By: Ranier Simons, ADAP Blog Guest Contributor
Although great strides have been made toward fighting HIV in the United States, several groups remain disproportionately impacted. Black communities are one of the groups experiencing a higher impact of HIV-related health disparities. Health disparities are differences in the incidence, prevalence, and mortality of a disease and its associated related adverse health conditions.[1] Multiple factors contribute to Black communities bearing more of the HIV burden than other groups. The characteristics of many communities of color social determinants of health are part of those factors. Social determinants of health (SDOH) include economic stability, education access, and quality, health care access and quality, neighborhood and built environments, and social and community context.[2] These SDOH are influenced by things like discrimination, racism, and poverty. In 2022, Black persons were disproportionately impacted by new HIV infections.[3]
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| Photo Source; HIV.gov |
According to PlusInc, which addresses health disparities in the United States, HIV disproportionately impacts Black and Hispanic/Latino Americans. PlusInc's HIV health disparities statement notes:
"While Black and Hispanic/Latino make up just 13.4% and 18.5% of the U.S. population, respectively, Black Americans account for 40.3% and Hispanic/Latino Americans account for 24.7% of the total population of Persons Living with HIV/AIDS (PLWHA). Additionally this disparity extends to the incidence, with 42% of new HIV diagnoses occurring in Black Americans and 27.8% in Hispanic/Latino Americans. According to the Centers for Disease Control and Prevention (CDC) 26% of new HIV diagnoses were among Black gay and bisexual Men who have Sex with Men (MSM), 23% were among Hispanic/Latino gay and bisexual MSM, and 45% among gay and bisexual MSM under the age of 35."
The lived experiences and cultural commonalities among Black communities contribute to the disproportionate HIV burden. Larry Scott-Walker, Executive Director for Thrivess, Inc., explains, “Many within the Black community have experienced some form of medical racism or implicit bias that prevents them from trusting those within the medical industrial complex.” Distrust in the medical system means a person has a lowered likelihood of actively seeking out medical knowledge and intervention, especially concerning HIV. Furthermore, many medical professionals lack cultural competency.
Cultural competency is understanding and respecting the beliefs, values, and histories of individuals of all cultural backgrounds.[4] In an article for Medical News Today, Dr. Luz Maria Garcini, assistant professor in the Department of Psychological Sciences at Rice University, stated, “Cultural competence improves interpersonal interactions, helps to build trust, conveys respect, reduces biases that may lead to inaccurate diagnoses and treatments, and increases the chances that patients may be more compliant with the medical recommendations given.”[4]
Socially, a good deal of HIV stigma also still exists in Black communities. Stigma can result in people not seeking out or maintaining HIV care, regularly testing, or even having discussions of an intimate nature socially. Traditionally, Black culture has been heavily influenced by the institution of the church. Thus, open sex-positive discourse is not pervasive. Shame and stigma are not only barriers to obtaining HIV-related knowledge but also facilitate poor decision-making and even partner selection. Most importantly, shame leads to isolation when data shows HIV-related stigma is mitigated by social support.[5]
Economically, the poverty rate in Black communities in 2022 was 17.1%. The overall national poverty rate was 11.5%. Black persons were 13.5% of the population but represented 20.1% of those living in poverty.[6] The South, regionally, had the highest rate of new HIV diagnoses. Coincidentally, the South also contained the highest concentration of the Black population in the United States at 56%, and next to the Northeast had the highest level of poverty.[7] Poverty usually results in one’s focus being centered on many things, with personal healthcare residing lower on the list. Poverty also usually lends itself to segregation. Black communities segregated in some impoverished areas are not located near quality hospitals or clinics. This is a barrier to access to care in terms of prevention, treatment, and medical education.
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| Photo Source: PlusInc |
Regarding poverty, Black communities have a higher likelihood of being uninsured or on publicly funded insurance.[8] The result is inadequate, non-existent, or inconsistent primary care. This also is a barrier to HIV and STI testing, HIV treatment and prevention, and management of other chronic medical issues. Even with access to private insurance, Black persons of lower socioeconomic status may not be able to afford the cost-sharing associated with utilizing their insurance plans in addition to the premiums. Avenues of medical assistance in terms of co-pay assistance, living expenses, insurance premium assistance, and even charity care exist. However, they are useless for those who find accessing them too complicated or are unaware of the options, especially when it comes to prevention.
