Health Disparities in HIV

Despite advances in the prevention and treatment of human immunodeficiency virus (HIV), there are certain communities that remain disproportionately affected by the disease. Many of the factors that drive the pandemic, such as poverty and race, are inextricably linked and leave entire communities vulnerable to infection.

Without the means to redress the historic lack of access to quality healthcare (or cultural issues like stigma, homophobia, and systemic racism), infections like HIV can spread rapidly through these communities. Not only are these groups more likely to get HIV, but they are less likely to be diagnosed or remain under medical care.

Today, around 1.2 million people are living with HIV in the United States, with over 36,800 new infections occurring every year. The communities at greatest risk include men who have sex with men (MSM), Black people and other people of color, women, and injecting drug users.

This article explores many of the factors the drive HIV infection rates in these and other communities.

Poverty

Poverty influences HIV transmission rates as much as it does any other communicable disease.

Unless there is coordinated investment in public health education, outreach, testing, treatment, and follow-up, an infection like HIV can spread like wildfire through vulnerable communities. While richer communities have access to these facilities, poorer communities often do not.

There is perhaps no better illustration of this than the breakdown of the U.S. HIV infection rate by income.

According to a study from the Centers for Disease Control and Prevention (CDC), no less than 76% of people living with HIV In the United States have a household income of less than $20,000 annually. Of these, 39% are unemployed, while 18% report recent homelessness.

Living in a poorer community can also leave residents doubting whether any governmental institution, including public clinics and hospitals, has their best interests at heart.

Healthcare Access

Today, a person newly diagnosed with HIV can live a normal to near-normal life expectancy if treated early. This not only requires the daily use of antiretroviral drugs but also consistent medical care to ensure that prescriptions are filled and the infection is properly managed. This is a bigger challenge than some might expect.

The Affordable Care Act (ACA) has gone a long way toward ensuring health coverage to people living with HIV. Prior to the enactment of ACA in 2010, around 30% of people with HIV were uninsured. Today, that has narrowed to around 11% uninsured.

Even so, around 132,000 people living with HIV in the United States have no health insurance of any sort, whether private, governmental, or work-sponsored plans.

Even if the uninsured are able to access treatment through patient assistance programs and other means, they are 24% less likely to achieve an undetectable viral load—the ultimate goal of treatment—than people with insurance.

In some states, the options for coverage are limited for low-income families. The recent fight to block Medicaid expansion is one such example. The expansion was meant to increase healthcare access to the poorest Americans. But the expansion was rejected in 12 U.S. states, and the fallout has been widely felt in communities at risk of HIV.

Race

Racism in the United States has led to disparities. People of color are disproportionately affected by both HIV and poverty.

According to the Census Bureau, the poverty rate among Black people currently stands at 18.8% compared to 7.3% for Whites. For Latinx people, the poverty rate is 15.7%. These differences alone contribute to higher HIV infection rates in communities of color.

In 2019, the percentage of new HIV infections broke down as follows:

• Black: 42%
• Latinx: 29%
• White: 25%
• Mixed race: 2%
• Asian: 2%
• Native American: 1%

Overall, people who are Black and Latinx are more likely to live in areas of racial segregation. These areas often experience higher rates of poverty, crime, drug use, and sexually transmitted diseases (STDs)—all of which drive HIV infection rates.

But poverty alone doesn't explain the disparities, Medical mistrust, fueled by failures of the healthcare system, has led some in the Black community (Black men especially) to adopt negative attitudes about condoms or embrace denialism that keeps them from seeking testing or treatment.

Moreover, the cultural stigma of having HIV can be especially impactful in marginalized communities where the risk of discrimination is real (and the avenues for recourse may be few).

Studies have shown that cultural biases like stigma and homophobia play a central role in the disproportionately high rate of infections in Black communities especially.

Men Who Have Sex with Men (MSM)

Men who have sex with men (MSM) account for the lion's share of HIV infections in the United States. Although MSM represent between 2% and 6.8% of the U.S. population, no less than 65% of all new infections are attributed to male-to-male sexual contact, according to the latest CDC report.

MSM are at risk of HIV for many reasons. Anal sex is an efficient means of transmission since rectal tissues are vulnerable to rupture, allowing the virus easy access into the body. Scientists estimate that the risk of infection from unprotected anal sex is, in fact, 18 times greater than the risk of unprotected vaginal sex.

But beyond the physiological risks, MSM are commonly faced with homophobia, stigma, and other biases that only amplify their vulnerability to infection. Because of this, some MSM will evade testing out of the fear that a positive diagnosis will force them to "out" their sexuality to family, friends, and coworkers.

The fear of abandonment, discrimination, and even violence will force others to hide their HIV status and manage their disease in secrecy. Faced with isolation and a lack of social support, some will even turn to alcohol and drugs to deal with anxiety and depression—behaviors that increase sexual risk-taking and promote the spread of infection.

The risk is further compounded when other issues like race and poverty are involved.

Women

Women, and most notably women of color, are also disproportionately affected by HIV compared to their heterosexual male counterparts.

The increased risk is due in large part to the vagina itself, which has a larger surface area of porous tissues than the male penis. Because of this, the risk of HIV from male-to-female is roughly double that from female-to-male.

But other factors can contribute, including traditional gender roles that dictate who in the relationship is "in charge." The economic dependence on a male partner and fear of abandonment can further decrease a woman's sense of sexual autonomy.

Intimate partner violence, including rape, is also a major driver for HIV infections. Studies have shown that women in violent relationships are at four times greater risk for contracting an STD, including HIV, than women in nonviolent relationships.

Among Black women in particular, these and other issues have led to disproportionally high rates of HIV—and not only compared to Black heterosexual males but to other groups of women as well. In fact, a Black woman's lifetime risk of HIV is 15 times greater than that of a White woman and five times higher than a Latinx woman.

Injecting Drug Use

Injecting drug use is the "hidden" HIV epidemic. Although injecting drug users represent a smaller proportion of new HIV infections, they are individually at higher risk due to the blood-borne transmission of the virus through shared needles and syringes.

Injecting drug users also tend to do less well when forced to manage both an addiction and HIV. In many cases, this can lead to a gap in treatment. By contrast, people on addiction treatment, such as methadone, are able to stick to HIV therapy better than those who actively shoot drugs.

Another factor stifling HIV treatment and care is the social stigmatization that injecting drug users commonly face. Many users are in fear of arrest or legal action.

In some communities, healthcare services can be unfriendly or unresponsive to the needs of injecting drug users. This includes the absence of clean needle exchanges designed to prevent the sharing of needles.

The public perception about injecting drug use has complicated efforts to identify and reach users in an effective way. Contrary to what many people believe, injecting drug use is higher among Whites than Blacks, with roughly 25% of users having a college degree or higher.

And, while 75% of injecting drug users live at or below the federal poverty level, there are also upper-income earners who inject drugs. This includes people who inject methamphetamine, the practice of which is driving HIV infection rates among MSM.

Because injecting drug use has become so widespread and has touched so many different communities, both urban and rural, public officials have begun to localize their response.

Even so, gaps in healthcare resources and the lack of an appropriate government response have led to outbreaks of HIV. One such outbreak occurred in 2015, when 215 people in Scott County, Indiana, were infected due to the opioid drug Oxycontin (oxycodone). It was only after the outbreak that the ban on clean needle exchanges was lifted.

Summary

HIV disproportionately affects certain communities. These include those who live in poverty, people who are uninsured, Blacks, men who have sex with men, women (especially women of color), and injecting drug users.