# Presentation: 901483

## The HIV/AIDS Epidemic and Black Americans

- Madeline Y. Sutton, MD, MPH
- Tonji Durant, PhD,
- Anna J. Satcher, MPH, Joseph Prejean, PhD, Xiaohong Hu, MS,
- Xiangming Wei, MS, Lisa M. Lee, PhD
- Division of HIV/AIDS Prevention
- National Center for HIV/STD and TB Prevention
- Centers for Disease Control and Prevention

- The findings and conclusions in this presentation are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention/the Agency for Toxic Substances and Disease Registry.

## Topics

- Impact of the HIV/AIDS epidemic on the Black community
- Reviewing the data
- Males
- Females
- Factors contributing to high infection rates among Black Americans
- Summary

## Data Source

- National HIV/AIDS Surveillance System
- Newly diagnosed HIV cases
- Reported from 2001 through 2004
- Adults and adolescents _>_13 years
- 33 states with confidential name-based reporting since at least 2000
- Adjusted for reporting delays
- Adjusted for persons reported without risk factor information

## 33 Reporting States for Estimated HIV Diagnosis, 2001-2004

- NV

- FL

- CO

- AZ

- NM

- UT

- ID

- WY

- ND

- SD

- NE

- OK

- AR

- LA

- MS

- AL

- MN

- IA

- MO

- TN

- SC

- NC

- VA

- IN

- OH

- WV

- WI

- MI

- NJ

- AK

- TX

- KS

- NY

**States with Confidential **
**Name-based **
**Reporting Since 2000**

## Leading Causes of Death Among Black Americans, 25-44, 2002

- Source: U.S. Centers for Disease Control and Prevention. National Vital Statistics Reports, Deaths: Leading Causes for 2002. Public Health Service, 2003 (Vol. 53, No. 17)

**Diabetes mellitus**

**Cerebrovascular diseases**

**Suicide**

**Nephritis, nephrosis & nephrotic syndrome**

- 10

- 1

- 2

- 3

- 4

- 5

- 6

- 7

- 8

- 9

- Deaths

- 0

- 500

- 1000

- 1500

- 2000

- 2500

- 3000

- 3500

- 4000

- 4500

**Assault**

**Heart Disease**

**Unintentional injury**

**Malignant neoplasms**

**HIV Infection**

- Cause of Death

**Chronic liver disease**

## People Living With HIV in the U.S., by Race/Ethnicity, 2003

***47%***

**34%**

**17%**

**1%**

- Source: Glynn et al.  2005 National HIV Prevention
- Conference, Presentation T1-B1101.

- Total:1,039,000 – 1,185,000 people

- Asian/PI=Asian/Pacific Islander
- AI/AN=American Indian/Alaska Native

## HIV and AIDS in Black Americans

- Estimated HIV infected blacks aged 18-49 years
- 2% 1999-2002
- More blacks report being tested for HIV
- 67% compared with 45% of whites
- More blacks test late for HIV*
- 40% compared with 37% of whites

- Source: Kaiser Family Foundation.  HIV/AIDS Policy Fact Sheet: Black Americans and HIV/AIDS,  December  2006.  *AIDS diagnosed within 12-months of HIV diagnosis.

## Analysis

- Objective:
- To assess trends in HIV diagnosis among non-Hispanic blacks  from 2001 through 2004
- Methods:
- Descriptive statistics
- Estimated number and rates of HIV diagnoses
- Estimated Annual Percent Change (EAPC) and 95% Confidence Intervals
- Overall
- Sex
- Metropolitan Statistical Area (MSA)
- Transmission category

## Estimated Persons Newly Diagnosed with an HIV Infection, 33 States, 2001-2004

- Estimated persons newly diagnosed-2001
- 41,000 total persons
- 20,000 Non-Hispanic Blacks
- Estimated persons newly diagnosed-2004
- 39,000 total persons
- 19,000 Non-Hispanic Blacks
- Non-Hispanic blacks 13% of population in 33 States
- Accounted for 51% of new HIV diagnoses

## Estimated Rates and Annual Percent Change Overall, by Sex and by Racial/Ethnic Group

## Estimated Number of Adults and Adolescents 

- Data from 35 areas with confidential name-based HIV infection reporting since at least 2000.

