Black Women and HIV: What you should know

1. Black Women and HIV: What you should know David J. Malebranche Assistant Professor Emory University Division of General Medicine

2. Agenda • HIV 101 • HIV Transmission • Behavioral Risk for HIV • Current HIV Treatment Guidelines • Black Women and HIV • “Down Low” Men and HIV • Conclusion/Questions

3. HIV 101 • Immune System Review • Bone Marrow: creates immune cells • Thymus: produces mature T cells • Spleen: blood filter for foreign material and stimulator of immune response • Lymph nodes: filter for lymphatic fluid, which carries foreign material

4. HIV 101 (cont’d) • Immune System Cells • T cells • CD4 – coordinates immune response ** • CD8 – kills viruses, tumors and parasites and suppresses immune response • NK cells – kills foreign invaders and infection • B cells – produces antibodies (proteins) to fight infection • Polymorphonuclear leukocytes (PMNs) – trap and digest foreign material and infections • Antigen presenting cells (APC) • Macrophages • Dendritic cells

6. HIV and the Immune System • HIV decreases CD4 T-cell count • Peripheral destruction • Decreased production/maturation in thymus • Two in HIV progression: • CD4 count (normal count 600-1500) • Viral load (amount of virus in bloodstream) • Train analogy

7. HIV Transmission • Vaginal/Anal sex • IV Drug Abuse • Vertical Transmission (during birth) • Breast feeding • Oral Sex? • Kissing? • Biting? • Saliva, Tears, Sweat?

8. Co-factors in Behavioral Risk • Mental Health – Depression, Anxiety, etc. • Sexually Transmitted Infections – Herpes, Syphilis, Gonorrhea, Chlamydia • Circumcision – increased risk for men • Media – blaming the victim • Poor risk assessment • Denial – risk behaviors, drug use, sexuality

9. Protecting Yourself from HIV • Mental Health – you’re not “crazy” • Education - Know your risk! • Abstinence • Have your sexual partners tested • Condoms • Microbicides - 2007 • Post-exposure prophylaxis (PEP) • Sperm Washing – before becoming pregnant

10. Condoms • Latex – best protection • Polyurethane – for those with latex allergy • Lambskin – porous; not the best barrier • Breakage rate – 2% • >90 - 98% effectiveness preventing: • Pregnancy • Gonorrhea/Chlamydia • HIV • Not as effective against Syphilis, HPV (warts) and HSV (herpes)

11. Acute Retroviral Syndrome • Flu-like illness – fever, muscle aches, sore throat, swollen lymph nodes • 2-8 weeks after HIV exposure • Rash distinguishes it from the flu • HIV Antibody test often negative • HIV viral load & glycoprotein testing • 30 – 70% of those infected will have this syndrome

12. HIV Testing Methods • Elisa Test – sensitive test (low false negative rate) – blood test • Western Blot – specific test (low false positive rate) – blood test • Orasure – Q-tip swab in mouth • Rapid results • Routine lab results

13. When to Start Antiretroviral Therapy?

14. HIV Medications NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NRTIs) • These drugs work by blocking Step 4, where the HIV genetic material is converted from RNA into DNA. Approved drugs in this class include: • AZT (Zidovudine, Retrovir®) • ddI (Didanosine, Videx®) ** • ddC (Zalcitabine, Hivid®) • d4T (Stavudine, Zerit®) • 3TC (Lamivudine, Epivir®) ** • Abacavir (Ziagen®) • Tenofovir (Viread) ** • FTC (Emtriva, Emtricitabine) ** • Combivir (AZT/3TC combination) • Trizivir (AZT/3TC/Abacavir combination)

15. Side Effects - NRTIs • Common • Headaches • Nausea • Diarrhea • Serious • Pancreatitis – inflammation of pancreas (All) • Lactic Acidosis – body burns fat(All) • Hypersensitivity – allergic reaction (Ziagen) • Peripheral Neuropathy – nerve burning (Zerit, Videx) • Anemia, Neutropenia – low blood counts (AZT)

16. HIV Meds (cont’d) NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS, (NNRTIs) • These drugs blocks the same step of the life cycle (step 4), but in a different way. Three NNRTIs have been approved: • Nevirapine (NVP, Viramune®) • Delavirdine (DLV, Rescriptor®) • Efavirenz (EFV, Sustiva®)

17. Side Effects - NNRTIs • Common • Elevated Liver Enzymes • Rash • Headache • Nausea/Vomiting • Serious • Dreams, Hallucinations, Mood Swings (Sustiva) • Severe rash with blistering (Viramune, Rescriptor)

