in HIV research and care, it is common to hear individuals articulate, "HIV is a black disease." More importantly, racial and ethnic disparities may diminish concern or relevance for those who are not directly impacted by HIV.

Friday is World AIDS Day, a day dedicated to raising awareness about the AIDS pandemic, and a day for remembering and honoring those who have succumbed to the disease. Although the CDC estimates there are 1.1 million Americans living with HIV and 1 in 7 who are HIV-positive are unaware of their status, HIV/AIDS has almost completely fallen off many Americans' radar.

Given these complexities, it is imperative to understand that any policies that impact poverty have the potential to impact disparities in the HIV epidemic. Addressing factors like unemployment, unstable housing, unequal access to quality education, and access to affordable health care all have implications for stopping this epidemic.

Overly simplistic approaches often lead media headlines to report things like, "Black individuals have higher rates of diabetes" or "Incidence of teenage pregnancy highest among Latinos." From a public health perspective, variations in prevalence and incidence for any health issue can be described using characteristics like race/ethnicity, gender, sexual orientation, or socioeconomics.

Yet there is little scientific evidence that these characteristics -- on their own -- create differences in being at risk for a disease. Rather, social systems and structures that differentiate groups can, and in fact do, drive disproportionate health problems among specific segments of the population. This is true of the US HIV epidemic.

It was also true in 1982, when The New York Times published an article with the headline "New homosexual disorder worries health officials" describing a new disease at that time called "GRID" (gay-related immune deficiency). Even though the content of the article noted that heterosexual women had also been diagnosed with the illness, the public use of the term "GRID" associated a virus with a particular group based solely on sexual identity. Even when the term for the disease shifted to AIDS (acquired immune deficiency syndrome), this dangerous association remained, misrepresenting disparities observed in the early HIV/AIDS crisis.

HIV is not a black or Latino disease today just as it was not a gay disease in the 1980s. HIV is a pathogen -- a virus. Like other viruses, HIV does not differentiate between host cells based on age, race/ethnicity, sex, gender or sexual orientation.

Rather, poor health outcomes, including increased incidence of infections like HIV, are linked with several key social and structural factors including employment, stable housing, and access to health care coverage and services. My team's research and many others' have shown that inequities within these critical domains directly contribute to the disparities seen in the spread of diseases like HIV.

In a recent report by the Stanford Center on Poverty and Inequality, investigators found consistent disparities in employment, housing, health care coverage and access to services. Similarly, the Pew Research Center reports that racial and ethnic gaps in income and earnings in the United States have remained constant, or have even widened, since the late 1960s, with racial and ethnic minorities disproportionately experiencing poverty. These persistent disparities highlight the ways these large social factors may negatively impact the health and well-being of minority populations at large, but also specific to the US HIV epidemic.

In 2012, the FDA approval of Pre-Exposure Prophylaxis, or PrEP, antiretroviral medications used to prevent HIV infection, spurring renewed optimism about reducing racial and ethnic disparities in HIV infection. Nevertheless, nearly six years later, racial and ethnic disparities persist, with studies showing lower PrEP awareness and use among racial and ethnic minorities. Although PrEP offers a promising weapon against HIV epidemic overall, its real-world use is limited by the same social and structural inequities that contribute to higher rates of HIV in minority communities.

Although scientifically effective, medications and behavioral interventions alone will not end the HIV epidemic. There is a need, now more than ever, to address racial and ethnic inequities that ultimately maintain disparities in health and broader well-being. Most importantly, there is a need to remind us that the HIV epidemic is relevant to everyone, not just those groups experiencing the disproportionate burden of HIV infection.

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