A Review of the Centers for Disease Control and Prevention's Response to the HIV/AIDS Crisis Among Blacks in the United States, 1981–2009

Abstract

Among US racial/ethnic groups, Blacks are at the highest risk of acquiring HIV/AIDS. In response, the Centers for Disease Control and Prevention (CDC) has launched the Heightened National Response to Address the HIV/AIDS Crisis Among African Americans, which seeks to engage public and nonpublic partners in a synergistic effort to prevent HIV among Blacks. The CDC also recently launched Act Against AIDS, a campaign to refocus attention on the domestic HIV/AIDS crisis. Although the CDC's efforts to combat HIV/AIDS among Blacks have achieved some success, more must be done to address this crisis. New initiatives include President Obama's goal of developing a National HIV/AIDS Strategy to reduce HIV incidence, decrease HIV-related health disparities, and increase access to care, especially among Blacks and other disproportionately affected populations.

Blacks and Hispanics in the United States have been disproportionately affected by HIV and AIDS, compared with non-Hispanic Whites, since the early years of the epidemic, although many have perceived the epidemic as affecting mostly White gay men.^1,2 (The term “Blacks” as we use it in this article includes African Americans, Caribbean Americans, Africans, and other persons of Black race who may not self-identify as “African American.” To be inclusive of all Blacks in the United States who are represented in national HIV surveillance data and HIV prevention efforts, we use “Blacks” throughout this article.) As early as October 1986, the Centers for Disease Control and Prevention (CDC) recognized the disproportionate impact of AIDS among racial/ethnic minority groups.³ In 1987, the CDC published the first in a series of articles about the prevalence and rate of HIV infection among racial/ethnic minority groups in the United States.⁴

From 1981 through 1988, Blacks accounted for 26% of AIDS cases while only representing 12% of the US population, and heterosexual contact and intravenous drug use were the primary modes of transmission among Blacks in this country.⁵ Early surveillance data showed a disproportionate impact of AIDS among Black and Hispanic women, and in late 1990, the CDC reported that although Black and Hispanic women represented only 19% of women in the United States, they accounted for 72% of US women diagnosed with AIDS.⁶ Furthermore, by the late 1980s it was clear that among men who have sex with men (MSM), Black and Hispanic men were disproportionately affected compared with other racial/ethnic groups.⁷

Racial/ethnic disparities in HIV/AIDS continue to be present at alarming rates in surveillance of HIV incidence, HIV diagnoses, AIDS diagnoses, and deaths among persons living with AIDS.^8,9 New and more reliable incidence data show that although Blacks made up 13% of the US population in 2006, they accounted for 46% of new HIV infections that year.^10,11 Among males, 40% of new infections occurred in Blacks, 41% in Whites, and 19% in Hispanics. Among females, 61% of infections occurred in Blacks, 23% in Whites, and 16% in Hispanics. The highest rates of new infections occurred among Black men and women (115.7 and 55.7 per 100 000 population, respectively) compared with men and women from all other racial/ethnic groups.¹⁰ Furthermore, the estimated lifetime risk of being diagnosed with HIV was higher for Blacks than for Whites: 1 in 16 Black males and 1 in 30 Black females in the United States will be diagnosed with HIV, compared to 1 in 104 White males and 1 in 588 White females.¹²

Injection drug use now plays less of a role in HIV transmission than it did in the 1980s. In 2006, sexual transmission (including heterosexual and male-to-male transmission) accounted for 90% of all new cases of HIV reported and 87% of new cases among Blacks.¹¹ This fact underscores the importance of improving the community-level understanding of HIV as a sexually transmitted infection (STI) and of improving our public health interventions that aim to delay the onset of sex, reduce numbers of sex partners, and increase safer-sex behaviors, including consistent and correct condom use.

