HIV remains a persistent and pervasive threat to the health, well-being, and human potential of many African American communities. As the impact of the epidemic among African Americans has grown, the Centers for Disease Control and Prevention (CDC), state and local public health agencies, and African American communities have stepped up efforts to address the crisis. While we have seen important signs of progress in reducing risk in many African American populations, the impact remains severe. Today, a heightened national response is urgently needed to build on progress to date and meet the serious challenges that remain.

HIV and AIDS: A Health Crisis for African Americans

African Americans are severely and disproportionately affected by HIV. While blacks represent approximately 13 percent of the U.S. population, they account for approximately half of the more than one million Americans currently estimated to be living with HIV, and have represented 40 percent of all deaths among people with AIDS in the U.S. to date. As new treatments have expanded the lifespans of people infected with HIV, the number of African Americans living with HIV continues to increase, creating more opportunities for HIV transmission.

Fortunately, even in the face of rising HIV prevalence, there have been no indications of increases in the overall rate of new HIV infections among African Americans. In fact, there have been signs of possible reductions in new infections among blacks in some areas hard hit by HIV, such as the state of Florida, and in populations hard hit throughout the country, including injection drug users and African American women. Additionally, mother-to-child transmission of HIV, which largely affects African Americans, has been dramatically reduced, and African American teens have reported significant declines in sexual risk behavior and increases in condom use in recent years.

Yet significantly more must be done to address the impact of HIV among African American men, women, and young people. The latest CDC data on new HIV diagnoses between 2001 and 2005 in the 33 states with long-term, confidential name-based HIV reporting show that:¹

• African American males continue to bear the greatest burden of HIV in the U.S. In 2005, the rate of HIV diagnosis (number of cases per 100,000 population) among black men was nearly seven times higher than that of white men, and more than twice that of black women.
• African American women are also severely affected. Among black women in 2005, the rate was more than 20 times that of white women.
• Racial disparities in HIV diagnoses are particularly severe among young people. Overall, blacks made up half (51%) of all new HIV diagnoses between 2001 and 2005. But among youth aged 13-24, blacks accounted for 61 percent of diagnoses.

CDC'S Commitment to Fighting HIV Among African Americans

As the impact of HIV on African Americans has grown over time, so have efforts to combat it. CDC works with partners across the nation to fight HIV on the front lines of the epidemic. Today, nearly half of CDC's domestic HIV prevention budget, or more than $300 million, is directed to fighting HIV in African American communities. CDC's efforts focus on the following areas:

Helping communities -- The largest share of CDC prevention funds for African American communities -- an estimated $244 million -- supports state and local health departments; national, regional, and community organizations; and health care providers across the U.S. CDC funds these partners to implement programs to reduce HIV risk behavior among African Americans; help those living with HIV to protect their sexual partners from infection; and increase HIV testing and links to HIV care. Their efforts include approaches such as intensive one-on-one and group counseling, peer outreach, and HIV testing in community-based and health care settings. Key programs that have been built over time include the following:

• Roughly $140 million is now directed to state and local health departments who work in partnership with local community groups to reach the African American populations at greatest risk in their area. Funding for this program has increased from $5.75 million in 1988.
• To supplement these efforts and provide additional support to hard-hit communities, CDC provides $30 million directly to community-based organizations to implement programs, an increase from $3 million in 1988.
• To help train local organizations to implement effective prevention efforts among African Americans, CDC partners with 16 leading national and regional AIDS organizations with expertise in HIV prevention, such as the National Minority AIDS Council and the Black AIDS Institute. Funding for this program has increased from roughly $4 million in 1988 to $15 million in 2007.

