Black women and AIDS.

Health and medicine explained.
Oct. 27 2004 6:43 AM

A Silent Epidemic

Why is there such a high percentage of HIV and AIDS among black women?

When Gwen Ifill asked a pressing question about AIDS during the vice-presidential debate, both candidates were utterly lost. "I want to talk to you about AIDS, and not about AIDS in China or Africa, but AIDS right here in this country, where black women between the ages of 25 and 44 are 13 times more likely to die of the disease than their counterparts," said Ifill. "What should the government's role be in helping to end the growth of this epidemic?"

Cheney did not bother trying to hide his ignorance. "I have not heard those numbers with respect to African-American women. I was not aware that it was—that they're in epidemic there [sic]," he said. Edwards resorted to dodge ball, spending his 90 seconds on AIDS in Africa, the genocide in Sudan, uninsured Americans, and John Kerry. "OK, we'll move on," said Ifill, who somehow restrained herself from rolling her eyes à la Jon Stewart.

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Cheney and Edwards both suffered sharp criticism for their shockingly vacuous replies—a competent briefing on HIV/AIDS in the United States could have made these men at least conversant on the topic in less time than it takes them to do their on-air hair and makeup. Besides, in debates, even a shallow answer scores more points than saying "I dunno" or changing the subject.

That said, coming up with a sophisticated answer to Ifill's question is a tall order. AIDS researchers don't have a solid explanation for why black women in America have such a shockingly high prevalence of HIV infection and AIDS, which makes it difficult to spell out precisely how the government should respond to the problem—other than to reach out to these women more aggressively and to conduct more studies.

The data that investigators do have makes it clear that heterosexual sex is the primary mode of transmission, accounting for 74 percent of the HIV/AIDS cases reported in 2002 in black American women. Yet attempts to tease out the dynamics that drive this heterosexual spread have led to more theories than hard facts, with researchers using such different methods to gather their data that it's hard to compare their results. One particularly splashy speculation also has attracted more of the spotlight than it deserves: black men "on the down low," who identify themselves as heterosexual but secretly have sex with men.

Without question, there is a higher percentage of HIV and AIDS in the black female population in the United States. The Centers for Disease Control and Prevention last year looked at data from 1999 to 2002 reported by 29 states that track HIV infections. The data are somewhat skewed because several states that have serious AIDS problems—including California, New York, and Illinois—did not at that time tally HIV infections. Still, the study found that black women accounted for nearly 72 percent of the female cases, while whites made up 18 percent and Hispanics 8.5 percent. Given that only 13 percent of Americans are black, you don't need a statistician to see the scale of the problem. (Encouragingly, the number of new HIV cases reported in women, regardless of race, did not increase during the four years that the study analyzed.)

When looking at people whose HIV infection progresses to the point of causing AIDS, the disproportionate toll on black women becomes clearer still. Black women in 2002 accounted for 67 percent of the country's AIDS cases among women. For the sake of comparison, consider that blacks had a rate of 48 cases per 100,000 blacks, while whites had a rate of 2 per 100,000 whites. There's an interesting geographic distribution of cases, too, that may offer important clues about forces propelling this particular epidemic: The vast majority of black women with AIDS live in the South and the Northeast. The CDC's HIV/AIDS statistics do not offer a breakdown of income and healthcare insurance, but that's an obvious place to look for explanations.

Ifill's question referred specifically to AIDS deaths in 25-to-44 year olds. The figure she cited actually took many AIDS researchers by surprise but seems to have come from the National Vital Statistics report issued last year that shows black women in 2001 had a rate of death from AIDS 14 times (not 13 times) higher than that of whites.

Why does such a problem exist? No compelling evidence suggests that blacks have any special genetic susceptibility to HIV. The CDC offers a laundry list of reasons of why African American men and women have relatively high rates of HIV infection and AIDS. The two most convincing explanations on the list: poverty and sexually transmitted diseases. The 2000 U.S. Census found that one in four blacks lived in poverty, and studies clearly have shown a strong link between poverty and the risk of HIV infection. Poor people also receive lower-quality healthcare, which means they will often progress from HIV infection to AIDS more quickly. And the link to sexually transmitted diseases, which create open sores that facilitate the spread of HIV, is equally clear-cut: Blacks are 24 times more likely to contract gonorrhea and eight times more likely to get syphilis.

The CDC list also includes community denial about injection drug use and homosexuality, but there is scant evidence to support the notion that those risk factors are somehow higher in blacks. In fact, injection drug use, a particularly effective way to spread HIV, is actually lower in black women than in white women: It accounted for 24 percent of HIV/AIDS cases among black females in 2002 and 34 percent among white females. It could be that black women are having sex with more men who are injecting drugs, but no compelling data back that conclusion, either.

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