Recent data show that Black women and men are also disproportionately affected by other STIs, including gonorrhea (Black–White ratio = 18:1), chlamydial infection (Black–White ratio = 8.1), primary and secondary syphilis (Black–White ratio = 7:1), Trichomonas vaginalis (Black–White ratio = 7:1), and genital herpes (Black–White ratio = 3:1).^13–16 Because the presence of STIs can serve as a marker of HIV risk and can facilitate HIV transmission by a factor of 2 to 5, the disproportionate rates of these STIs in Black communities need to be addressed with increased screening and treatment efforts as part of a comprehensive plan to stop the ongoing sexual transmission of HIV.^17,18 In addition to a higher prevalence of STIs in our Black communities, other complex factors that disproportionately affect Blacks—such as higher levels of poverty, decreased access to preventive and required health care, institutionalized racial discrimination, and disrupted social networks caused by higher rates of incarceration—contribute to the HIV epidemic among Blacks in this country.^3,19

PROGRAMMATIC RESPONSES TO HIV/AIDS AMONG BLACKS

Based on these and other data, the CDC initiated a wide range of activities to: (1) better understand the factors that drive the HIV/AIDS epidemic among Blacks in the United States, (2) expand HIV testing and access to HIV medical care, (3) develop new interventions and scale up the availability of effective interventions, and (4) mobilize Black communities to combat the HIV/AIDS crisis facing them.

In 1985, the CDC started providing dedicated HIV-prevention resources to state and local health departments, and the agency launched a national effort to educate the public about HIV and AIDS. As our understanding of the epidemic and its disproportionate impact on Blacks in the United States grew, so did the CDC's efforts to develop and target effective and culturally appropriate programmatic, research, and intervention efforts for these highly affected communities.

Since the early part of the epidemic, the CDC has worked with national, state, and community partners to support HIV testing, provide prevention services for high-risk HIV-negative persons and persons living with HIV, and help strengthen capacity, infrastructure, and partnerships with health departments and community-based organizations (CBOs) to address the HIV/AIDS epidemic. In 1993, to improve community buy-in and support for federally funded HIV prevention efforts, the CDC started forming community planning groups (CPGs) that are cochaired by community and health department representatives.²⁰ CPGs help to ensure that HIV-prevention resources and interventions are appropriately prioritized and targeted to the most affected communities on the basis of local epidemiological data.²⁰ CPGs continue to affect local HIV-prevention planning efforts, but many have faced challenges in trying to ensure a balanced representation of key stakeholders and trying to incorporate disparate ideas for next steps as part of the planning process.²¹ A recent study suggests that the CDC's guidance on CPGs should be updated to better address organizational factors and provide mechanisms to manage internal group conflict and thus improve the informed decision-making process for CPGs, ultimately enhancing HIV-prevention efforts in the communities they serve.²¹

In addition to CDC-funded efforts in health departments, the CDC directly funds minority CBOs that provide HIV-prevention services to communities of color.²² CBOs involve the local community, define solutions for the HIV epidemic, and work toward realizing those solutions, making leaders in the provision of HIV/AIDS services. HIV-prevention CBOs continue to remain effective, and they continue to receive ongoing training and technical assistance from the CDC.²² Minority CBOs were first directly funded by the CDC in 1988, and minority HIV-prevention organizations were first funded in 1989, to provide capacity-building assistance to local and regional CBOs serving communities of color. One such capacity-building program—the Institute for HIV Prevention Leadership, initially funded by CDC in 2000—has trained more than 300 HIV CBO program managers to date and has significantly increased CBO capacity to conduct more effective HIV-prevention programs.²³

In 1998, upon recognizing that the domestic HIV epidemic was continuing to evolve among Blacks in the United States, the CDC convened a meeting of Black providers and community leaders to update them on surveillance data showing the alarmingly high—and, at that time, steadily increasing—numbers of HIV diagnoses and AIDS cases among Blacks and to discuss ideas for addressing these situations. Later that year, President Clinton declared the HIV/AIDS epidemic among US Blacks a national crisis. The federal government also created the Minority AIDS Initiative, which was groundbreaking in 2 ways: (1) it created resources to address racial/ethnic disparities in HIV and HIV-related health outcomes, and (2) it created opportunities to expand community-based capacities to serve people of color living with HIV and AIDS.²⁴