Researching effective new prevention strategies -- CDC regularly develops and evaluates new behavioral and biomedical approaches to prevent HIV. These efforts are critical to address the evolving factors that place African Americans at risk, and to increase the number of strategies that CDC's partners can use to reduce infections. CDC currently targets approximately $14 million to evaluate new approaches for preventing HIV among African Americans. Key research proects in recent years have ranged from working with African American individuals at high risk to reach others in their social networks with HIV testing and prevention, to conducting biomedical research to determine if HIV medications, used prior to exposure to the virus, can provide an additional measure of protection among those at high risk.

Tracking the epidemic -- CDC is working to improve systems to track the course of the HIV epidemic among racial/ethnic and risk groups nationwide, and to ensure that limited HIV prevention resources are directed to areas that need them most. An estimated $41 million currently serves African American communities in this area. Key activities include a new national system to monitor risk behaviors and the reach of prevention programs. The system has already provided crucial data on HIV prevalence and risk behavior among African American men who have sex with men (MSM), and will soon produce important data on inection drug users and heterosexuals. CDC has also worked to develop and implement a new system that more directly monitors HIV incidence (the rate of new infections), which will provide a much clearer picture of current trends among African Americans.

Integrating HIV, STD, and TB prevention -- Because HIV is associated with many of the same risk behaviors as other sexually transmitted diseases (STDs), and because people with HIV are at increased risk for TB, a proportion of CDC's STD and TB program spending (approximately $8 million) is directed to HIV prevention efforts for African Americans.

A Heightened National Response

Although HIV prevention efforts have grown substantially over time and have made important progress, major unmet needs remain. Further reducing the toll of HIV among African Americans will require a heightened, intensified national response from all sectors. CDC has consulted extensively with African American leaders over the past two years to identify the most urgent needs. CDC, its public health partners, and African American leaders can reduce the burden of HIV in African American communities by focusing on four critical pathways to success:

• Expanding the reach of HIV prevention services -- Including providing greater access to proven interventions for black MSM and women; supporting prevention efforts in additional venues such as workplaces and mental health facilities; and increasing training for communities implementing prevention programs.
• Increasing opportunities for HIV diagnosis and treatment -- Ensuring that more health care providers receive training to implement routine HIV screening among African American patients; implementing new efforts to motivate African American men and women at risk to be tested and to reduce the stigma associated with testing; and providing rapid HIV testing in additional venues in African American communities, such as churches, clubs, and mobile vans.
• Developing new, effective interventions -- Collaborating on research to address the urgent need for additional interventions designed and tailored to the specific needs of African Americans now at greatest risk, including black MSM, high-risk men and women in correctional facilities, and youth; increasing the involvement of black researchers in HIV prevention; and more quickly translating research into practice.
• Mobilizing broader community action -- There have been many bold examples of sustained and new leadership in the fight against HIV -- from African American entertainers, civic organizations, HIV prevention organizations, faith leaders, and others. But even more is needed. National and local public health organizations and African American community leaders must deepen their partnerships in order to expand the reach of prevention efforts and reduce the stigma of HIV.

CDC's Intensified Efforts

To advance this heightened response, CDC is intensifying its own efforts in each of these areas and directing the majority of all newly available resources to these strategies. For example, in fiscal years 2006 and 2007, CDC has directed nearly two-thirds of newly available funding ($22.4 million of $35.7 million) to the four areas described above. (Funding becomes available on an annual basis, primarily as a result of the conclusion of existing projects.)

CDC has expanded or launched a number of new projects in the four areas of the Heightened Response:

• Expanding reach of prevention programs -- Examples of CDC's recently launched or expanded efforts in this area include:
  • Providing training to health departments and community-based organizations (CBOs) on recently-proven behavioral interventions for African Americans, such as group counseling and peer-led programs for black women
  • Helping communities adapt a proven intervention to meet the needs of black MSM (see sidebar)
  • Initiating new efforts to help CBOs evaluate the impact of their programs on risk behavior and HIV testing among the African Americans they serve
• Increasing opportunities for diagnosis and treatment -- Examples of CDC efforts include:

  Expanding HIV Screening in Labor and Emergency Departments Ensuring that people with HIV are aware of their infection and linked to prevention and care services is an urgent priority. CDC recommends routine HIV testing for all adults and adolescents in health care settings. One critical tool is the rapid HIV test, which provides results in as little as 20 minutes. To reach more African Americans with rapid HIV testing and links to care, CDC is conducting a series of workshops with staff from hospital labor/delivery and emergency departments in six metropolitan areas with a high burden of HIV among African Americans to develop specific plans for implementing routine screening in their facilities, using rapid tests whenever possible. The first workshop took place in Los Angeles in February 2007.

