The killing of George Floyd by Minneapolis police on May 25 has led to Black Lives Matter protests across the USA and globally, highlighting racial inequalities. Approximately 1000 people are killed by US police per year, as reported by various sources, and stark racial disparities exists. The rate at which Black people in the USA are killed is more than twice that for white people. The structural and systemic racism evidenced by this violence permeates every aspect of US society including the HIV care continuum.
About 13% of the US population are Black, but according to 2018 figures, 43% of people living with HIV in the USA are Black and 42% of new HIV diagnoses are in in Black people. In 2016, the proportion of white people living with HIV who were diagnosed, in receipt of care, and virally suppressed was 89%, 69%, and 60%; for Black people the figures were 85%, 61%, and 48%. The gap in viral suppression rates is particularly stark, and many of the factors involved, such as lower income, housing instability, and lack of antiretroviral coverage via insurance or government programme coverage, reflect the wider racial economic inequities. Addressing the racial pay gap and ensuring equitable access to health care would do much to correct this.
Some groups are especially vulnerable. Over 2 million people in the USA are currently incarcerated and 40% of them are Black. The rate of HIV in prisons is between five to seven times greater than in the general population. Around 14% of transgender women in the USA are estimated to be living with HIV. For Black transgender women the figure is 44%.
White people are six times more likely to be prescribed pre-exposure prophylaxis (PrEP) than are Black people. Health-care providers are less likely to discuss PrEP with Black clients. Use of electronic health records to identify PrEP candidates could help overcome health-care provider bias; however even the algorithms used in health-care software are subject to racial biases. Black people are also less likely to have access to health care, so many key conversations never happen in the first place. Attempts to increase access to PrEP for the uninsured, which could help redress the balance, have had disappointing results. In nearly 6 months since a scheme opened with Gilead's donation of medication for 200 000 people only 891 people have benefitted.
Black people are underrepresenteded in clinical trials. For example, the DISCOVER trial led to the licensing of tenofovir alafenamide and emtricitabine for cisgender men as PrEP by the US Food and Drug Administration last year. Only 10% of participants were Black. As we previously argued for gender, it is unacceptable that licensing studies of new products do not reflect the underlying population and those who would most benefit from more options.
Although this Editorial focuses on the USA, many other countries, including the UK where our offices are based, are also blighted by inequities in society and health care that fail Black communities. Recent protests have caused people and organisations globally, The Lancet HIV included, to reflect on their own role in racial inequities and how we can contribute to change. We recognise that we must do more to challenge these injustices and to support the work of people seeking to address racial inequities in HIV and health worldwide.
Our July issue contains an Article on modelling data from Bohdan Nosyk and colleagues, which reveals the most cost-effective combinations of interventions to reduce HIV incidence, which would lead to reductions in racial disparities, in six major US cities. Also in this issue, Chi-Chi Udeagu and colleagues used data on partner services from New York City to examine the engagement in care of previously reported partners and suggest a role for this data in targeting services for those not in care, who are most likely to be young and Black.
In any other year, we would currently be anticipating an International AIDS Society meeting, which was planned to take place in San Francisco and Oakland, and has since moved to a virtual format due to COVID-19. No doubt the Black Lives Matter movement and the implications for HIV programmes would have been at the forefront of discussion, particularly in the context of President Donald Trump's 2019 pledge to end HIV in the USA by 2030. A pledge to ending the US HIV epidemic is a hollow promise unless the racial disparities that accompany it are addressed. The President is not engaging in the long overdue examination of white privilege and structural racism. It is the commitment and focus of Black Lives Matter protestors that give us hope that change can occur.