An Approach to Achieving the Health Equity Goals of the National HIV/AIDS Strategy for the United States Among Racial/Ethnic Minority Communities

Since the early 1980s, substantial progress has been made in the prevention and treatment of human immunodeficiency virus (HIV) infection in the United States. However, HIV remains a major public health concern due in part to significant disparities ¹ in rates of infection among racial/ethnic minority communities, with black/African American (hereinafter referred to as African American) and Hispanic/Latino populations being the most affected subgroups. ² African Americans comprised 44% of new HIV diagnoses in 2014, despite representing only 12% of the population; 23% of new HIV diagnoses were among Hispanics/Latinos, who represent about 16% of the U.S. population. Gay, bisexual, and other men who have sex with men (MSM) are the most disproportionately affected subpopulations among African Americans and Hispanics/Latinos. In 2014, an estimated 78% of diagnosed HIV infections among African American males and 84% of diagnosed HIV infections among Hispanic/Latino males resulted from male-to-male sexual contact. ² The causes of these disparities are complex and interrelated and can be attributed to myriad individual, social, contextual, and environmental factors. Accordingly, prevention strategies to reduce disparities must be based on an integrated, targeted approach that addresses the individual, social, structural, and contextual environments in which disparities occur. ³

The White House released the National HIV/AIDS Strategy (NHAS) for the United States in 2010 and updated it in July 2015. Both the 2010 and 2015 NHAS provide a plan for federal agencies to address HIV-related disparities by reducing mortality in communities at high risk for HIV, adopting community approaches to reduce new HIV infections, and reducing HIV-related stigma and discrimination. The updated NHAS lists action steps to reduce HIV-related disparities, including scaling up effective, evidence-based programs that address social determinants of health and promoting evidence-based public health approaches to HIV prevention and care. ^4,5

In 2012, a multidisciplinary workgroup was convened in the Division of HIV/AIDS Prevention at the Centers for Disease Control and Prevention (CDC) to review research on factors that contribute to disparities in rates of HIV infection among racial/ethnic groups and develop an approach for achieving the health equity goals of the updated NHAS in African American and Hispanic/Latino communities. In this article, we discuss the existing literature on factors that contribute to disparities in rates of HIV infection among racial/ethnic groups and present an approach for achieving the equity goals of the updated NHAS in African American and Hispanic/Latino communities. Practitioners, policy makers, intervention program managers, community-based organizations, and other partners in HIV prevention can use this approach to guide collective actions and monitor progress toward health equity in these communities.

Factors That Contribute To Disparities in HIV Rates

Individual risk behaviors (e.g., having multiple partners, not using condoms) alone do not account for disparities in rates of HIV infection among racial/ethnic groups. ^{6 –8} These disparities are associated with differences in the social and structural environments in which risk behaviors occur. ^9,10 For example, some African American and Hispanic/Latino communities experience high rates of sexually transmitted infections (STIs), ¹¹ poverty, ^{12 –14} and incarceration, ^{15 –19} as well as low levels of socioeconomic status and education. ^{8,12 –14} The patterns of assortative sexual-partner selection (i.e., selecting sexual partners who are of the same race/ethnicity) ^6,20 in these communities, coupled with the higher background prevalence of HIV infection and other STIs, may create sexual networks that facilitate HIV transmission among these racial/ethnic populations. ^{14,21 –23} High rates of poverty and low levels of education can affect access to high-quality health care and HIV prevention and care services. ²⁴ High incarceration rates may disrupt social and sexual networks, leading to more risky behaviors and fragmented care for individuals who are in and out of the penal system. ^{15 –19} Additionally, Hispanics/Latinos face obstacles to care because of immigration status and language barriers. ¹⁴

HIV is one of the most stigmatizing illnesses in the United States. Stigma and related attitudes within and about racial/ethnic minority communities are typically disparaging of HIV. ^{25 –27} Such attitudes may lead HIV-positive people in these communities to be less likely to disclose their HIV status and to feel less connected to social support systems. ^25,26 HIV-positive members of racial/ethnic minority communities may experience the combined negative effects of HIV stigma, racism, and racial discrimination, which are associated with increased psychological distress and sexual risk behavior among people living with HIV infection. These factors may impede efforts to stop the spread of HIV and may further increase disparities among African American and Hispanic/Latino populations. ^{25 –27}

Differences in antiretroviral therapy (ART) use by race/ethnicity are documented frequently in the scientific literature, with results showing that use of ART is lower for African Americans than for non-Hispanic white people and Hispanics/Latinos. ^{28 –30} African Americans and Hispanics/Latinos are also less likely to be aware of their HIV status and less likely to be retained in care than non-Hispanic white people. ^31,32 These differences may explain the lower rates of viral suppression among African Americans and Hispanics/Latinos compared with non-Hispanic white people. Lower rates of viral suppression in racial/ethnic minority communities may produce sexual networks in which HIV transmission is more likely.

African American and Hispanic/Latino MSM experience additional challenges. African American and Hispanic/Latino MSM do not engage in more risky behaviors (i.e., having multiple partners, not using condoms) than MSM of other racial/ethnic groups. ^{30,33 –37} The higher background prevalence of HIV ^30,33,34,37 and assortative partner selection practices ^33,36,37 in these communities, along with stigma ^{33 –36,38,39} and homonegative attitudes, ^{33 –36,38 –40} place African American and Latino MSM at higher risk for HIV infection than MSM of other racial/ethnic groups. Compared with MSM of other racial/ethnic groups, African American MSM are also less likely to be aware of their HIV status, and those who are aware of their status have lower rates of linkage to care, retention in care, and viral suppression. ⁴⁰

An approach to Address the Problem

Given the factors associated with HIV-related disparities among African Americans and Hispanics/Latinos, prevention approaches must be informed by an integrated and targeted approach that addresses the individual, social, structural, and contextual environments in which these disparities occur. ⁴ The workgroup offers the following approaches to address inequities in rates of HIV among African American and Hispanic/Latino communities.