The Minority AIDS Initiative, which is administered by the Department of Health and Human Services, serves as a resource for HIV/AIDS prevention, research, and treatment by giving federal agencies targeted funding to reduce HIV/AIDS disparities among Blacks and other communities of color at high risk for HIV.²⁴ These funds, totaling $166 million in fiscal year (FY) 1999, $404 million in FY2004, and $387 million in FY2009 (slightly less than FY2008 and not adjusted for inflation),²⁵ are used to address high-priority HIV prevention, research, and treatment needs in highly affected communities of color. The Minority AIDS Initiative was officially made into law when it was incorporated in the Ryan White Treatment Modernization Act passed by Congress in 2006. Today the Minority AIDS Initiative continues to bridge the gap in HIV preventive and medical service delivery by providing services to underserved communities, empowering local community-based providers to implement specific interventions to reach their communities, and supporting research in these disproportionately affected communities.

Early diagnosis and treatment of HIV are vital components of efforts to stop transmission of HIV and progression to AIDS in Black communities. To that end, the CDC launched the Advancing HIV Prevention initiative in 2003.^26,27 This initiative focused new energies on working with HIV-infected persons to decrease further HIV transmission, and it directly affected previously described local CPG efforts by identifying persons living with HIV/AIDS as the first-priority population for CPGs. The Advancing HIV Prevention initiative consisted of 4 strategies for HIV prevention: (1) making HIV testing a routine part of medical care, (2) encouraging people to learn their HIV status through increasing the availability of nonmedical HIV testing locations, (3) increasing prevention efforts by working with HIV-infected persons and their partners, and (4) decreasing perinatal HIV transmission and officially recommending routine opt-out HIV screening during prenatal care.^20,26

Several Advancing HIV Prevention demonstration projects were funded with more than $27 million. Implementation of many Advancing HIV Prevention projects focused on populations with a high percentage of Blacks. Six of 9 Advancing HIV Prevention demonstration projects included HIV testing in clinical and nonclinical settings to identify persons with unrecognized HIV infection; of approximately 107 000 rapid HIV tests performed from 2003 to 2007, 1100 incident cases were identified, and more than 80% of newly identified HIV-infected persons were from minority racial/ethnic groups.²⁷ To further build upon Advancing HIV Prevention efforts, the CDC continues to explore strategies to more efficiently provide HIV testing. These efforts include a scale-up of a successful social-network approach to identifying persons with undiagnosed HIV infection,²⁸ programs to increase HIV testing at historically Black colleges and universities,²⁹ and testing programs in correctional settings.³⁰

Advancing HIV Prevention initiative outcomes also helped inform the CDC's revised recommendations for routine, voluntary HIV screening in health care settings for all patients aged 13 to 64 years in the United States.³¹ In addition, the CDC provided a total of $70 million in supplemental funding for “Expanded and Integrated HIV Testing for Populations Disproportionately Affected by HIV, Primarily African Americans” in 2007 and 2008.³² This effort expanded HIV-testing programs in jurisdictions with the highest AIDS rates among Blacks and complemented the 2006 revised recommendations for routine HIV testing at health care venues. In 2007, 23 jurisdictions were funded, and 25 were funded in 2008. In the first 18 months of the project, participating sites reported conducting more than 840 000 tests and identifying more than 10 000 HIV infections.

