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HIV/AIDS Among African American Men: The Time is Now
HIV/AIDS Among African American Men: The Time is Now
by
R.L. McCullough
The global AIDS epidemic is now in its fourth decade, and while the efficacy of HIV treatment protocols have advanced greatly, the prevention of the spread of the virus remains problematic in the extreme.
Los Angeles County, California remains a leading locus of new, previously undiagnosed HIV infections at a rate exceeded only by that of New York City and a handful of other entirestatesin which there are multiple urban centers of significant population. In spite three decades worth of well-funded programs designed to curb the spread of HIV, the 62% fatality rate among infected individuals within Los Angeles County has remained consistent since the outbreak was first diagnosed in 1981.
The State of California Department of Public Health, through its Office of AIDS, began reporting statistical analysis of HIV infection incidence statewide in 1983. At that time, statewide reported cases totaled less than 10,000. Today in California, that number is close to 170,000, with 38,846 (17.7%) of those reported as African American males, nearly one-third of whom reside in Los Angeles County, giving the county the #1 ranking as a “Top 10 HIV(AIDS)” area in the state.
That grim distinction is augmented by recent data in the 2013 Los Angeles County Annual HIV Surveillance Report,which indicates that of those adults infected with the virus, 20% are African American, triple their percentage of the overall population (7%) within the county. Of those HIV-positive African Americans in the county, 13,914 are men (nearly five times the rate of infected African American women), with new cases of AIDS among African American men being reported at double the rate of Latino men and quadruple the rate of white men. Fully one-third of African-American menin Los Angeles County who engage in sexual contact with other males are currently diagnosed as HIV-positive (
Assessing today’s reality
Today, there are approximately 60,000 Los Angeles County residents infected with HIV and more than 20,000 living with full-blown AIDS—a number that reflects the improved availability of more advanced treatment today than in 1981, when there were zero long-term AIDS survivors—with one-third of those unaware of their HIV status.
Regardless of the efficiency of data collection and the protocols for tracking the rate of the spread of HIV, it’s clear that solutions to the epidemic remain elusive and that the underlying causes for the increasing rate of infection need to be addressed from many fronts.
The fact that more than half the people who have died from AIDS since the discovery of the virus are African American, and that African American men are now the majority gender for new cases with 81% of those infections reported pursuant to homosexual contact, there is a clear need for culturally-focused gender-specific educational intervention and community sponsored HIV testing which specifically targets African American men.
Objectives
Any program that is designed to effectively stem the rising tide of HIV infection among African American men living in Los Angeles County clearly needs a revised strategy of communication, education, counseling, and social pathology awareness beyond those currently in place, and which are clearly failing to meet their objectives. The goals of any program of intervention, prevention, and education must be singularly focused upon reversing the current rate of HIV transmission among the group most responsible for the current rates of infection: African American Men.
There are multiple transmission vectors driving the current accelerating spread of HIV among African American men: high-risk sexual behaviors, primarily homosexual in nature, and injection of illicit street drugs. Arresting these behaviors, the product of which will be a decline in the rate of new infections, is the urgent objective of this study and any institutional efforts ensuing from it.
Conceptual framework
The prevention of AIDS and the spread of HIV are the explicit concern of multiple publically funded city, county, and state agencies, as well as of a number of privately funded charitable organizations.
AIDS/LifeCycle, Aids Support Network, AIDS.org, AIDS Project Los Angeles, HIVLA.org, the Los Angeles County Department of Health, Being Alive, and more than two dozen other public and private organizations—many of which are heavily funded by political and industry-specific interests—perform remarkable work in serving those individuals affected by HIV infections and AIDS. The majority have as their mission the improvement of the lives of those infected, their families, and their loved ones. None appear to have as their primary objective the correction of those sociological phenomena lying at the root cause of today’s increased rate of infection among African American men. A lack of proper interpretation of the statistical data regarding this demographic group may be a contributing factor to this failure of focus.
There are currently a number of HIV prevention campaigns directed at the African American community, few of which target African American men exclusively. These programs include Act Against Aids, which uses a mass media outreach to communicate risk factors leading to infection, Take charge. Take the test., which reaches out to African American women only, and Let’s Stop HIV Together, which is a broad-spectrum effort to remind people that HIV knows no gender, race, age, or socio-economic barriers.