- Data have been adjusted for reporting delays. Age as of end of year.

- Estimated Number of Adults and Adolescents

- Living with HIV/AIDS, by Sex, 2001–2004—35 Areas

- No. of persons  (in thousands)

- Males

- Females

- Year

- 250

- 300

- 350

- 400

- 200

- 150

- 100

- 50

- 0

- 2001

- 2002

- 2003

- 2004

## Proportion of HIV/AIDS Cases among Adults and 

- Adolescents, by Transmission Category

- 2001–2004—35 Areas

- Note. Data include persons with a diagnosis of HIV infection regardless of their AIDS status at diagnosis.

- Data from 35 areas with confidential name-based HIV infection reporting since at least 2000.

- Data have been adjusted for reporting delays and cases without risk factor information were proportionally

- redistributed.

- Cases, %

- Year of diagnosis

- 0

- 5

- 10

- 15

- 20

- 25

- 30

- 35

- 40

- 45

- 50

- Male-to-male sexual contact

- High risk heterosexual contact*

- Male-to-male sexual contact and IDU

- Injection drug use (IDU)

- 2001

- 2002

- 2003

- 2004

- * Heterosexual contact with a person known to have or at high risk for HIV  infection.

## Estimated Number and Proportion of HIV/AIDS Cases 

- Data from 35 areas with confidential name-based HIV infection reporting since at least 2000.

- Data have been adjusted for reporting delays and cases without risk factors information were proportionally

- redistributed.

- ** Total includes 60 persons of unknown race or multiple races.

- Estimated Number and Proportion of HIV/AIDS Cases

- among Adults and Adolescents Attributed to High Risk

- Heterosexual Contact*, by Race/Ethnicity, 2004—35 Areas

- Cases

- 1,862

- 8,599

- 1,970

- 123

- 69

- 12,683

- 15

- 68

- 16

- <1

- <1

- Race/Ethnicity

- White, not Hispanic

- Black, not Hispanic

- Hispanic

- Asian/Pacific Islander

- American Indian/

- Alaska Native

- Total**

- %

- * Heterosexual contact with a person known to have or at high risk for HIV  infection.

## Estimated Rates and Annual Percent Change in HIV Diagnoses among Adults and Adolescents by Race/Ethnicity for 33 States, 2001-2004—Overall

- EAPC= -5.3*

- EAPC= 0.6

- EAPC= -6.5

- EAPC= 9.5*

- EAPC= 3.0

- *Statistically significant

- Asian/PI=Asian/Pacific Islander
- AI/AN=American Indian/Alaska Native

## Estimated Rates and Annual Percent Change in HIV Diagnoses among Adults and Adolescents by Race/Ethnicity for 33 States, 2001-2004—Male

- EAPC= -4.4*

- EAPC= 1.4

- EAPC= -4.7

- EAPC= 8.1*

- EAPC= 2.4

- *Statistically significant

- Asian/PI=Asian/Pacific Islander
- AI/AN=American Indian/Alaska Native

## Estimated Number and Annual Percent Change in HIV Diagnoses among Adults and Adolescents by Race/Ethnicity for 33 States, 2001-2004—MSM

- EAPC= 2.5

- EAPC= 4.5

- EAPC= 18.9*

- EAPC= 3.3

- EAPC= 2.1

- *Statistically significant

- MSM=Men who have sex with men
- Asian/PI=Asian/Pacific Islander
- AI/AN=American Indian/Alaska Native

## Estimated Rates and Annual Percent Change in MSM Related HIV Diagnoses among Adult and Adolescent Males by Race/Ethnicity for 33 States, 2001-2004

- EAPC= .31

- EAPC= 1.9

- EAPC= 0.17

- EAPC= 13.5

- EAPC= 1.1

- *Statistically significant

- MSM=Men who have sex with men
- Asian/PI=Asian/Pacific Islander
- AI/AN=American Indian/Alaska Native

## Estimated Number and Annual Percent Change in HIV Diagnoses among Adults and Adolescents by Race/Ethnicity for 33 States, 2001-2004—Male High-Risk Heterosexual Contact 

