African American Gender Politics and the AIDS Epidemic: A Critique of Current HIV Intervention Strategy – Tali Schiller

The AIDS epidemic has been an unprecedented medical and public health issue for the last 30 years. Never before has a disease been so difficult to fight medically, socially, and in the public health sphere.  Our national policy has been more than up to the challenge to extend the required effort and financial backing – in fiscal year 2012 alone, the United States earmarked $21 billion for domestic research, prevention, and care and treatment of HIV (1).  Early awareness campaigns, such as SILENCE = DEATH and the Australian Grim Reaper commercial, were instrumental in teaching the public about HIV in the early days of the epidemic; efforts to maintain HIV in the public’s mind, and to educate them about how to prevent transmission, is still very much a priority.  This tremendous effort to prevent the transmission of AIDS through information and awareness is almost unmatched in the field of public health.  Why, then, has the HIV infection rate failed to drop?

The Center for Disease Control and Prevention reports that the domestic new infection rate has remained steady for the last 10 years, with about 50,000 new infections per year.  The African American population makes up a disproportionate percent of these new infections – though only 16% of the total population, African Americans accounted for 44% of new infections in 2009 (2).  Of this population, women of color are the most affected: in 2010, African American women made up two-thirds (64%) of new AIDS diagnoses and 57% of new HIV infections among the entire female population of the United States (2).  These rates show no sign of decreasing, despite millions of dollars spent on education and prevention messages broadcast on every medium. 

African American women are at an especially high risk for contracting HIV.  In 2010, black women were nearly 15 times more likely to be infected with HIV than white women, and nearly 1 in 30 black women will be diagnosed with HIV/AIDS in her lifetime (3).  AIDS is the primary cause of death among African American women aged 25 to 34 (4).  Studies have shown that black women do not engage in riskier behavior than other women, but social dynamics place them at a higher risk.  Factors that increase black women’s risk of contracting HIV include differential access to health information, unequal access to healthcare and prevention materials, low self-esteem and a lack of empowerment, alcohol and drug use, poverty, sex-ratio imbalance, and a number of others (5).  These causes work synergistically to increase HIV transmission in the African American community.  The most important factor to consider is low perceived susceptibility to risk of infection – black women have a significantly lower perceived risk than women of other races, even those who participate in known high-risk behaviors (6). 

The CDC is fighting back against new HIV infections.  They have made a serious commitment to the African American community through a multi-pronged approach targeting different sections of the population.  The Act Against AIDS Leadership Initiative (AAALI) is a $16 million partnership between the CDC and leading organizations that represent the communities hit hardest by HIV.  The Expanded Testing Initiative is a $50 million per year, three-year expanded testing program to increase HIV testing in the African American community.  The CDC provides financial and technical support to community-based testing and prevention organizations, such as the WILLOW program, Sister to Sister, Nia, and Many Men, Many Voices.  The CDC has also created the current Act Against AIDS campaign, which delivers HIV testing information through the “Testing Makes Us Stronger” campaign for black men who have sex with men (MSM) and “Take Charge. Take the Test.” for the black heterosexual female population (7).  These financial commitments, and many more, are inspired by President Obama’s July 2010 National HIV/AIDS Strategy, new policy to address the problem of domestic HIV (8). 

The CDC’s response to steady HIV infection rates among the heterosexual African American female population was to develop the national campaign “Take Charge. Take the Test.” (TCTT), focused on timely testing as a vehicle to increase awareness of HIV status and therefore increase treatment. It combines aspects of several intervention models – Health Belief Model, Theory of Planned Behavior, and the Ecological Model – to create the theoretical framework.  The audience was also segmented; the CDC selected “single, African-American women aged 18–34 years, with some college education or less, who earned US$30,000 or less per year, resigned in certain zip codes of high prevalence for HIV/AIDS, and who were having unprotected sex with men”(9). TCTT is currently the largest and most comprehensive national response to the high incidence of HIV infections in the black female population, launched in ten major US cities where a significant percent of black women are affected.  This comprehensive effort to reach the black female community is larger than any that precedes it.  So why isn’t it working?   

