Today’s NYTimes has an article on the epidemic of HIV among African Americans in the US.

I almost skipped it, figuring it was just another politicized “Ain’t it awful” article blaming the problem on racism and the lack of universal health care.

However, it is a fairly good article about the world wide fight against the HIV virus, a multi pronged approach that stresses education, condom use, limiting partners, and marital fidelity to prevent new cases of HIV and funding treatment (especially to pregnant women) prolongs the lives with those on HIV while lowering transmission to newborns.

One problem in the US is that HIV is much more common among African Americans. But the epidemiology (i.e. who has the disease and how it is spread) is not as simple as it sounds.

In the early 1980’s, docs in the inner city became aware that Babies of drug abusing moms were dying from immune deficiencies in Brooklyn; this was about the same time that doctors on the west coast were noticing “gay pneumonia” deaths. The high rate of positive HIV tests among inner city US Army recruits was also noticed as far back as the early 1980’s.

But with the leveling out of HIV in the gay community due to medication and behavior changes, this second level epidemic now needs to be addressed.
illustration from CDC website shows the race of people diagnoes with HIV in 2005.

Pretty graphic, isn’t it? Blacks are ten percent of the population, but almost half of new HIV cases.

My work has mainly been in rural areas, where minorities were Hispanic or Native Americans, where we had few HIV cases, but the way you work to improve health in any group is the same: you have to know and like the people, and stay there for a few years, to really get their trust. One has to be sensitive to the community concerns, and knowledge of religious and other value systems.

The black community in northern cities is not monolithic: It includes Southern immigrants, families who lived in the North for generations,various African immigrants and various West Indian communities. The approach to a Black Baptist may not be the same as to a Haitian Catholic nor a Somali Muslim immigrant.

That is why community outreach programs from churches, are valuable: the church remains there (government programs tend to come and go) and there is a community in the church that can easily network in the larger community.

Racism is part of the problem of delivering medicine in the black inner city community: A distrust of the “white” medical community to start with.The Tuskegee experiment still is remembered, so if side effects of medications occur, some people fear it is deliberate. Often doctors in the hospitals are foreigners whose English is highly accented. And then you have the problems of poor education (also partly due to racism and poverty) so that a complicated medication schedule may not be followed.

Prevention may not be a simple as the “safe sex” commercials imply: a lot of HIV is due to coerced sex among teenaged girls who may lack the self esteem to say “no”. There is also the rarely discussed problem of bisexual men, jail rape, and IV drug use. There is racism here too: A rich cocaine using lawyer won’t go to jail but a poor person selling it to the lawyer to feed his own habit will.

There may also be a genetic reasons for the high rate of HIV,.

The low rate of circumcision might also contribute to the high rate of infection: HIV is rare among Muslim Africans who circumcise their boys.

But how does one reach HIV positive people who aren’t regular clinic patients?

This article, in the Seattle Post Intelligence, is a good article on grass roots outreach programs. Some programs are run by individuals, others by churches, and many are funded by private or government grants.

This makes a lot more sense than having a uniform federal program, which is full of red tape and outsiders to try to start a program from scratch. Many churches and local organizations already have outreach programs, and it makes more sense to fund one that is already in place.

One of the agreements between Obama and Bush is the need to fund such church based programs).

Black churches in the Northeast and those with self-identified progressive congregations and liberal theologies were most likely to be taking part in the program, a finding that surprised the researchers, who concluded that the White House has not used the program as a political tool as some critics have suspected.

A second point that Seattle article brings up is new to me: HIV among African immigrants.

This article is about an outreach in immigrants, who often don’t speak English well, and may have trouble navigating the complicated medical system, especially to get their medicines paid for.

A survey of Washington DC area, it found 70% of recent African immigrants don’t have insurance, thanks to the 1990’s welfare reforms of Bill Clinton, that won’t allow immigrants to get on Medicaid until five years after they get a green card, and a 2005 program requiring you prove citizenship to get Medicaid coverage.

This is another issue where Bush, McCain and Obama are on the same side:

In June 2007, a bipartisan group of senators, with White House backing, introduced a bill proposing health care reforms that would have improved immigrant access, but the bill was opposed by both the Democratic and the Republican parties, and did not become law.

In July, the Washington Post quoted Arizona Senator John McCain on the repercussions: “You will see the states and cities scrambling to pass their own laws and regulations. You’re going to get a completely contradictory set of policies.”

But the policy schizophrenia McCain described has been going on for years as states, counties and the District of Colombia have used their own funds to provide immigrants, even undocumented ones, with health services.

The final aspect of HIV in minorities is that HIV is increasing among Blacks in the South.

Fifty-four percent of African Americans reside in the South. The region has experienced the most rapid increase in AIDS cases, with Southern states leading the nation in the number of people living with AIDS and the proportion of women and African Americans with AIDS living in rural areas.

The state of HIV/AIDS in the South is exacerbated by heightened factors in the region, including a health care delivery system in crisis; a significant stigma surrounding the disease; high rates of poverty; the prevalence of racism, sexism and homophobia; and high incarceration and immigration rates.

This is a problem. When I was a small town doc, it was hard to get my patients seen by the university specialists (300 miles away). Yet many small town docs just don’t see enough cases of HIV to feel competent to treat an infection. The few cases I have had usually only came for acute care, but often I  had to check with their specialists before I gave them treatment, so I wouldn’t miss anything.

In small town clinics, despite “privacy” laws, everyone knows everything about everyone else. So you might not want to be seen, because your next door neighbor’s daughter works as a secretary in medical records and word might get around that you are gay or shooting up drugs on weekends.

Immigrants face even more problems: Cultural and language problems in rural areas with few translators and where immigrant groups are less integrated than in northern cities. A lot of us doctors took a “medical Spanish” course, and Yes, by law we docs are required to hire translators for our patients, but the ones that wrote the law never had to face finding a Hmong or Lakota  or ASL translator at 11 pm in a small rural community.

The good news is that the Ford Foundation is planning a $1.55 million grant to help build up local community resources in  seven southern US states.

Hopefully, in time, the HIV rate will stabilize and lower in this area of the country, just as it has in many parts of Africa and in other areas of the US.


Nancy Reyes is a retired physician living in the rural Philippines. Her website is Finest Kind Clinic and Fishmarket, and she writes medical essays at HeyDoc Xanga Blog. 


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