  • Convening workshops with hospitals to help them implement routine, rapid HIV testing in their labor/delivery and emergency departments (see sidebar)
  • Providing rapid testing and prevention services at a range of African American community events, such as gatherings of black college students and minority gay pride events
  • In 2008, CDC will significantly expand HIV testing efforts in African American communities with $63 million proposed in the President's 2008 budget
• Developing effective interventions -- Examples of CDC efforts include:

  Developing Interventions for Incarcerated Men Upon Release Prisons bring together a population of individuals at high risk for HIV infection, and studies have shown that inmates are nearly five times more likely to have HIV than the general U.S. population. The vast majority of inmates with HIV became infected before they entered the correctional system. Because most inmates are ultimately released, a critical goal of HIV prevention programs in prisons is to help inmates reduce their risk behavior after re-entering their communities. CDC is working with three organizations to develop and evaluate new prevention models to help HIV-positive inmates reduce their sexual and drug-related risk behaviors after release so that they can avoid transmitting HIV to their partners.

  • Developing and testing new interventions for incarcerated African American men, to help them reduce their risk behavior after being released (see sidebar)
  • Evaluating new interventions for African Americans at high risk that have been developed by local community and research organizations but have not been tested for effectiveness
  • Studying new, more effective ways to reach and enroll bisexually active men who do not identify as gay in HIV prevention research

• Engaging African American Small Businesses CDC and state/local health departments are partnering with African American merchants -- from barbershops to music stores -- in several cities to help reach their communities with HIV prevention information and links to testing and prevention services. Participating business owners distribute HIV awareness messages on items such as shopping bags and beverage sleeves, and help reduce the stigma of HIV and HIV testing by initiating conversations with their customers. Today, about 75 Detroit merchants are participating in the seven zip codes with the highest HIV prevalence in that city, and roughly 60 Chicago merchants are participating along the city's historic 87th Street corridor. Local chambers of commerce and national African American organizations, such as 100 Black Men of America, are helping promote merchant involvement, and the program is expanding to five additional cities.

  Mobilizing broader community action -- CDC has long worked with leaders in the African American community to reduce the impact of HIV among African Americans. CDC will build upon these existing partnerships and make new connections with African American leaders who have the power and influence to expand the reach of HIV prevention to all African Americans at risk. Examples of CDC efforts include:
  • On March 8th, bringing together African American leaders from all walks of life to discuss concrete actions that can be taken to reach all African Americans with the tools and knowledge they need to protect themselves and their loved ones from HIV. Participants include prominent entertainers, civic leaders, representatives of faith communities, and business people who share a commitment to intensifying HIV prevention efforts for African Americans
  • Partnering with faith leaders to hold forums in 10 cities across the South to help churches identify specific actions they can take to support prevention efforts, encourage HIV testing, and reduce the stigma of HIV
  • Expanding efforts to engage African American small businesses in HIV prevention (see sidebar)
  • Working with medical and nursing associations to provide leadership to their members on how to expand routine HIV testing for African American patients

References

1. CDC. Racial/Ethnic Disparities in Diagnoses of HIV/AIDS -- 33 States, 2001-2005. MMWR 2007;56:189-193. Note: New HIV diagnoses do not necessarily represent new infections, because some individuals with new HIV diagnoses were infected recently, while others were infected long ago.