I. Structural Barriers to Care

Considering the creation of an intervention for any disease requires contextualizing it within a socio-cultural framework: no disease exists in a vacuum, but HIV is more susceptible to societal factors than most.  Its stigmatized routes of transmission create a complicated environment in which to create effective public health messages.  Any such message must contend with a 30-year long association with homophobia, drug use, and sexual promiscuity.  In the African American community, these stigmatized activities are additional to the barriers of being black in America – poverty, segregation, and the historical fallout of a 300-year history with slavery.

Research has shown that black women and black gay men, the two populations of color with the highest incidence of HIV, have a similar number of sexual partners and use condoms as often as their white counterparts (10). Individual-level behaviors do not fully explain the racial disparity; in fact, a focus on behavior increases stigma by suggesting that individuals’ bad decisions are solely to blame for their poor health outcomes.  Instead, we must regard health inequalities within the socio-cultural context of race when considering HIV disparity, as with any other health problem that disproportionately affects communities of color.  Some factors that foster health inequalities include segregation in housing, education, employment, and health care, and racially skewed mass incarceration (10). 

Racial segregation by neighborhood increases HIV risk and prevalence. Residents of low-income, minority neighborhoods are also significantly less likely to have access to medical care or prevention methods (11).  Studies show that within a medical practice, black patients are treated differently than their white counterparts and that African Americans are likelier to live or seek care in areas where the healthcare quality is low for all patients (12). Even if they have access to healthcare, African Americans are less likely to have a regular source of primary care and therefore a trusted source of medical care (12).

Geographical segregation also makes communities of color less likely to have access to medical education – important for both seronegative individuals, to maintain their negative status, and seropositive individuals, to maintain their health and make sure transmission stops with them.  Timely diagnosis is an important factor when considering both HIV prognosis and spread in the population.  It is estimated that 1 out of 5 HIV+ individuals don’t know their status (2), affecting both their health and the health of any potential sexual partners; left untreated, HIV is more likely to develop into AIDS more quickly, and is more likely to be transmitted through unprotected sexual contact or intravenous drug use.  Lower rates of medical access, information, and quality have real and quantifiable consequences for the viral load in African American communities.  It is absolutely vital to place any intervention aimed at the African American community in general, and black women in particular, within a context of social determinants and social justice by moving beyond individual-level behavioral risk factors.   The downstream consequence of poor health outcomes should be recognized as the result of upstream factors such as the distribution of wealth.  It may also be worth noting that many health behavior change models depend on the use and spread of health information, in addition to raising self-efficacy, to inspire health change.  Due to the structural problems the African American community faces, behavior-changing information does not spread as widely in their community and therefore does not have the desired effect.

II. Gender Power Imbalance

In the United States, there are approximately 9 African American men for every 10 African American women (13); this creates a sex-ratio imbalance that is frequently cited as a leading cause of relationship insecurity and a fundamental reason for a gender power imbalance.  Since 83% of HIV transmission is through heterosexual contact (14), a dearth of acceptable sexual partners may lead women to choose partners with higher HIV risk.  Therefore, the factors that contribute to a woman’s position within a sexual network may place her at a higher risk of contracting HIV.

The ratio imbalance stems from a number of factors that remove African American males from the community, including higher mortality rates from disease, high violence rates, and high rates of incarceration (15).  Black men are overrepresented in prison systems.  More than 12% of men ages 20-29 are in jail or prison, and black men are more likely to be incarcerated than white men for the same crime (16).  This “sexual network” concept – that a group of individuals are connected directly or indirectly through their sexual contact – has deep ramifications for the African American community.  Many individuals choose sexual partners from within their neighborhoods, so even if they do not engage in high-risk behavior, the systematic segregation will also increase the risk of a high-risk partner (17).  This relatively small network of potential partners allows transmittable sexual diseases to spread more rapidly. In fact, the high viral load of certain inner city segregated communities has been compared to that of third-world countries (18). 

The theory of concurrent relationships may offer some important insights about the spread of HIV in the African American community.  Previously mentioned factors such as high incarceration and low sex-ratio lead to an especially high number of concurrent relationships, which are “multiple simultaneous sexual relationships or sexual relationships that overlap in time” (19). A study conducted by Morris et al. found that the rates of concurrency in African American male participants between the ages of 20 and 38 were 3.5 times higher than their White counterparts and 1.9 times higher than men of other racial backgrounds. In the same study, African American females had rates of concurrency at 2.1 times higher than their White counterparts and 4.1 times higher than women from other racial backgrounds (19). 