Cross-agency collaboration among federal agencies that addresses factors associated with HIV-related health disparities

Collaboration among federal agencies to address the economic, educational, and justice-related (i.e., incarceration) factors associated with HIV-related disparities may be a primary resource for achieving health equity. These collaborations could identify effective methods for improving educational attainment; decreasing incarceration rates; and mitigating the effects of poverty, unstable housing, and employment status on access to, and engagement in, high-quality HIV care and prevention services.

Increase awareness of HIV status among African Americans and Hispanics/Latinos living with HIV

Increasing awareness of HIV status, especially among African American and Hispanic/Latino MSM, through HIV testing is essential for reducing the risk of transmission and for addressing disparities. Individuals who were HIV infected but unaware of their status accounted for 30% of HIV transmissions in 2009. ⁴¹ CDC recommends that all people aged 13–64 years be tested for HIV at least once in their lifetime. ⁴² Individuals at high risk for HIV should be tested at least annually. The U.S. Preventive Services Task Force also recommends that clinicians routinely screen people aged 15–65 years for HIV. ⁴³ Despite these recommendations, an estimated one in eight Americans living with HIV infection is unaware of their HIV status. ⁴⁴ Effective strategies for increasing awareness of HIV status include supporting routine HIV testing in clinical settings with new testing technologies ⁴⁵ (e.g., emergency departments that see a large number of racial/ethnic minority individuals), expanding HIV testing initiatives in nonclinical settings, facilitating and promoting the use of HIV antigen-antibody combination assays to identify acute infections, ⁴⁵ strengthening partner services, and facilitating linkage to and reengagement in care. Implementing this approach will facilitate early diagnosis of HIV infection and allow infected people to obtain treatment that can improve the quality and length of their lives, lead to reductions in high-risk behaviors, and reduce the likelihood of HIV transmission. ^45,46 Expanding testing initiatives in nonclinical settings has the potential to reach more racial/ethnic minority individuals and decrease disparities in awareness of HIV status.

Identify and implement methods to improve viral suppression among African Americans and Hispanics/Latinos living with HIV

Access and adherence to ART are essential for viral suppression, which reduces morbidity and the likelihood of HIV transmission. Identifying evidence-based interventions that are effective in promoting linkage to, retention in, and reengagement in care and increasing the use of ART among racial/ethnic minority communities, particularly interventions tailored to MSM, are necessary to increase viral suppression among people living with HIV. ^28,44 Mistrust of the medical establishment may be a barrier to accessing HIV care and treatment services, especially among African Americans. ²⁸ Consequently, training for health-care providers could focus on providing services for racially and ethnically diverse patient populations and on teaching techniques for promoting trust in patient–provider relationships. Additionally, training providers on effective methods for delivering treatment and prevention services to racial/ethnic, sexual, and gender minority groups is crucial for addressing HIV-related disparities in these subpopulations.

Promote community-level risk-reduction approaches

The most efficacious community-level strategies to reduce disparities address the social and structural conditions that may facilitate HIV transmission and impede care and treatment. ^10,47 Strategies that have demonstrated efficacy in reducing transmission in racial/ethnic minority communities and MSM include condom distribution programs, ⁴⁸ behavioral interventions, ⁴⁹ anti-stigma campaigns, ⁴⁹ provision of ART, ⁴⁹ preexposure prophylaxis, ⁵⁰ and nonoccupational postexposure prophylaxis for individuals at risk for HIV, specifically serodiscordant couples. ^51,52

Encourage additional research to address gaps in knowledge to inform strategies

Information is lacking on the pathways through which the social, economic, and structural factors described in this article affect HIV-related health disparities among African Americans and Hispanics/Latinos. Buot and colleagues proposed a model that specifies likely ways that social inequality, income inequality, and poverty contribute to racial/ethnic disparities in HIV incidence. ⁹ More research is needed to identify the causal pathways through which the factors discussed in this article contribute to racial/ethnic disparities and to test these hypotheses to determine where best to intervene to have the maximum effect.

Estimate and monitor measurable outcomes and impact

A major challenge to monitoring outcomes is the limited availability and use of uniform definitions for health equity across agencies and in the scientific literature. Measures are needed to assess improvements in the socioeconomic factors associated with HIV-related health disparities and how these improvements are linked to reductions in risk behavior and transmission and improvements in care and treatment.

Conclusion and Next Steps

More than three decades after recognition of the first case of acquired immunodeficiency syndrome, and despite the discovery and implementation of effective treatment and prevention efforts, disparities in HIV infection remain. Although current prevention efforts and the advent of ART in recent years have helped to stabilize the number of new infections, continued growth in the number of HIV-infected people who are undiagnosed and those who are diagnosed but not in care will ultimately lead to more new infections if prevention, care, and treatment efforts are not intensified. Although challenging to implement, social and structural interventions delivered at the community level hold the greatest promise for optimal synergy with behavioral and biomedical strategies, and for reaching health equity goals. In addition to ongoing federal collaborations, public–private partnerships, community mobilization, and greater community engagement may be required to support health equity efforts.