One glaring prevention strategy discrepancy identified among Black communities is the utilization of PrEP. As expressed by Scott-Walker, “When we look at the poor uptake of PrEP within Black communities, it is clear that not enough education, community buy-in, and galvanization efforts have been attempted.” When appropriately used, PrEP, whether oral or injectable, has proven to be 99% effective at preventing sexual HIV infection while reducing injection drug use-related HIV transmission by 74%.[9] However, data shows that 94% of Whites who can benefit from PrEP have been prescribed it, contrasting with 13% of African Americans who can benefit from it.[10]
Utilizing PrEP requires laboratory tests and medical visits usually covered by insurance, whether private or Medicaid. Additionally, by law, insurance plans are not supposed to charge co-pays, co-insurance, or deductibles for PrEP.[11] However, for the uninsured, it is more expensive. For the uninsured, beginning PrEP could cost around $2,700, which includes $1,000 for lab tests and medical visits.[10] The uninsured monthly prescription of generic Truvada would cost about $60 per month, with the brand name costing upwards of $2,000 per month. Moreover, without insurance, the required quarterly lab tests and medical visits would be, on average, around $15,000 per year.[11,12,13]
Tragically, lifesaving long-acting injectable (LAI) PrEP is even farther out of reach for some Black communities. Cabotegravir, trade name Apretude, is a long-acting injectable form of PrEP. It is administered by injection every other month. Logistically, this would be very beneficial to Black populations who dealt with transportation difficulties, housing instability, or treatment adherence. However, long-acting injectable PrEP is very expensive, and access is even more challenging than with standard oral PrEP. Apretude is administered in a clinic setting and covered under the medical portion of insurance, not the prescription drug benefit. Therefore, it is subject to cost-sharing that oral PrEP is not. Additionally, it is too expensive to pay for out of pocket. Moreover, some African Americans are not located in areas with feasible access to physicians who can administer Apretude.
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| Photo Source: American Psychological Association |
The machinations of the diverse factors contributing to the disproportionate impact of HIV in the Black community are complex. The interactions of various aspects of policy, economics, culture, and social frameworks create a web that is hard to navigate for a solution to HIV health disparities in Black communities. This is why Scott-Walker states, “organizations that are explicitly committed to and reflective of Black communities are so essential in bringing about real change.”
[1] CDC. (2024, January 17). Health Disparities in Black or African American People. Retrieved from https://www.cdc.gov/health-disparities-hiv-std-tb-hepatitis/populations/black-african-american.html
[2] U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (2024). Healthy People 2030. Retrieved from https://health.gov/healthypeople/objectives-and-data/social-determinants-health
[3] CDC. (2024, May 21). Fast Facts: HIV in the U.S. by Race and Ethnicity. Retrieved from https://www.cdc.gov/hiv/data-research/facts-stats/race-ethnicity.html.
[4] Pelc, C. (2022, November 9). What is cultural competency, and why is it crucial to healthcare? Retrieved from https://www.medicalnewstoday.com/articles/what-is-cultural-competency-and-why-is-it-crucial-to-healthcare
[5] Williams, R. S., Stetten, N. E., Cook, C., Cook, R., Ezenwa, M. O., & Lucero, R. (2022). The Meaning and Perceptions of HIV-Related Stigma in African American Women Living With HIV in Rural Florida: A Qualitative Study. The Journal of the Association of Nurses in AIDS Care: JANAC, 33(2), 118–131. https://doi.org/10.1097/JNC.0000000000000252
[6] Shrider, E. (2023, September 12). Poverty Rate for the Black Population Fell Below Pre-Pandemic Levels. Retrieved from https://www.census.gov/library/stories/2023/09/black-poverty-rate.html#:~:text=The%20official%20poverty%20rate%20of,Census%20Bureau%20data%20released%20today.
[7] Moslimani, M., Tamir, C., Budiman, A., Bustamante, L., & Mora, L. (2024, January 18). Facts about the U.S. Black population. Pew Research Center. https://www.pewresearch.org/social-trends/fact-sheet/facts-about-the-us-black-population/
[8] N.D. (2022, April 14). HIV and AIDS Among Black Americans. Retrieved from https://www.webmd.com/hiv-aids/hiv-aids-in-blacks-alarming-crisis
[9] HIV.GOV. (2024, June 27). Pre-Exposure Prophylaxis. Retrieved from https://www.hiv.gov/hiv-basics/hiv-prevention/using-hiv-medication-to-reduce-risk/pre-exposure-prophylaxis#:~:text=Why%20Take%20PrEP%3F,74%25%20when%20taken%20as%20prescribed.
[10] Scaturro, M. (2024, April 16). HIV crisis in Atlanta made worse by racial disparities in treatment. Retrieved from https://www.ajc.com/news/health-news/hiv-crisis-in-atlanta-made-worse-by-racial-disparities-in-treatment/XPM2SEVXBRADJHMIBFH4C2O2U4/
[11] HealthHIV. (2024). Insurance and paying for PrEP. Retrieved from https://pleaseprepme.org/paying-prep/#:~:text=Did%20you%20know%20that%20most,PrEP%20a%20Grade%20A%20recommendation.
[12] Varney.S. (2022, March 3). HIV Preventive Care Is Supposed to Be Free in the U.S. So, Why Are Some Patients Still Paying? Retrieved from https://kffhealthnews.org/news/article/prep-hiv-prevention-costs-covered-problems-insurance/#:~:text=The%20costs%20can%20be%20daunting,can%20total%20%2415%2C000%20a%20year.
[13] Srikanth, K., Killelea, A., Strumpf, A., Corbin-Gutierrez, E., Horn, T., & McManus, K. A. (2022). Associated Costs Are a Barrier to HIV Preexposure Prophylaxis Access in the United States. American journal of public health, 112(6), 834–838. https://doi.org/10.2105/AJPH.2022.306793
Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association, but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about public health-related issues and updates.
