Improve the Quality of Life Related to HIV and the Black Community: HIV and AIDS Inequity in the Black Community: Proximal Solutions to Distal Determinants

Abstract

This literature review describes the historical impact of HIV and AIDS among Black populations in United States (US), as well as the misalignment between root causes of HIV-related inequities and HIV prevention efforts. Specifically, we describe how distal factors (including structural racism) contribute to the disproportionate rates of HIV infection within Black communities. Further, we highlight consequences of focusing primarily on proximal determinants of acquiring HIV. Finally, we share some brief conclusions and recommendations to help move towards eliminating HIV and AIDS inequities among Black populations.

Introduction

The United States (US) Census defines Black/African American populations as persons “having origin in any of the Black racial groups of Africa” (U.S. Census Bureau, 2021). While individuals racialized as Black/African American (hereafter, Black) represent approximately 13% of the total US population, Black populations account for the majority of human immunodeficiency virus (HIV) diagnoses and acquired immunodeficiency syndrome (AIDS) deaths in the US, annually (Centers for Disease Control and Prevention [CDC], 2019). Importantly, the disproportionate incidence of HIV among Black populations cannot be explained by individual-level factors such as genetics/ancestry or differences in sexual behavior (Millett, Flores, Peterson, & Bakeman, 2007; Buot, et al., 2014). In fact, literature indicates that HIV and AIDS inequities in the US are primarily driven by social rather than biomedical or behavioral factors (Zeglin & Stein, 2015).

The overarching goal of this literature review is to describe the historical impact of HIV and AIDS among Black populations in the US, along with the misalignment between root causes of HIV-related inequities and HIV prevention efforts. We describe how systemic factors, including structural racism, contribute to disproportionate rates of HIV infection within Black communities. Further, we describe how most evidence-based interventions focus primarily on addressing proximal determinants of HIV-related inequities. Finally, we share some brief conclusions and recommendations to help move towards eliminating HIV and AIDS inequities among Black populations across the US.

Evolution of HIV Inequity in the Black Community

AIDS was first recognized in 1981 and HIV was identified as the cause of AIDS in 1983 (Melhuish & Lewthwaite, 2018; Shampo & Kyle, 2002). In the US, non-Hispanic White men represented the primary population initially affected by HIV and AIDS in the early 1980s, and male-to male sex was (and still is) the highest mode of HIV transmission (CDC, 2001). Specifically, from 1981–1987, non-Hispanic White populations accounted for 59.7% of persons living with AIDS, while Black populations accounted for 25.5% (CDC, 2001). However, in 1992, AIDS-related mortality was recorded as the seventh cause of excess deaths among Black populations in the US (Satcher et al., 2005). As time progressed, the percentage of non-Hispanic White populations living with AIDS had decreased to 34%, while this percentage increased to 44.9% among Blacks populations (CDC, 2001). Notably, highly-active antiretroviral therapy was introduced as a treatment for HIV in the mid-1990s and AIDS rates for White populations began to decline, while rates in Black populations increased – a shift that underscores inequities in access to health care and allocation of HIV treatment within Black communities (Gebo et al., 2005).

HIV-Related Outcomes among Black Populations

When comparing Black and White US populations, respectively, across HIV incidence, prevalence, and AIDS-related mortality, Black Americans experience stark disparities in all categories, including HIV incidence (45.0 vs 5.3 per 100,000), HIV prevalence (1,027.5 vs 153.9 per 100,000), and AIDS-related mortality (16.1 vs 2.5 per 100,000) (CDC, 2019). Among Black people in the US, populations currently most affected by HIV include gay, bisexual, and other men who have sex with men (MSM) and Black women (Tillerson, 2008; CDC, 2019). From 2015 through 2019, Black MSM accounted for more than 36% of new HIV infections diagnosed annually (CDC, 2019). Furthermore, Black MSM have lower rates of being retained in HIV medical care and achieving viral suppression in comparison to other racial/ethnic MSM populations (CDC, 2019), further highlighting disparities along the HIV continuum for Black MSM. In the US, Black women and adolescents make up only 13% of the female population, while accounting for up to 55% of new HIV infections diagnosed between 2015–2019 (CDC, 2019). On the other hand, non-Hispanic White women and adolescents make up 62% of the female population in the US, while only accounting for 22% of new HIV infections (CDC, 2019). Black women and adolescents diagnosed with HIV also die at disproportionately higher rates than their White counterparts (11.6 vs 0.8 per 100,000, respectively) (CDC, 2019). The evolution of HIV as a health issue primarily impacting Black populations mirrors the trajectory of most health inequities in the US and globally – that is, those who are most socioeconomically disadvantaged have disproportionate rates of negative health outcomes.