Additionally, HIV testing efforts are increasingly being integrated with other STI and HIV services provided by health departments and other service providers, and the CDC recently developed guidance in support of these integrated services.³³

HIV-PREVENTION RESEARCH AMONG BLACKS

Throughout the course of the epidemic, the CDC has supported HIV-prevention research conducted by scientists both inside and outside the agency. Developing and supporting behavioral interventions for at-risk and HIV-positive Blacks in the United States is a central element of the CDC's approach to preventing HIV transmission among Blacks. The CDC's HIV Prevention Research Synthesis Project conducts meta-analyses of data from scientifically rigorous behavioral and clinical intervention trials in an effort to provide objective assessments for CBOs and other groups that implement these interventions in their local communities.^34,35 Prevention Research Synthesis analyses have shown that behavioral interventions significantly reduce sexual risk among young adults, MSM, heterosexual men and women, and drug users and can be successfully implemented in at-risk communities.^35–44 Prevention Research Synthesis reviews are updated annually; as of May 2009, the Prevention Research Synthesis project had identified 63 interventions with strong evidence of efficacy.^45,46 Of these, 34 (54%) were developed for Blacks or were evaluated in a study in which the majority of participants were Black (Table 1).^47–56

TABLE 1.

Selected HIV Prevention Interventions Included in the Centers for Disease Control and Prevention's Diffusion of Effective Behavioral Interventions Project

Intervention	Study Population	Description	Main Outcomes
d-up!47	Black MSM	Community-level intervention for Black MSM that is designed to change social norms by enlisting popular opinion leaders. The opinion leaders are trained to change risky sexual norms and endorse risk reduction in conversations with their friends and acquaintances.	Decreased unprotected anal intercourse.
	100% enrolled were Black		Decreased number of unprotected sexual partners.
Focus on Youth + ImPACT48,49	At-risk Black youths (aged 13–16 y) from low-income neighborhoods	Small-group and parent–child-dyad intervention designed to reduce substance and sexual risk behaviors of high-risk youths. The intervention emphasizes decision-making, goal setting, communication, negotiation, and consensual relationships. Includes a single session delivered individually to each youth and his or her parent or guardian that emphasizes parental monitoring and communication and includes skills-building exercises.	Among participants who were sexually active at baseline, lower rates of sexual intercourse.
	100% enrolled were Black		Among participants who were sexually active at baseline, lower rates of unprotected sex.
Healthy Relationships50	HIV-positive men and women	Small-group intervention focused on building skills and self-efficacy to make informed and safe decisions about risk disclosure and behavior. Activities included feedback reports, discussion sessions, role-playing, and movie-quality video clips to teach and practice decision-making and problem-solving skills.	Decreased unprotected anal and vaginal intercourse among all participants.
	74% enrolled were Black		Decreased unprotected anal and vaginal intercourse with non–HIV-seropositive partners.
Promise51	At-risk youths	Community-level intervention focused on risk reduction through distribution of role model stories and prevention materials. Activities included collecting information about HIV risk behavior in the community, creating role model stories based on personal accounts of community members, and recruiting and training peer advocates to distribute role model stories and prevention materials.	Increased condom use with main sexual partners.
	Injection drug users and female sex partners
			Increased condom use with nonmain sexual partners.
	Female commercial sex workers
	Men who have sex with men
	Residents of areas with high STD prevalence
	54% enrolled were Black
RAPP (Real AIDS Prevention Project)52	At-risk women	Community-level intervention focused on HIV risk reduction. Activities included assessing community knowledge of HIV, using peer networkers for community outreach, engaging in individual-level safer-sex discussions, and engaging in small-group gatherings to promote HIV risk reduction.	Increased condom use during vaginal sex with main partner.
	73% enrolled were Black
Project RESPECT (Brief Counseling Intervention)53	At-risk men and women at STD clinics	Two-session individual-level intervention that provided client-centered HIV prevention counseling in conjunction with HIV testing. Focused on identification of personal risk factors, barriers to change, and development of an achievable personalized risk reduction plan.	Decreased new sexually transmitted infections.
	59% enrolled were Black		Decreased unprotected vaginal sex.
SISTA (Sisters Informing Sisters on Topics About AIDS)54	At-risk Black women	Small-group intervention focused on preventing HIV sexual risk behavior via gender and culturally relevant activities. Activities included behavioral skills practice, group discussions, lectures, role-playing, prevention video viewing, and take-home exercises.	Increased consistent condom use.
	100% enrolled were Black
Street Smart55	Street youths (aged 11–18 y)	Small-group intervention focused on building individual skills to prevent HIV risk behavior. Activities included scripted and nonscripted role-playing, problem-solving activities, and video production.	Decreased unprotected sex among women.
	59% enrolled were Black
Voices/Voces56	Adult men and women at STD clinics	Small-group intervention focused on building individual skills to prevent HIV risk behavior. Activities included viewing culturally specific videos and facilitated group discussion.	Decreased STD incidence among men.
	62% enrolled were Black