Notably, only the program Testing Makes Us Stronger is specifically aimed at the African American MSM population. Because of the strong homophobic culture among African Americans—the source of which is often traced to African American Christian churches’ notion of sin—gay African American men (the MSM community) culturally veil their activities by avoiding gay/straight labeling, designating active MSM men as “on the down low”. Such a subculture, where men conduct active male-female relationshps with girlfriends or wives to conceal their homosexual proclivities and thereby put both female partners and other men at risk for HIV transmission, does little to stem the tide of infection. Given this widespread reluctance of African American men to self-identify as homosexual, even among those who are exclusively homosexual in behavior, there is little wonder why programs targeting those who engage in homosexual contacts has had limited apparent effect.
High-risk sexual activity among both genders is often driven by manifold socio-economic factors affecting African Americans thereby concentrating the spread of HIV within this group almost exclusively. Epidemiological data points to substantially higher rates of all sexually-transmitted infectious diseases among African Americans. As a whole, STD infections—many of which increase vulnerability to HIV infection—occur among African Americans at nearly 20 times the rate of whites, with a significant percentage of infections traced to homosexual behaviors between men.
Because African American men comprise a low population percentage in the U.S., their rates of HIV infection among “men who have sex with men” (MSM) may appear deceptively low. But when the population imbalance between African Americans and other ethnic groups (whites, Latinos, Asians) is taken into account, statistics indicate no less than 72% of African American men contract HIV as a result of MSM behaviors.
For African American heterosexual men who couple exclusively with African American women—the partner selection norm within the racial group—the risk of HIV exposure transmitted by African American women, while on the decline, remains significant. Despite a 20% decline in HIV infection among African American women in the past decade, they continue to comprise fully 65% of the nation’s population of women so infected and 29% of the infected African American population, numbers attributed primarily to heterosexual contact with African American men. Again, repeated exposure to sexual partners from a disproportionately infected population in general points to a higher potential for the unmitigated spread of HIV infection.
Because, as above, African Americans in the main have sexual relations within their race-community, young African American males are currently the population most affected by the spread of HIV, with infection rates double that of other MSM ethnic groups. This significant risk is only exacerbated by the economic motivation of young MSM men to engage with older MSM men who have likely had higher numbers of sexual contacts and increased HIV exposure. Among African American gay men, younger MSM individuals are commonly drawn into relationships with older gay men out of economic necessity. When younger gay men find material and financial support with older gay men in exchange for sexual contact, their own HIV exposure increases exponentially.
Other sociological, generational, and cultural factors further define the problem of prevention among the community of African American men. Because young MSM African Americans are—unlike whites and Latinos—less likely to be openly engaged in a homosexual lifestyle, they are far less likely to be responsive to programs of educational outreach directed toward their age group. These same young African American homosexual men are—more so than older gay African American men—more likely to have exclusively homosexual contacts, increasing their likely exposure to HIV infection.
Compounding the issue of HIV spread via sexual activity of any kind, nearly ten percent of HIV infections within the African American community—males included—is a direct product of illicit drug injections. This is a rate of infection that far exceeds that of other ethnic groups. Moreover, those African Americans infected with HIV tendto have a more rapid onset of AIDS and experience poor survival outcomes.
Strategies
Based upon today’s data, the population group most “at risk” and concomitantly putting others as well as themselves at risk is African American men.
All efforts at mitigating the deadly potential effects high risk sexual behaviors and intravenous illicit drug use will be most effective if they specifically target African American men. This is not an issue of conducting another “AIDS walk” in West Hollywood, where the most at-risk population is not African American men. This is not a matter of holding another Hollywood “gala” to fund-raise for an AIDS service organization like AIDS Project Los Angeles. Of course, large treasure chests for those service organizations providing support to those already infected with HIV are a good thing. But they do very little to prevent the spread of the virus today, tomorrow, and beyond.
To have any hope of stemming the rising tide of HIV infection among African American men, a targeted program of education, intervention, and one-on-one accountability needs immediate implementation.