Distal Determinants of HIV and AIDS Inequities

The social determinants of health (SDOH) framework posits that “environments in which people are born, live, learn, work, play, worship, and age” significantly impact their health outcomes (US Department of Health and Human Services [DHHS], 2010). As such, social, political, and economic factors greatly influence HIV-related inequities among Black populations (Braveman, 2014). Another important public health framework, the social ecological model (SEM), uses a systems perspective to help organize determinants of health along a continuum from proximal to distal determinants (Baral, Logie, Grosso, Wirtz, & Beyrer, 2013). Distal determinants can be described as structural factors such as economics, policy, and community infrastructure, which serve as fundamental or root causes of health. Proximal determinants are often described as the most direct (i.e., easily observable) causes of a particular heath outcome (Baral et al., 2013). In the context of HIV, proximal determinants may be individual-level factors such as genetics, culture, and sexual behaviors (Baral et al., 2013).

Research suggests that individual behavior, such as condom use and number of sexual partners, does not adequately explain differences in rates of HIV infection (Hallfors, Iritani, Miller, & Bauer, 2007). There is increasing evidence that SDOH play a much larger role, yet surveillance systems do not routinely collect data on many of these distal determinant (Aral, Adimora, & Fenton, 2008; Dean & Fenton, 2010). For example, education and housing are strongly associated with HIV incidence, both of which are inextricably tied to poverty (Zeglin & Stein, 2015). Poverty affects where individuals live, housing quality and stability, access to and quality healthcare, and other important social conditions (Adimora, Schoenbach, & Floris-Moore, 2009). In turn, poverty is at the root of HIV and AIDS inequities (Adimora et al., 2009). One fourth of all those infected with HIV in the US pass through the criminal justice system (Kraut-Becher et al., 2008). As such, disproportionate rates of incarceration also influence HIV-related inequity among Black populations who account for 47% of the prison population (Kraut-Becher et al., 2008). Additionally, high rates of incarceration among Black men reduces the male-to-female ratio in many Black communities, impacting risk for HIV infection (Kraut-Becher et al., 2008).

Structural racism is an important social determinant that undergirds racial health inequity in general, and HIV-related inequities in particular. Structural racism operates in the US as the complex interaction of macro-level systems, policies, and institutional practices resulting in the unfair advantage of non-Hispanic White populations and the simultaneous disadvantage Black populations (Powell, 2007). Structural racism, like the SEM, is best understood from a systems perspective which focuses on relationships among multiple intersecting processes rather than singular linear causes (Powell, 2007). Structural racism impacts housing, educational and employment opportunities, access to health care, safety, and social networks, which all influence risk for HIV infection (Aral et al., 2008; Zeglin & Stein, 2015). Structural racism is an important, if not the most important, distal determinant of HIV-related inequities. For example, neighborhood segregation, which is rooted in structural racism (e.g., Redlining), helps facilitate unfair policing practices within Black communities and disproportionate incarceration rates, in turn, increasing risk for acquiring HIV (Kraut-Becher et al., 2008).

Proximal Solutions to Distal Determinants of HIV-Related Inequity

Despite evidence that SDOH (including structural racism) are at the root of HIV-related inequities (Dean & Fenton, 2010), most interventions are not focused on addressing these distal determinants (Crepaz et al., 2007; Rotheram-Borus, Swendeman, & Chovnick, 2009; Adimora & Auerbach, 2010; Sipe et al., 2017; Jeffries & Henny, 2019; Williams, Lawrence, & Davis, 2019). Most evidence-based HIV interventions developed and implemented among Black populations focus on proximal determinants including knowledge, awareness, attitudes, sexual behavior, and substance abuse (Jemmott, Jemmott, & Fong, 1992; Diallo et al., 2010; Kogan et al., 2012; Zellner et al., 2016; Prado, Lightfoot, & Brown, 2013). For example, the Color It Real program is a culturally-tailored intervention designed to decrease risky sexual behavior, substance abuse, and perceived stress among African American heterosexual men and women, aged 18–24 (Zellner et al., 2016). While some interventions address factors at the family and community levels (e.g., Strong African American Families), strategies focus mainly on enhancing HIV knowledge and modifying related behaviors (Prado et al., 2013).