Note. MSM = men who have sex with men; STD = sexually transmitted disease.

Selected Prevention Research Synthesis interventions with evidence of efficacy are packaged and disseminated nationwide. “Packaging” means that user-friendly implementation and training materials are developed by CDC's Replicating Effective Programs Project^57,58 and disseminated by the Diffusion of Effective Behavioral Interventions (DEBI) program, which seeks to bring science-based HIV-prevention interventions to state and local health departments, CBOs, and other HIV service providers.^59,60 As of June 2009, materials and trainings were available for 21 interventions,⁵⁹ and 15 new interventions were being prepared for dissemination in 2009 and 2010. Of these, 20 were developed specifically for Blacks or were tested in studies in which a majority of the sample population was Black. These interventions address a range of subpopulations within the Black community, including heterosexual women and men, youth, MSM, injection drug users, and persons living with HIV (Table 1).

Since the inception of the DEBI program in 1999, more than 8500 individuals have been trained to deliver HIV-prevention interventions for Blacks who are at risk for or living with HIV. The CDC continues to work to increase the number of culturally appropriate DEBI programs and to package and disseminate them more quickly. Some public health partners have reported barriers to DEBI implementation, including: (1) the challenges of adapting evidence-based, multilevel interventions to real-world time constraints; (2) an increased need for greater local health department technical assistance and monitoring; and (3) a critical need for a wider menu of interventions for all high-risk populations.^60,61 Reaching the disproportionately affected Black MSM community is especially challenging because of greater resistance to self-disclosure of MSM behaviors, decreased knowledge of or access to community resources, and a lack of culturally relevant and appropriate interventions for Black gay men.^62,63

Despite the range of HIV-prevention interventions for Blacks in the United States, many unmet prevention needs remain. The CDC continues to support research to develop a wide range of new behavioral and biomedical interventions for Blacks. These efforts include research with Black MSM, heterosexual men, and women to develop and test new interventions, assess locally developed interventions, and evaluate the effectiveness of scientifically proven interventions in the field. For example, the CDC is supporting demonstration projects to compare the relative cost-effectiveness of existing community-based HIV-testing strategies to reduce undiagnosed HIV infections among Black women and men and stop HIV transmissions that are caused by being unaware of one's HIV status. Additionally, male circumcision is being further explored as a potentially effective biomedical intervention to decrease sexual transmission of HIV among heterosexual Black men in the United States.⁶⁴

Although individual risk behavior contributes to HIV transmission, it alone does not account for disparities in HIV/AIDS among Blacks in the United States. Behavioral studies must be complemented by studies that investigate how we affect deeply entrenched social determinants that contribute to and often create the foundation for ongoing HIV transmission.^3,65–68 The CDC is conducting research to better understand and plan interventions targeted at the social, community, financial, and structural factors that contribute to HIV risk among Blacks. For example, the CDC is collaborating with local researchers to conduct epidemiological research on individual and social determinants of HIV risk among Black MSM and is currently involved in similar research focused on Black women in the southern United States.

