Overcoming the Epidemics: Racial Disparities in HIV and STDs
By Deana McRae Health Policy Associate, National Black Caucus of State Legislators

When compared to the U.S. population, African Americans and other minorities are contracting HIV and other sexually transmitted diseases (STDs) at a disproportionate rate, despite the efforts of federal, state and local agencies. While African Americans represent approximately 13 percent of the nation’s population, HIV and STDs disproportionately affect them each year. This fact illustrates the ever-increasing need for education and prevention within the African American community.

The Centers for Disease Control and Prevention (CDC) estimates that in 2003, more than 1 million persons in the United States were living with an HIV infection and about 40,000 new HIV infections occur each year. According to CDC’s 2004 HIV/AIDS Surveillance Report, African Americans accounted for 50 percent of all HIV/AIDS cases diagnosed in 2004. By the end of 2004, an estimated 415,000 individuals were living with AIDS in the United States and 43 percent of them were African Americans.

In addition to HIV, other STDs continue to be a major U.S. public health challenge. CDC estimates that 19 million new sexually transmitted infections occur each year. Data in CDC’s 2004 STD Surveillance Report showed higher rates of all STDs among minority racial and ethnic populations when compared to whites. Additionally, the U.S. Department of Health and Human Services’ Healthy People 2010 chapter on Sexually Transmitted Diseases notes that race and ethnicity can be recognized as risk markers for prevalence of STDs in association with other important factors, such as poverty, access to quality health care, and living in urban settings in the United States.

STD EPIDEMIC AFFECTING AFRICAN AMERICANS

The three major nationally reportable STDs are chlamydia, gonorrhea, and syphilis. The most frequently reported bacterial STD in the U.S. is chlamydia; CDC estimates that there are approximately 2.8 million new cases of chlamydia each year in the U.S. Chlamydia is easily cured, but is usually asymptomatic and often undiagnosed. If left untreated, it can cause severe health consequences for women, including pelvic inflammatory disease (PID) which can lead to ectopic pregnancy, chronic pelvic pain and infertility. In addition, women infected with chlamydia are up to five times more likely to become infected with HIV, if exposed. African American women have the highest rate of reported chlamydial infection. In 2004, CDC reported that the rate of chlamydia among African American females was more than seven times higher than the rate among white females.

With gonorrhea, the second most frequently reported bacterial STD, racial disparities are even more pronounced, and African Americans are the most heavily affected. While gonorrhea rates have continued to decline since 1975, and the rate among African Americans fell 3 percent between 2003 and 2004, the reported rate for African Americans remains 19 times greater than for whites. In 2004, African Americans accounted for 70 percent of the reported cases of gonorrhea. African American females ages 15 to 24 had the highest gonorrhea rate of any age and race/ethnic group in 2004, followed closely by African American females ages 20 to 24. Gonorrhea, like chlamydia, is easily curable, but is often untreated because it is asymptomatic. It can lead to severe health consequences in women; up to 40 percent of untreated cases of gonorrhea lead to PID.

The third major reportable STD is syphilis. Syphilis is a highly infectious disease, but easily curable in its early (primary and secondary) stages. If left untreated, it can lead to serious long-term complications, including nerve and organ damage and even death. Congenital syphilis (the transmission from mother to child) can cause stillbirth, physical deformity and neurological complications in children who survive. Syphilis also facilitates the spread of HIV, increasing transmission at least two- to five-fold.

During the 1990s, the rate of primary and secondary (P&S) syphilis reported in the U.S. decreased, and in 2000, the rate was the lowest since national reporting began in 1941. These historically low rates and the concentration of syphilis in a small number of geographical areas, led CDC to develop its National Plan to Eliminate Syphilis. Since its implementation in 1999, significant progress has been made in reducing racial disparities in syphilis.

In 2004:
• There was an 80 percent decrease in the disparity in P&S syphilis rates between African Americans and whites since 1999;
• African Americans still accounted for 41 percent of the reported cases of P&S syphilis;
• The P&S syphilis rate for African Americans was 5.6 times greater than the rate for whites;
• The disparity in congenital syphilis decreased 47 percent since 1999; and
• The congenital syphilis rate for African Americans was 16 times the rate for whites, compared with 30 times the rate in 1999.

While there has been progress, syphilis remains a problem among African Americans living in poverty and in the southern region of the United States.

ECONOMIC BURDEN

In addition to the physical and emotional toll associated with HIV/AIDS and STDs, these epidemics are an economic burden as well. The economic impact includes the cost of medical visits and prescriptions, lost wages due to illness, as well as lower on-the-job productivity. In Fiscal Year (FY) 2006, the U.S. government budgeted $12.6 billion for programs for people living with HIV/AIDS. The majority of funding from the government goes to Medicaid and Medicare, the Ryan White CARE Act, and the AIDS Drug Assistance Program. About one in five people living with HIV receive Medicare coverage and most of those also receive Medicaid benefits. At least 15 million new cases of STDs are reported annually; while an estimated $8 billion is spent each year to diagnose and treat STDs and STD-related complications, not including HIV. An estimated 18 million new cases of non-HIV STDs occur each year at an estimated annual cost of $11.4 billion in year 2000 dollars.