- EAPC= 2.7*

- EAPC= -1.9

- EAPC= 2.5

- EAPC= 38.9*

- EAPC= -4.9*

- *Statistically significant

- Asian/PI=Asian/Pacific Islander
- AI/AN=American Indian/Alaska Native

## Estimated Number and Annual Percent Change in HIV Diagnoses among Adults and Adolescents by Race/Ethnicity for 33 States, 2001-2004—Male Injection Drug Use

- EAPC= -2.9

- EAPC= -12.8

- EAPC= -0.3

- EAPC= -1.0

- EAPC= -9.7*

- *Statistically significant

- IDU=Injection Drug Use
- Asian/PI=Asian/Pacific Islander
- AI/AN=American Indian/Alaska Native

## Estimated Rates and Annual Percent Change by Metropolitan Statistical Area (MSA) and Racial/Ethnic Group

- Defining MSAs
- Greater than 500,000 persons = Urban MSAs
- 50,000 to 500,000 = Peri-urban MSAs
- < 50,000 = Rural MSAs

## Estimated Average Rates† of HIV Diagnoses by Metropolitan Statistical Area  (MSA) and Race/Ethnicity for 33 States, 2001-2004††

**Estimated Average Rates**†** of HIV Diagnoses by Metropolitan Statistical Area  (MSA) and Race/Ethnicity for 33 States, 2001-2004**††

- MSAs of >500,000=Urban
- MSAs of  50,000-500,000=Peri-Urban
- MSAs of  <50,000=Rural

- †Rates are average rates per 100,000 population in the 33 States, 2001-2004.
- ††Trends reported in text not shown here.

## Severe Impact on Black Women:Estimated Numbers and the Annual Percent Change by Race/Ethnicity and Transmission Category, Women

## Proportion of HIV/AIDS Cases and Population among 

- Female Adults and Adolescents, by Race/Ethnicity

- 2004—33 States

- White, not Hispanic

- Black, not Hispanic

- Hispanic

- Asian/Pacific Islander

- American Indian/

-    Alaska Native

- HIV/AIDS cases

- N*= 10,391

- US Female Population

- N = 78,607,053

- <1%

- 3%

- <1%

- 1%

- 68%

- 72%

- 17%

- 14%

- 11%

- 13%

- Note. Data include persons with a diagnosis of HIV infection regardless of AIDS status at diagnosis. Data from 33 states with confidential

- name-based HIV infection reporting since at least 2000. Data have been adjusted for reporting delays.

- *Includes 49 female adults and adolescents of unknown race or multiple races.

## Estimated New HIV/AIDS Diagnoses among Females by Race/Ethnicity — 33 U.S. States, 2001-2004

***68%***

**16%**

**15****%**

**<1%**

- Source: Centers for Disease Control and
- Prevention.  “Racial/Ethnic Disparities in Diagnoses
- of HIV/AIDS – 33 States, 2001-2005.” *MMWR* 2005;56(09).

- Asian/PI=Asian/Pacific Islander
- AI/AN=American Indian/Alaska Native

## Estimated Number of HIV/AIDS Cases and Rates 

- for Female Adults and Adolescents, by Race/Ethnicity

-  2004—33 States

- Race/Ethnicity

- White, not Hispanic

- Black, not Hispanic

- Hispanic

- Asian/Pacific Islander

- American Indian/

- Alaska Native

-       Total**

- Cases*

- 1,782

- 7,009

- 1,400

- 94

- 57

- 10,391

- Rate

- (cases per 100,000

- population)

- 3.2

- 67.0

- 16.3

- 4.1

- 7.7

- 13.2

- Note. Data include persons with a diagnosis of HIV infection regardless of AIDS status at diagnosis.

- Data from 33 states with confidential name-based HIV infection reporting since at least 2000.

- Data have been adjusted for reporting delays.

- * Data exclude persons from U.S. dependencies, possessions and associated nations because of the lack

- of census information by race and age categories for these areas.

- ** Includes 49 female adults and adolescents of unknown race or multiple races.