The CDC is also involved in research evaluating structural interventions to reduce HIV risk among Blacks. Examples of this research include a study focused on economic intervention with impoverished women in the South⁶⁸ and a study examining the effects of providing housing to homeless and unstably housed persons living with HIV, the majority of whom are Black.^69,70

In addition, the CDC funds the Minority HIV/AIDS Research Initiative, which provides funding support to Black and Hispanic researchers who are conducting HIV/AIDS research in affected Black and Hispanic communities.⁷¹ These minority-led studies are asking key questions and providing important tools that can be used to more effectively work with communities of color for improved HIV prevention and control. In addition to providing critical data, this effort builds the capacity of Black and Hispanic investigators to conduct HIV-related research by supporting the development of researchers who are early in their careers and by encouraging more established researchers to begin studying HIV in communities of color.

HIV-PREVENTION COMMUNICATIONS WITH BLACKS

Culturally appropriate HIV/AIDS awareness and prevention communication messages are also a component of effectively reaching highly affected communities of color. CDC has continued to expand its HIV communications efforts by developing and delivering messages for the general public, health care organizations, and HIV-prevention partners and providers, including faith-based institutions and the populations they serve. HIV-prevention efforts mounted by faith-based institutions are particularly important for reaching many Black communities; at the same time, such efforts are often challenging because of religious stigma surrounding HIV-associated same-sex behaviors.^72–75 The CDC continues to work with faith-community leaders and institutions in Black communities and recently held a series of faith-community forums in Atlanta, Baltimore, and New York City. The forums allowed CDC staff and faith-community leaders to discuss the impact of HIV/AIDS and stigma in Black communities and to stress the importance of working collaboratively to more effectively communicate with Black men and women to fight the HIV/AIDS epidemic.

Social marketing campaigns to communicate important HIV-related messages to Blacks in the United States have also recently been developed. One such campaign is Act Against AIDS, a 5-year, multiphase communication campaign launched in 2009 and designed to support CDC efforts to reduce HIV incidence among Blacks and other highly affected populations in the United States. The CDC has partnered with other federal agencies and the Kaiser Family Foundation as part of this campaign to ensure that HIV/AIDS media messages are appropriately developed and disseminated to reach Blacks and other highly affected communities. The “9½ Minutes” kickoff phase of Act Against AIDS sought to remind all US residents of the real threat of HIV.⁷⁶ Additionally, Act Against AIDS makes HIV/AIDS education and prevention materials available to the public and updates them as new data become available (http://www.cdc.gov/hiv/aaa).

THE HEIGHTENED NATIONAL RESPONSE

As part of its commitment to work with partners in innovative ways to combat the HIV/AIDS epidemic within the Black community, the CDC launched its Heightened National Response to Address the HIV/AIDS Crisis Among African Americans in 2007. The Heightened National Response initiative demonstrates a renewed support for increased coordination of the CDC's programmatic and research efforts to combat HIV/AIDS among Blacks in the United States. In preparation for the Heightened National Response initiative, the CDC hosted external expert consultations to review the current state of the epidemic and hear feedback and suggestions from a non-CDC perspective. As a result of these consultations, the CDC expanded and refined its programmatic and research efforts and sought new ways to involve highly respected leaders in the Black community in HIV prevention. In 2007 and again in 2008, Heightened National Response partners—including Black leaders in business, faith, health, educational, civic, social, arts, entertainment, and media sectors—convened to share ideas and contribute to a collective effort to fight the HIV/AIDS crisis in the Black community.

As of October 2008, more than 200 Black leaders made commitments to take action to fight HIV/AIDS as part of the Heightened National Response. The commitments made by these leaders and the CDC as part of the Heightened National Response are guided by the 4 pathways of the Heightened National Response Action Plan to end the HIV/AIDS epidemic within the Black community: (1) expanding the reach of prevention and capacity-building services; (2) increasing opportunities for diagnosing and treating HIV; (3) developing new, effective prevention interventions; and (4) mobilizing broader community action (Table 2). Heightened National Response collaborations and the progress they have achieved prove that by bringing together both governmental and nongovernmental partners who are passionately committed to stopping the spread of HIV/AIDS, we can successfully combat the epidemic among the Black community in the United States. One example of this type of collaboration is the CDC's participation in Take a Loved One to the Doctor Day. As part of this annual event at clinical settings across the country, the CDC provides HIV prevention and testing information during morning radio shows and in the context of routine medical visits.

