Helene Gayle Director, HIV, TB and Reproductive Health Bill and Melinda Gates Foundation

1. HIV/AIDS in the African American Community: Confronting the Challenge Helene Gayle Director, HIV, TB and Reproductive Health Bill and Melinda Gates Foundation

2. “Our lives begin to end the day we become silent about things that matter.” Martin Luther King, Jr. —

3. Continuing spread in Africa, Caribbean Emerging epidemics Possible resurgence in high income countries Anticipated escalation of new infections 45 million new infections by 2010 28 million infections are preventable HIV/AIDS Challenges

4. Adults and Children Estimated to be Living with HIV/AIDS, End 2002 Eastern Europe & Central Asia 1.2 million Western Europe 570 000 North America 980 000 East Asia & Pacific 1.2 million North Africa & Middle East 550 000 South & South-East Asia 6 million Caribbean 440 000 Sub-Saharan Africa 29.4 million Latin America 1.5 million Australia & New Zealand 15 000 Total: 42 million Source: UNAIDS, December 2002

5. HIV/AIDS IN AMERICA TODAY

6. Cases Deaths Adults/Adolescents 849,780 482,330 9,220 5,342 Children (<13 years) 859,000 487,672 Total AIDS Cases and Deaths Reported 1981 – 2002, United States

7. Proportion of Estimated Adult/Adolescent AIDS Cases by Exposure Category and Year of Diagnosis, 1985 – 2002, United States Men who have sex with men (MSM) Percent of Cases Injection drug use (IDU) Heterosexual contact MSM & IDU 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 Year of Diagnosis

8. Proportion of AIDS Cases, by Race/Ethnicity and Year of Report, 1985 – 2002, United States White, not Hispanic Black, not Hispanic Percent of Cases Hispanic American Indian/ Asian/Pacific Islander Alaska Native 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 Year of Report

9. Impact on Families: Adults • 1 in 50 African American and 1 in 160 African American • women is infected with HIV • African American men’s rates of AIDS is 8X higher than White men’s • African American women’s rates of AIDS is 20X higher than White women’s Source: CDC. HIV/AIDS Surveillance Report. Atlanta: US Department of Health and Human Services, Public Health Service, 2001 (Vol. 13, No. 2)

10. 1 HIV infection 2 Heart disease 3 Unintentional injury 4 Cancer 5 Homicide 6 Cerebrovascular disease 7 Suicide 8 Diabetes mellitus 9 Chronic liver disease 10 Nephritis, nephrosis & nephrotic syndrome Leading Causes of Death Among African Americans, 25- to 44-Years-Old, United States, 2001* Deaths * Preliminary death-certificate data for 2001

11. African American Adult and Adolescent AIDS Cases By Exposure Group, 1993 to 2001 45 IDU 40 35 MSM 30 % of Cases 25 Heterosexual 20 15 10 5 0 1993 1994 1995 1996 1997 1998 1999 2000 2001 Year of Report Source: U.S. Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report. Atlanta: Department of Health and Human Services, Public Health Service, 2002 (Vols. 7-13)

12. African American Men and Womenwith AIDS • AIDS case rate is more than 2X higher in men than women (109.2 • vs. 47.8) • MSM is the number one mode of transmission of HIV in men (37%) • IDU and Heterosexual activity are the number one mode of • transmission in women (39% respectively) Source: CDC. HIV/AIDS Surveillance Report. Atlanta: US Department of Health and Human Services, Public Health Service, 2001 (Vol. 13, No. 2)

13. MSM Risk Behaviors among African Americans 37% - 61% reported unprotected anal intercourse in the past 6 months 40% - 43% reported multiple sex partners in past 12 months 37% - 51% reported exchanging sex for money or drugs

14. HIV Prevalence and Incidence Among 2,942 YMSM (23-29 years) in Six Cities*, 1998-2000, United States HIV Prevalence HIV Incidence 35 32 30 25 20 14.7 Percent 14 13 15 7 10 4.4 3.5 2.5 5 0 Total White AA Latino * Baltimore, Dallas, Los Angeles, Miami, NYC, Seattle Source: U.S. Centers for Disease Control and Prevention. Morbidity and Mortality Review (MMWR) 2001, 50:440-443)