Because of the difficulty in penetrating the male African American cultural aversion to candor regarding homosexuality, and because older African American MSM individuals have been culturally indoctrinated in the subterfuge of “on the down low”, efforts to “out” this historic pattern must be part of any discussion. The perception of shame ingrained among MSM adult African American men requires immediate mitigation. The education of women—many of whom are passive co-conspirators in the persistence of the “down low” duplicity—needs to be on a parallel track with their male partners.
Will this, in effect, be a cultural “outing” of MSM African American men who have historically and currently lead a private sexual life with males separate and distinct from their heterosexual relationships? It may indeed. But a failure to expose—and at least bring into the light of meaningful awareness and public discussion—the duality of MSM African American men who conduct heterosexual relations consigns any hope of turning back the current tide of HIV infection to grim frustration, misery, and social expense.
Because we are all subject to the media impressions swirling through our days and nights, because many of us—black, white, male, female—subscribe to the notion that media figures deserve our attention, recruiting a number of African American male spokesmen to engage the public in a revised perspective on MSM behaviors and the damage wrought by the failure of African American men to submit to HIV testing is an immediate step in the right direction. The Hollywood celebrity community is constantly raising money to support AIDS service groups; selected members of that community would have a greater impact upon the desired outcome of prevention if they stepped forward to communicate directly to African American men of all sexual proclivities and behaviors to inform them that the greatest shame is not in being homosexual, but in perpetrating behaviors dangerous to themselves and all other members of their ethnic community.
This African American male celebrity outreach is best achieved by reaching out to them with data reflecting the negative consequences of their silence. A unified consortium of African American entertainment figures, working in concert with a singular message of acceptance for African American homosexuality will do far more than today’s conspiracy of silence.
Those most at risk by African American MSM behaviors, and by the attendant rise in HIV infection rates, are young African American boys and men. As above, many of them are driven to MSM behaviors out of economic and social necessity. When there is no father in the home to provide sincere heterosexual male values or to provide the financial support required to raise a family, many young African American males engage in sexual contact with older African American males in order to put money in their pockets. When those young African American males are below the age of consent, there must be a concerted and publically-declared effort to punish adult violators in the explicit interest of preventing the victimization of children. The African American community at large must call upon Los Angeles County political leaders to order law enforcement to act in the interests of vulnerable African American males under the age of majority.
With the objective of turning the tide of HIV infections among African American men around, Los Angeles County political leaders must demand that the State of California Legislature reduce the penalties for the possession of some recreational drugs for personal use. With California’s prisons incarcerating a widely disproportionate number of African American men for periods of time far above the average for similar offenses, homosexual contact is, for all practical purposes, encouraged by the state. “Gay for the stay” is a behavioral norm in California prisons among those inmates doing substantial amounts of time, many of whom serve considerable sentences for non-violent drug offenses. When those African American men are eventually released from prison, regardless of their sexual orientation, they have a significant chance of having been infected with HIV during their incarceration and of spreading it further.
Los Angeles County Health Department leaders must work directly with community leaders to make HIV testing among African American men the norm. Absent highly unlikely legislation requiring all citizens to submit to HIV testing (which may not have the desired effect of controlling behaviors anyway), incentives for testing must be created. Because a large percentage of African American men in the county are under-employed and face financial struggle in today’s challenging economy, a significant monetary incentive for regular, periodic HIV testing should be implemented. Paying $100 cash to each and every resident over the age of 18 in Los Angeles County (including African American men) as an incentive to submit to semi-annual HIV testing would cost the county $2Billion annually, substantially less than the current lifetime HIV treatment cost of $620,000for each those 80,000 individuals currently infected with HIV, 20,000 of whom suffer from AIDS and whose treatment costs are substantially greater. Given the reality that testing of every resident of Los Angeles County—many of whom are not sexually active simply due to age considerations—would be impractical and unnecessary, under any cost-effectiveness rationale, testing/detection is a bargain compared to the costs of current treatment protocols.
Moving forward, the Los Angeles County Board of Supervisors must institute HIV testing protocols as a requirement for any county employment; if the county can compel testing for the presence of marijuana in the bloodstream prior to awarding employment or any contract, it can compel HIV testing as well.
If current trends continue, if we persist in patchwork feel-good solutions to the continued increase in the rate of HIV infection among African American men and the community at large, the costs of treatment will soon overwhelm the health care resources of Los Angeles County and the State of California.