TABLE 2.

The Centers for Disease Control and Prevention's (CDC) Heightened National Response (HNR) Action Plan: 2007

HNR Pathway	Selected Internal CDC Actions	Selected External Partner Actions	Selected Examples
Expanding the reach of effective prevention and capacity-building services	Increasing investment in prevention and capacity-building programs serving Blacks and enhancing culturally appropriate strategies for delivering services to this population	Building linkages with other organizations that provide related social and health services to Blacks	Expanding the dissemination of Many Men, Many Voices, a program that reduces HIV and STD risk among MSM of color
Increasing opportunities for diagnosing and treating HIV	Increasing investments in and expanding access to HIV testing and treatment of Blacks	Increasing access to HIV testing and treatment services by offering them or partnering with community organizations that offer them	Providing rapid testing and prevention services at a range of Black community venues such as churches, college campuses, concerts, and minority gay pride events
Developing new, effective prevention interventions	Initiating new research projects to test newly developed, community-based, or adapted interventions for Blacks who may be at increased risk for contracting or transmitting HIV	Involving Black community stakeholders in developing and implementing research designs that address a range of issues related to accessing HIV prevention, treatment, and care services	Examining ways to reduce HIV risk behaviors among unemployed and underemployed Black women in the Southeast through an intervention that supports education and training for the women to start their own businesses
Mobilizing broader community action	Developing new channels for working with partners and communicating about the impact of HIV/AIDS on Black families and communities, and about the consequences of silence and stigma about HIV	Breaking the silence and increase awareness of HIV/AIDS among friends, family, coworkers, and others within Black communities	Partnering with Black small-business owners in local communities in several cities to help reach their community members with HIV prevention information and testing services

Note. MSM = men who have sex with men; STD = sexually transmitted disease.

Other Heightened National Response efforts include the newly established Act Against AIDS Leadership Initiative. This initiative partners the CDC with 14 of the nation's leading historically Black organizations to integrate HIV awareness and prevention into their current and future outreach programs and to help ensure that culturally relevant communications about the HIV epidemic reach a wide range of Black communities (Table 3).

TABLE 3.

Partner Organizations in the Centers for Disease Control and Prevention's ACT Against AIDS Leadership Initiative: 2009

Organization	Description
100 Black Men of America	National alliance of leading Black men of business, industry, public affairs, and government whose mission is to improve the quality of life for Blacks, particularly Black youths.
American Urban Radio Networks	The nation's only Black-owned network radio company, which broadcasts programming to more than 300 radio stations nationwide.
Coalition of Black Trade Unionists	The nation's oldest and largest independent Black labor organization.
Congressional Black Caucus Foundation	A nonpartisan, nonprofit public policy, research, and education institute to help improve the socioeconomic circumstances of Blacks in the Americas and other underserved communities.
National Action Network	A leading national civil-rights organization.
National Association for the Advancement of Colored People	The nation's oldest and largest civil-rights organization, with more than 500 000 members and supporters nationwide.
National Coalition of 100 Black Women	A nonprofit advocacy organization supporting women of color through leadership development, networking, political action, health awareness, mentoring, and scholarship.
National Council of Negro Women	A coalition of national Black women's organizations connecting nearly 4 million women worldwide to lead, develop, and advocate for women of African descent as they support their families and communities.
National Medical Association	The largest and oldest organization representing Black physicians and their patients in the United States.
National Newspaper Publishers Association	A 67-year-old federation of more than 200 Black community newspapers from across the United States.
National Organization of Black County Officials	A coalition of Black elected and appointed officials within county government for all 50 states.
National Urban League	The nation's oldest and largest community-based movement devoted to empowering Blacks to enter the economic and social mainstream.
Phi Beta Sigma Fraternity	A predominantly Black fraternity founded in 1914 and dedicated to public service.
Southern Christian Leadership Conference	One of the oldest and most influential civil-rights organizations in the United States, with strong ties to faith-based institutions in the Southern United States.