NATIONAL PROGRAMS ADDRESSING THESE EPIDEMICS

As health disparities persist, federal agencies have been working toward improving public health conditions within minority communities. The FY 2006 U.S. Federal Government budget invests more than $17 billion for domestic AIDS treatment, prevention and research, including $2.1 billion for the Ryan White program. The budget provides continued support in the AIDS Drug Assistance Program, which provides life-saving anti-retroviral drug treatments for individuals that cannot afford them. In addition, the U.S. Department of Health and Human Services (HHS) launched programs and initiatives targeting racial and ethnic minority communities in the fight against specific diseases, such as HIV/AIDS and STDs.

Within HHS, CDC’s National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP – proposed) is responsible for public health surveillance, research and programs to prevent and control HIV/AIDS, viral hepatitis, other STDs and tuberculosis (TB). Additionally, in 1986, the Office of Minority Health (OMH) was created within HHS with the mission to improve and protect the health of racial and ethnic minority populations through the development of policies and programs that will eliminate health disparities. OMH coordinates programs to assist HHS in the implementation of initiatives addressing minority health disparities, such as the HHS HIV/AIDS Initiative for communities of color. One component of the initiative was the use of supplemental funding under the Ryan White CARE Act to establish AIDS Education and Training Centers at Historically Black Colleges and Universities (HBCUs) to provide ongoing AIDS education. The Minority HIV/AIDS Initiative, another OMH program, is part of HHS’ Initiative to Eliminate Racial and Ethnical Disparities. The initiative provides funding to various areas, including community-based organizations (CBOs), state and local health departments and correctional institutions to help address the HIV/AIDS epidemic within the minority populations.

CDC has established various initiatives and programs to address health disparities among minority communities.

• In 1999, CDC launched the Racial and Ethnic Approaches to Community Health (REACH 2010) Program, designed to eliminate health disparities in six areas, including HIV/AIDS, through community collaborations in designing, implementing and evaluating community-driven and culturally appropriate strategies.
• In April 2003, CDC announced an initiative, “Advancing HIV Prevention (AHP): New Strategies for a Changing Epidemic," aimed at reducing the number of new HIV infections that occur each year in the United States. The AHP initiative expands on current HIV prevention strategies and includes four major strategies:,
- Make HIV testing a routine part of medical care;
- Implement new models for diagnosing HIV infections outside medical settings;
- Prevent new infections by working with persons diagnosed with HIV and other partners; and
- Further decrease perinatal HIV transmission.
Seven demonstration projects were funded to test the feasibility of the four AHP strategies. One project was Using Social Network Strategies for Reaching Persons at High Risk for HIV Infection in Communities of Color.
• Historically low rates and the concentration of syphilis cases in a small number of geographic areas in the U.S. led to the development of CDC’s National Plan to Eliminate Syphilis, announced by Surgeon General Dr. David Satcher in 1999. The program gives priority funding to areas with high prevalence and morbidity in order to reduce P&S syphilis and increase the number of syphilis-free counties. It focuses on the improvement of a community’s health by removing syphilis and reducing the risk of HIV transmission and other health threats associated with syphilis.
• In recent years, CDC funded various new projects to improve the health of minorities disproportionately affected by HIV and sexually transmitted diseases, including:

- The HIV Prevention Survey for HBCUs which assesses the availability of HIV prevention and testing services and the willingness to offer routine HIV testing on each campus;
- CDC’s Prevention Response to the North Carolina HIV Infection Outbreak, which provides funding to support training for peer volunteers to adopt community level HIV prevention interventions;
- In Robeson, N.C., the high rate of infectious syphilis was largely in African American and Native American communities and the county was recently ranked highest in infectious syphilis among U.S. counties. Despite challenges associated with providing STD prevention and control services in a rural setting, Robeson County collaborated with the North Carolina State Health Department to conduct extensive outreach screening and STD health education activities, including both syphilis and HIV testing, as well as condom distribution and public information campaigns; and
- In addition to maintaining syphilis prevention and control efforts in predominantly poor and underserved minority communities, in 2002 CDC provided funding for projects in eight cities with the greatest number of syphilis cases among men who have sex with men (MSM). These projects worked with community organizations and local health departments to increase syphilis screening, symptom recognition and outreach efforts among MSM. Results of the projects were published in a special issue of the journal Sexually Transmitted Diseases in October 2005.

HOW CAN LEGISLATORS ADDRESS THE EPIDEMICS?

At a time when health disparities are overwhelming minority communities, state and local agencies cannot progress without a unified effort to integrate more prevention efforts into an already fragile health care system. African American state legislators should acknowledge that HIV and STD rates among African Americans have remained disproportionately high and demand increased efforts from federal, state and local agencies.

To reduce the spread of HIV and STDs, state policymakers can take the following steps: 1) Implement a Call to Action, in which state officials are urged to put minority health as a priority on their agenda, and 2) Create a task force to work in partnership with federal agencies to improve health services and prevention programs within their states. Other strategies include:

• Increase state resources to address specific minority health issues, such as HIV and STD infections;
• Review state public health surveillance reports and plans to understand existing conditions and support resolutions as recommended by the National Association of County and City Health Officials (NACCHO);
• Reallocate state funding toward programs that improve access to care and address emerging health-related issues impacting minority communities;
• Establish and use programs to offer health services to low-income and minority populations, including: a safe HIV and STD testing environment, educating individuals on HIV and STDs, access to treatment and care, and prevention methods;
• Push for insurance plan coverage for women age 25 and younger to be routinely screened for STDs during annual gynecological visits; and
• Support collaboration among health departments, community organizations, and state and local agencies to launch education programs and prevention initiatives.

African American communities can combat HIV and sexually transmitted diseases. However, it is urgent that state legislators, officials, and public health departments work together and take coordinated action.