The consequences of these gender inequalities for HIV are clear. Expressed by Newsome et al: “African American women contending with the gender ratio imbalance that exists may relinquish negotiating power in their relationships, be more likely to settle for less desirable partners, accept infidelity, and agree to engage in unprotected sex” (15).

A black woman’s sexual relationships can be informed by concurrency, instability, and an imbalance of power.  These limiting factors often result in disassortative mixing by HIV risk, in which low-risk individuals partner with high-risk individuals due to lack of choice and therefore become high risk themselves.  This system of arrangements puts black women in high-risk situations not of their own making; individual-level risk behavior is meaningless when confronted with a system that puts women at higher risk through no fault of their own.  These gender-based configurations of power stymie traditional behavioral theories’ suggestion that knowledge of risk should result in an increase in self-protective behaviors.  The inherent imbalance of power in sexual relationships naturally leads to an inability to engage in self-protective behaviors – when your sexual options are limited, bargaining for monogamy and condom use is not an option. 

III. Spiritual Worldview and Self-Efficacy

A review of the current literature reveals that by far the most important thing to consider when discussing HIV transmission in black heterosexual females is that they have a much lower perceived risk of infection than comparable populations.  This belief holds the key to understanding their high HIV transmission rates.  Several factors to consider concerning its genesis are the high levels of spirituality and religiosity historically found in the African American community, the optimism and fatalism associated with spirituality, and the power of an entrenched worldview coping mechanism (20).

Spirituality and religiosity have been associated with the African American community as a coping mechanism for systematic oppression (21).  The community depends on religion in times of adversity, and prayer is an important tool in times of need.  African American women in particular report a high level of spirituality and religiosity and “heavily rely on a sense that everything is in the hands of a higher power” (20).  In times of special need or stress, all individuals are known to depend on extant coping mechanisms; this has been shown to be true in cases of extreme illness or disease, such as HIV (20).  However, certain aspects of this religious coping mechanism clash with medically approved prevention or maintenance behaviors recommended for the avoidance of HIV (22). Also, belief in a higher power is associated with higher levels of optimism. This suggests the concurrence of optimism bias, the theory that individuals have an optimistic underestimation of their vulnerability to negative consequences.  Optimism bias has been shown to be a contributing factor to the spread of HIV in the African American community (23).  This is perhaps related to African Americans viewing AIDS as only a gay white male disease (17) and therefore not viewing their risky behavior as risky enough to place them in danger of contracting HIV. 

Belief in a higher power also correlates with the principle of fatalism, or the amount of control people feel they have over their lives and future. Powe (1996) stated, “In addition to poverty, oppressive forces such as the long history of slavery, segregation, discrimination, substandard health care, and the subsequent perceptions of meaninglessness, hopelessness, and social despair provide the environment for the emergence of fatalism [among African Americans]” (24).  People with fatalistic attitudes have been shown to participate less frequently in preventive health behavior (20).  In a study on cancer risk, African Americans and women reported higher levels of fatalism than European Americans and men (25).  This study can easily be extrapolated to HIV; African American women feel as though they have little control over whether or not they contract HIV, and so do not feel as though they need to take precautionary measures, such as condom use or regular HIV testing.  Studies show that although black women are, in fact, in possession of a great deal of knowledge about HIV transmission and prevention (due to years of targeted education), the combined optimistic bias and fatalism inherent in their religion-based coping worldview leads to a lower personal perceived risk of HIV contraction.  This difference in known versus perceived risk may also avoid the cognitive dissonance inherent when pursuing behaviors one knows are risky but does not feel one has the power to avoid.

IV. Proposed Intervention

What lessons can be learned from this social and psychological profile?  First of all, the real source of many issues of public health can be found upstream.  The health problems of the African America community extend far beyond the prevalence of HIV, and the underlying cause is the systematic racism, poverty, and segregation endemic in the community. Interventions geared toward changing individual behaviors are useless without considering the socio-cultural framework that the individual is part of.  It’s impossible to understand a black woman without also understanding how her gender, history, value system, and sexual network affect her behavior, and how they interact to create seemingly irrational behavior patterns.