NEW OPPORTUNITIES AND NEXT STEPS

The ongoing public health response to the domestic HIV epidemic has faced many challenges, including domestic HIV funding that is not always fully aligned with the pace of the epidemic, but new opportunities are emerging. The CDC is reviewing and evaluating new HIV behavioral and clinical research proposals, as well as community planning, development, and dissemination of effective interventions, to ensure that we realize our goal of helping disproportionately affected Blacks in the United States. New approaches with Black MSM, women, youth, people who do not identify as gay, and incarcerated populations are imperative because the HIV-prevention needs of these groups have not been fully understood and incorporated into ongoing efforts. Research efforts to better understand the diversity among US Blacks, as well as Black sexuality in the context of HIV/AIDS prevention and improved sexual health, are warranted as we work toward more targeted interventions for Blacks.⁷⁷ Development of new interventions for Blacks, particularly Black MSM, is lagging behind efforts to help other heavily affected communities.

New data on HIV transmission through prison sexual networks suggest that routine HIV screenings and access to HIV care for affected populations in US prisons may be important interventions to explore. Black men accounted for almost 70% of these transmissions in a recent study, consistent with their disproportionate representation as part of the national prison system.^78,79 New efforts to incorporate routine HIV screening and treatment services for prison populations and to provide prevention interventions may be warranted; such efforts could directly affect ongoing HIV transmission when HIV-infected persons are released from prison and return to their communities. The CDC is working with other federal and nonfederal partners to explore further expansion of prison-based HIV screening, treatment, and prevention efforts.

In terms of funding, domestic HIV prevention represents only 4% of the federal HIV/AIDS budget, and its share of the overall budget has decreased over the course of the epidemic.²⁵ Approximately half of the CDC Division of HIV/AIDS Prevention's programmatic, surveillance, and research funding (which totals more than $600 million per year) is directed toward efforts serving Blacks in the United States. The CDC is reevaluating the current distribution of these resources and is working to increase the impact of these resources in Black communties.

Important challenges remain in addressing social determinants of health that contribute to disparities in HIV and AIDS among people of color in this country. They include many sociocultural (and difficult to affect) factors, such as poverty, low literacy, stigma, unemployment, homelessness, racism, homophobia, and being underinsured or uninsured, which decreases access to acceptable health care.⁸⁰ The CDC cannot tackle these societal issues alone; accordingly, the CDC recently invited academic, scientific, public health, and community partners to its first external consultation on social determinants of health and infectious diseases. The agenda included a discussion of social determinants and associated strategies that can be systematically prioritized to accelerate the reduction of racial/ethnic and gender health disparities for infectious diseases, including HIV. The consultation attendees also suggested partner pairings and initiatives that should be explored to more effectively reduce structural and systemic barriers to health and improve health equity. Addressing social and structural determinants that fuel the spread of HIV/AIDS among Blacks in the United States will require a coordinated and sustained effort on the part of federal, state, and local agencies and organizations; people living with and affected by HIV; and Black leaders from all sectors of society.

There are also new opportunities arising from the recent reintroduction of the Routine HIV Screening Coverage Act in the 111th Congress.⁸⁰ This bill would require health insurance plans to cover routine HIV tests under the same terms as other routine health screenings and would allow for broader compliance with the 2006 recommendations for routine HIV screenings in health settings.^31,81 Efforts that increase alignment of best public health practices with executive-branch goals will improve overall HIV prevention and intervention synergy and will enhance our ability to stop the ongoing spread of HIV disease within Black communities. Collaborative efforts by HIV partners on all fronts, in conjunction with a movement toward a National AIDS Strategy developed and implemented by the Office of National AIDS Policy at the White House, will allow for greater efficiency and effectiveness as we battle HIV/AIDS in the United States, especially within highly affected Black communities.