## Estimated New HIV/AIDS Diagnoses among Black Females by Transmission Category – 33 U.S.  States, 2001-2004

**80%**

**18%**

**1%**

- Black Women are at Risk Primarily through Heterosexual Activity

- Source: Centers for Disease Control and
- Prevention.  “Racial/Ethnic Disparities in Diagnoses
- of HIV/AIDS – 33 States, 2001-2005.” *MMWR* 2005;56(09).

- IDU=Injection Drug User

## Estimated Rates and Annual Percent Change in HIV Diagnoses among Adults and Adolescents by Race/Ethnicity for 33 States, 2001-2004—Female

- EAPC= -6.8*

- EAPC= -2.1

- EAPC= -13.0*

- EAPC= 14.3*

- EAPC= 4.8

- *Statistically significant

- Asian/PI=Asian/Pacific Islander
- AI/AN=American Indian/Alaska Native

## Estimated Number and Annual Percent Change in HIV Diagnoses among Adults and Adolescents by Race/Ethnicity for 33 States, 2001-2004—Female High-Risk Heterosexual Contact 

- EAPC= -4.2*

- EAPC= -1.4

- EAPC= -7.7*

- EAPC= 18.9*

- EAPC= 12.3

- *Statistically significant

- Asian/PI=Asian/Pacific Islander
- AI/AN=American Indian/Alaska Native

## Estimated Number and Annual Percent Change in HIV Diagnoses among Adults and Adolescents by Race/Ethnicity for 33 States, 2001-2004—Female Injection Drug Use 

- EAPC= -9.8*

- EAPC= -4.1

- EAPC= -14.4

- EAPC= 21.5

- EAPC= -2.4

- *Statistically significant

- IDU=Injection Drug Use
- Asian/PI=Asian/Pacific Islander
- AI/AN=American Indian/Alaska Native

## Risk Factors for Black Women

- Low condom use, low knowledge of partner risk, low perceived risk (Yancey et al., 2001)
- 45% did not use a condom at all in past 2 months
- 60% did not know male partner’s HIV status
- 70% perceived little or no risk of HIV infection
- Low condom use even when partner is HIV-positive (Buchacz et al., 2001)
- Greater likelihood of STD infection and re-infection (Korte et al., 2004)
- Non-monogamy

## Why the Black Community is Disproportionately Affected by  HIV/AIDS?

## Limited Access to Effective HIV Treatment among Blacks

- Nearly half of eligible HIV-positive adults not receiving HIV treatment
- Blacks less likely than whites to have access to HAART
- Greatest barrier to accessing anti-retroviral therapy – lack of diagnosis

- Source: Teshale et al., 12th Conference on Retroviruses and Opportunistic Infections, February 2005.  Abstract 167; Gebo et al., 2005.

## Blacks’ Access to Care Especially Limited

- Blacks with HIV more likely than whites to be uninsured (22% vs.17%)
- Blacks, overall, less likely to be privately insured than whites (14% vs. 44%)
- Blacks, overall, more likely to postpone medical care
- Lack of transportation
- Other competing needs

- Source: Kaiser Family Foundation.  HIV/AIDS Policy Fact Sheet: Blacks and HIV/AIDS, December 2006.

## Summary

- Despite declines non-Hispanic blacks remain disproportionately affected
- Estimated rates of HIV diagnoses declined
- Estimated numbers of HIV diagnoses declined

## Analysis Limitations

- Limited availability of HIV diagnosis data
- 33 States represent 63% of AIDS cases
- Missing data for transmission category and reporting delays
- Statistical adjustments
- Data not representative of all HIV infected persons
- Non-testers
- Test anonymously

## Public Health Implications

- Accelerate pace of implementing effective strategies
- Continue monitoring trends
- Conduct confidential name-based reporting
- States and U.S. Territories
- Enhance existing and develop new strategies
- Advancing HIV Prevention Initiative (AHP)
- Decreasing the number of unrecognized infections
- Strengthening non-traditional community partnerships

## Thank You! 

- Questions/comments:
- 	Madeline Sutton, MD, MPH
- 	Centers for Disease Control and Prevention
- 	Division of HIV/AIDS Prevention
- 	Epidemiology Branch
- 	404-639-1814
- 	MSutton@cdc.gov