Second, accurate knowledge is the vital center of many health interventions, yet knowledge alone is not enough to warrant substantive change.  Many models address this disparity between knowledge and behavior through the addition of self-efficacy; raising an individual’s efficacy is the theoretical answer.  The problem with behavioral models is that black women already know they are at a higher risk of HIV and they know safe sex will protect them.  Educational interventions have taught them all about HIV.  The problem is, all of the other factors that create the worldview of a black American woman combine to decrease her perceived risk.   This occurs in order to avoid the cognitive dissonance inherent in participating in the risky behaviors known to be associated with HIV transmission while not feeling like she has the power to avoid these risky behaviors.  Behavioral interventions may teach safe sex and regular HIV testing, but women will continue to ignore them as long as that is the sacrifice they must make for the comfort of feeling protected by their heterosexual relationship.  But if the HIV incidence rates in the black female population are to be reversed and eventually stopped, the first goal must be prevention through engaging people’s existing worldviews on a societal scale. 

The components of the proposed intervention are as follows:

a.) There is no simple solution for the root cause of health inequality. The best way to address the important HIV implications of skewed incarceration statistics, wealth inequality, racism, and segregation is to eliminate these systematic inequalities.  This is easier said than done.  The Obama administration’s National HIV/AIDS Strategy and Implementation Plan makes great strides in this area by focusing not only on HIV testing and education, but by also addressing disparities as the root cause of high HIV transmission rates.  Some action items suggested by this plan include making HIV tests available to low-income populations, promoting a holistic approach to health, and adopting community-level approaches to reduce HIV infection rates (8).  Still, it’s clear that tackling the root causes of poor health outcomes will take generations, and may only be addressed on a national level by increasing social funding.

b.) Increasing HIV testing in the African American community, the primary goal of the CDC’s “Take Charge. Take the Test.” campaign, is an important way to improve health outcomes for HIV+ individuals, but the main message of any HIV intervention should be to avoid infection in the first place.  Decreasing HIV infection must be the primary message if HIV rates are ever to decrease, in any population.  If you test positive, it’s already too late.

c.) Black women are doubly disenfranchised by their race and their gender.  These factors combine to increase their powerlessness in many situations, including HIV prevention, because most prevention techniques depending on changing male behavior.  Women may not feel empowered to ask their partners to use a condom or ensure monogamy, two of the most important HIV prevention behaviors.  Any intervention aimed at the black female population would acknowledge that telling women to always use a male condom is problematic and instead turn to other options. An answer may be to create new or popularize existing prevention techniques in which the woman is empowered to practice safe sex on her own terms.  One such existing technique is the female condom, a tool that allows women to dictate their own safety.  Leaving women’s safety from sexually transmitted infections in men’s hands just because affordable, comfortable female-controlled safe sex tools are unavailable is ridiculous and untenable.

d.) The cognitive dissonance created by the struggle between safe sex knowledge and core values is a powerful psychological force.  Additional HIV transmission education is not the answer, and HIV testing comes too late.  The fatalism and optimism inherent in spirituality are too firmly entrenched within the African American worldview to be denied; the only response is to use cultural values of similar importance as a fundamental building block of HIV prevention campaigns.  One potentially powerful appeal may be to Family.  Familial relationships, and keeping the family together, would act as a significant existing cultural touchstone to draw from.  If HIV prevention were framed as a duty to protect family and community rather than just a duty to individual health it may resonate more with the target audience.  This reframing would align the goals of the target audience with the goals of health promotion, reducing cognitive dissonance and psychological reactance, and would allow women to act on their health knowledge. 

Although a significant and vital amount of resources have recently been dedicated to eliminating HIV transmission in the African American community and specifically in women, certain fatal social science errors permeate current health interventions.  Recognizing the flaws in individual-level, behavioral interventions when applied to racial minorities is the first step to creating socially sensitive and appropriate health campaigns.  Any health campaign created to address the problem of HIV prevalence in the African American female population should include elements of social funding, should focus on HIV prevention rather than testing as an outcome, should empower women to demand safe sex by popularizing a female-based safe sex tool, and should reframe staying HIV-free using the core value of Family or an equally powerful value for the African American community.  The sooner this is implemented, the sooner we will have an AIDS-free generation. 

REFERENCES

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24. Powe, Barbara. (1996). Cancer Fatalism Among African-americans: A Review of the Literature. http://ezproxy.bu.edu/login?url=http://www.sciencedirect.com/science/article/pii/S0029655496800200.

25. Conrad, M., Brown, P., & Conrad, M. (1996). Fatalism and breast cancer in Black women. Annals of Internal Medicine, 125, 941-942.