Recommendations to Advance HIV-Related Inequity Research and Practice

Given that HIV-related inequities are rooted in SDOH, failure to address these distal determinants violates principles of public health ethics such as social justice and beneficence, as well as negatively shape public perceptions about populations most affected by HIV (e.g., perpetuating stereotypes). Furthermore, ignoring SDOH in HIV prevention efforts wastes valuable resources by developing and implementing interventions that are ineffective at reducing HIV-related inequities. The following sections provide recommendations to enhance public health efforts to eliminate HIV-related inequities by addressing structural racism and other SDOH.

Engage and Empower Black Communities in HIV/AIDS Research and Practice

It is essential that power imbalance is addressed at all levels, and within all phases, of HIV prevention research and practice. Not only is it important to engage Black communities in HIV prevention efforts, but it is equally important that Black scholars are centered in HIV inequity research (Best, Fletcher, Kadono, & Warren, 2021). As many Black scholars experience marginalization in ways that mirror the communities most impacted by HIV, these perspectives are invaluable for understanding and appropriately addressing HIV inequities. The CDC provides funding to support Black and Hispanic early career investigators to conduct HIV epidemiologic and prevention research aimed at reducing racial/ethnic inequity in the US (Prado et al., 2013). These and other efforts are necessary to address structural racism within the research process, and to enhance HIV inequity research itself.

Reframe HIV and AIDS Inequity Language

Over three decades ago, the US DHHS noted that racial/ethnic minority populations in the US “have not benefited fully or equitably” from systems responsible for ensuing health (US DHHS, 1985). As such, HIV-related inequities are unnecessary, avoidable, and unjust (Braveman, 2014); and HIV prevention efforts that do not explicitly address SDOH only serve to perpetuate these inequities. For example, race is commonly listed as a risk factor for HIV-related and other health inequities (Crear-Perry, Maybank, Keeys, Mitchell, & Godbolt, 2020). Framing race, rather than racism, as a risk factor for acquiring or transmitting HIV is problematic and functions to further stigmatize already marginalized populations (Crooks, Donenberg, & Matthews, 2021). Similarly, framing HIV-related inequities based on proximal risk factors such as sexual behavior (e.g., men who have sex with men [MSM]) further stigmatizes and dehumanizes priority populations, which is especially relevant for populations most affected by HIV (Crooks et al., 2021; Fletcher, Jiang, & Best, 2021).

Develop and Implement Multi-Level Interventions to Address HIV and AIDS Inequity

Inaccurate framing of HIV and AIDS inequities can also contribute to development and implementation of ineffective public health interventions – that is, most interventions to date have largely focused on individual-level factors. Thomas and colleagues (2011) propose a fourth generation of health inequity research that is grounded in critical race praxis and utilizes multi-level, structural interventions to address racism and other SDOH. HIV prevention researchers and practitioners should integrate biomedical, behavioral, and social/structural factors in their approaches to effectively reduce and eliminate HIV-related inequities. Currently, there are limited strategies that address SDOH, especially structural racism. The Expanded Syringe Access Program (ESAP) is one example of a multi-level intervention which provides health education, referral to community resources, and it permits pharmacy syringe sales without a prescription within inner-city communities in Harlem, NY (Fuller et al., 2007). This program leverages existing resources and builds community capacity through interdisciplinary partnerships with organizations that explicitly address relevant social and structural determinants (e.g., drug treatment, housing, and job placement). Existing evidence-based interventions could be enhanced by collecting/utilizing data and incorporating strategies focused specifically on SDOH and structural racism to adequately address a wider range of HIV-related risk factors (Carter & Jeffries, 2019).

Conclusion

This literature review highlights the misalignment between root causes of HIV and AIDS inequities and public health efforts to address these inequities in the Black community. In March 2021, the National Institutes of Health (NIH) launched the UNITE initiative “to address structural racism and promote racial equity and inclusion at NIH and within the larger biomedical research enterprise” (NIH, 2021). One of five primary objectives of UNITE involves addressing racial health inequities in the US through enhanced support of health equity research (NIH, 2021). To meet this objective, SDOH and structural racism must be at the forefront of efforts to address HIV-related and other health inequities which disproportionally impact Black communities. This involves meaningful engagement and empowerment of Black community members and scholars; reframing stigmatizing language used to describe HIV and AIDS inequities; and implementing HIV-prevention interventions that comprehensively address multiple socio-ecological levels to enhance effectiveness.