15. Proportion of HIV-Infected Young MSM Unaware of Their Infection, by Age-group and Race/Ethnicity* White 93 Black 91 100 Latino 78 75 74 71 80 66 Mixed 55 60 Percent Unaware 40 20 0 15-22 years 23 - 29 yrs. Age Group *n=206 HIV-infected MSM aged 15-22 years; n=367 HIV-infected MSM aged 23-29; six US metropolitan areas, 1994-2000. Source: U.S. Centers for Disease Control and Prevention. Morbidity and Mortality Review (MMWR) 2002, August 23: 51(33); 733-736

16. IDU Risk Behaviors among African Americans Up to 85% reported inconsistent condom use 12% - 32% reported multiple sex partners 21%-80% reported sharing needles

17. Heterosexual Risk Behaviors among African Americans 16% - 32% report multiple sex partners in the past 3 months 74% - 88% report inconsistent condom use 24% - 82% had been diagnosed with an STD

18. Impact on Families: Youth • 44% of AIDS cases among 13-24 year olds are African American • 59% of cases among young men • MSM is the number one mode • of transmission in young men (60%) • 41% of cases among young women • Heterosexual activity is the • number one mode of transmission • in young women (56%) Source: U.S. Centers for Disease Control and Prevention. National Center for HIV, STD and TB Prevention. Division of Sexually Transmitted Diseases. 2001

19. High Risk Behaviors Among African American Youth 30% - 86% of adolescents report inconsistent condom use 25% - 56% of adolescents are sexually active 50% - 71% of adolescents report drug or alcohol use

20. Prevalence of HIV infection is 5 times greater in incarcerated populations vs. general public (Rapposelli, et al., 2002) CDC cross sectional surveillance study revealed that 12% of HIV infected persons were diagnosed while incarcerated (Nakashima et al., 2002) HIV Testing in Correctional Settings

21. HIV Prevention is Challenging… But it isn’t any harder than living with HIV. Focus on Prevention

22. Mass media Voluntary counseling and testing Targeted peer counseling School-based programs Programs for out-of-school youth Workplace programs Condom social marketing Public sector condom distribution Harm reduction programs and drug treatment STD treatment Prevention of mother to child transmission Effective Prevention Tools

23. Gateway to care and treatment Has independent efficacy as prevention intervention especially in HIV-infected people Broader knowledge of serostatus permits the development of prevention programs that specifically target people living with HIV/AIDS Potential of anti retroviral therapy to reduce infectiousness VCT – A Key Element in Integrating Prevention and Care

24. Interventions that operate at the environmental or structural level and alter the context for individual action Examples: 100% condom brothels Closing of gay bathhouses in San Francisco Legalizing over the counter sales of needle and syringes in pharmacies Increased alcohol taxes Structural Interventions

25. Factors Affecting HIV Prevention Individual micro-level factors Structural intermediate-level factors Structural macro-level factors Individual level knowledge of HIV risk and prevention Area-based treatment center and neighborhood characteristics; poverty and deprivation Socio-economic status of populations Individual characteristics targeted in prevention programs Structural level laws, policies, standard operating procedures; environmental conditions and resources of individuals Economic underdevelopment, gender inequality Personal vulnerabilities such as knowledge and skills Economic conditions or policies Societal vulnerabilities such as discrimination of HIV-positive Programmatic vulnerabilities such as education and services Class, race, gender, sexuality inequalities Source: Sunartojo, 2000.

26. Prevention Framework Decrease in Risky Behavior Enabling Environment Decrease in HIV Incidence Empowerment for Prevention Service and Commodities Modify Biologic Factors

27. The best way to predict the future • is to invent it. • — Alan Kay

28. The best time to plant a tree is twenty years ago The next best time is now - African Proverb