Two years ago, the nation’s oldest civil rights organization and oldest university formed a partnership to investigate the persistent racial disparity in HIV/AIDS in the United States.
With the help of national partners from academia, the non-profit sector, government, and medicine, Harvard University’s Center for AIDS Research and the NAACP held a symposium in Boston to offer explanations for why African-Americans make up a startling share of Americans dying of HIV/AIDS.
When this group of experts reviewed the research literature, they verified what AIDS activists have clamored for since the 1980s—that the U.S. needs increased access to care and a comprehensive response to social inequalities to successfully fight AIDS. Although the U.S. has made important steps toward this type of policy response, the current threat of across-the-board budget cuts in Washington threatens to reverse progress toward ending the epidemic and reducing this disparity.
In many respects, African-Americans bear the brunt of the HIV/AIDS epidemic in this country. Accounting for only 14 percent of the population in 2009, black Americans represent a disproportionate 44 percent of new HIV infections. Black Americans are also much more likely to die of the disease than their white counterparts, with blacks making up 57 percent of all HIV-related deaths in 2007. Even more troubling is that the gap in HIV-related mortality rates between blacks and whites has increased more than two-fold since 1985, reflecting continuing inequalities in access to treatment and stark differences in socioeconomic status across races.
Recognizing this, participants in the symposium generated policy recommendations that ranged from including African-Americans in clinical trials for new medicines to integrating African-American studies into public school curricula as a means of empowerment. By and large, these proposals emphasized that social determinants — such as poverty, lack of insurance, discrimination, and inequalities in education — work to create the gap in HIV infection and HIV-related mortality in blacks versus other groups.
For instance, participants highlighted that black Americans are currently more likely to be uninsured than white Americans (20 percent versus 11 percent), making access to HIV/AIDS medications more difficult for African-Americans. Black young people are also much more likely to attend public schools, where sex education is neither required nor guaranteed to be funded in more than half of all U.S. states.
These social determinants may contribute to the reasons why black Americans are more likely to be “late testers,” or to learn of their HIV status only months before developing full-blown AIDS. Notably, factors like widespread stigma, inadequate access to primary care, and the inability to reveal one’s sexuality to their primary care physician were cited as barriers to diagnosis and treatment for HIV. Ultimately, participants in this symposium — along with several other public health experts and AIDS service providers — have made the case that the role of social and economic inequalities in HIV transmission calls for a broader social policy response to the epidemic.
However, in today’s political environment, where the dramatization of a fiscal cliff and the terror of sequestration keep many policy wonks in the grip of suspense, it is hard to imagine the possibility of fully-funded social policies that begin to truly address the complexity of HIV/AIDS. In fact, with domestic discretionary spending very much on the chopping block — and both Democrats and Republicans responsible for placing it there — the heads of community programs all across the country move forward in a precarious circumstance, not knowing whether the work they do to keep HIV-positive-persons in safe and affordable housing, for example, will exist in the next fiscal year.
However, what is distinct, and hopeful, in the current political landscape is the unprecedented level of institutional and legislative commitment to combating HIV/AIDS and the mesh of social factors driving the epidemic. To their credit, the White House’s Office of National AIDS Policy issued the first National HIV/AIDS Strategy in 2010, explicitly highlighting the need to address disparities in HIV/AIDS, and noting the role of stigma and discrimination in the spread of HIV. With past administrations paying considerable attention to the AIDS epidemic outside of the United States, this marks a major shift in executive-level commitment to the domestic epidemic.
Additionally, as we approach full implementation of the Affordable Care Act (“Obamacare“) in 2014, we can move forward with greater confidence that people living with HIV will no longer be discriminated against by insurers because of their pre-existing condition, and that this barrier of access to care will be removed.
However, other vital federal and state-level public health programs—including Medicaid, the AIDS Drug Assistance Program and the Housing Opportunities for Persons with AIDS program—currently face the threats of cuts with the impending fiscal cliff and require protection from members of Congress.
Following the re-election of a president who understands the social determinants of HIV, we must not forget to address the root causes of the epidemic. Given the evidence of such strong connections between poverty, discrimination and other social inequalities and HIV, this is perhaps the only sure way to combat the spread of the virus and to end AIDS. Even at the edge of this fiscal cliff, the U.S. must keep its commitment to the social policies that will prevent those of us most at risk from falling off.
Alecia McGregor is a Ph.D. candidate in Health Policy at Harvard University
*Disclaimer: This article does not reflect the opinions and views of the NAACP or Harvard University, only those of the author herself.