18. HIV Meds (cont’d) PROTEASE INHIBITORS (PIs) • These drugs block Step 7, where the raw material for new HIV virus is cut into specific pieces. Six protease inhibitors have been approved: • Saquinavir (SQV, Invirase® and Fortovase®) • Indinavir (IDV, Crixivan®) • Ritonavir (RTV, Norvir®) – “boosted” regimens • Nelfinavir (NFV, Viracept®) • Amprenavir (APV, Agenerase®) • Kaletra (ritonivir/lopinavir) • Atazanavir (Reyataz)

19. Common Diarrhea Nausea Headaches Fatigue Rash Liver irritation Serious Kidney Stones (Crixivan) Fat deposits/wasting Diabetes (high blood sugar) High Cholesterol Bone damage Side Effects - PIs

20. HIV Meds (cont’d) • FUSION INHIBITORS • These drugs block Step 2, blocking HIV’s ability to infect healthy CD4 cells by adhering to its outer membrane. One fusion inhibitor has been approved: • Fuzeon (Enfuvirtide) – administered as a twice daily subcutaneous injection

21. Side Effects – Fusion Inhibitors • Injection site reactions • Allergic reactions • Pneumonia • Leg and foot nerve pain • Insomnia • Depression • Constipation • Pancreas problems

22. Initiation of Antiretroviral Therapy • 2 NRTIs and 1 NNRTI • D4T/3TC and Sustiva • Combivir and Kaletra • 2 NRTIs and 1 PI or “boosted” PI • Combivir and Viracept or Crixivan • Combivir and Kaletra What’s the best regimen to start with???

23. Vertical Transmission • HIV transmission from mother to child • 25 – 30% HIV transmission risk to infant without treatment • Treatment • AZT – reduces transmission from 27% to 10% compared to placebo • Viramune – reduces transmission from 21% to 12% compared with AZT

24. HIV and Black Women • Statistical disclaimer – be critical thinkers • Greatest risk factors • 38% through heterosexual sex • 25% through IVDU • “Significant” number of black women contract HIV through sex with IVDU • 64% of HIV infections among all U.S. women in 2001 • Why are infections occurring??

25. The “Down Low” • What does Down Low mean? • Who is more at risk for HIV – “Down Low” men or “Gay” – identified men?

26. The meaning of “Down Low” • Secretive • Undercover • Discreet • An R. Kelly Song • A homosexual black man who doesn’t identify as “gay” • A homo “thug” • A married or coupled heterosexual man who has sex with men on the side

27. Deconstruction

28. Black Masculinity Two main roles during slavery: • Physical labor • Breeding

29. Theatrical Movie Stereotypes

30. Athletes

31. Hip Hop Artists

32. Criminals

33. Black Masculinities Combined

34. “GAY”

35. The social construction of “gay” • Rainbow flags • Pink triangles • Pride Marches • “Will and Grace” • “Queer as Folk” • “Queer Eye for the Straight Guy” • Homophobia vs. “Gay-o-phobia” • Religion • Culture

36. Gender Role Conflict • “Occurs when rigid, sexist, or restrictive gender roles result in personal restriction, devaluation, or violation of others or self.” • Gender-Role Conflict Scale (GRCS) – 37 item scale • Success, Power and Competition • Restrictive Emotionality • Restrictive Affectionate Behavior between men • Conflicts between Work and Family Relations (O’Neil et al., 1986)

37. So What is “Down Low” in the context of HIV prevention? Battle of the brainwashing and discrimination Black Masculine Stereotypes Vs. “Gay” Stereotypes

38. “Down Low” relation to HIV • Myths: • More promiscuous than heterosexual or “gay” men alone • More likely to have unprotected sex • More likely to have HIV • Reality: • Potential mode of HIV transmission to black women (and other black men) • Thirty-three percent of black men with HIV contract it from IV drug use

39. Qualitative Research • 8 Focus Groups • 81 self-identified BMSM • Atlanta, NYC and Upstate NY • NYC Dept. of Health, Columbia University and New York State Black Gay Network • $25 participant compensation • Support from AIDS Education Training Center (AETC)

40. Racial Stress “Being a black man is a hard struggle. Not just being gay, being straight – being a general black man is an everyday struggle. I don’t care how you put it, white America either wants me in a cell or a grave.” (Rochester, 21) “Because we’re black, we all have the same face. So when you approach somebody, they think that you’re going to automatically cross them in a very aggressive, intimidating way. You’re black first.” (Atlanta, 33) “For me, whether it’s sexuality or just gender, its always gonna be an issue of race. I’m gonna be seen as a black man.” (Albany, 42)

41. Gender Role Expectations “You know, that's the way I was brought up. Grow up, go to high school, go to college, marry a woman… Then you have children. And you had a house, the dog, and I grew up like that, and I did that. I did the marriage thing, and the children, and the wife. You know, but that's because that's what was instilled in me. And I remember on my wedding day my big brother said to me, he said, ‘You know you don't have to do this.’ He saw something in me I didn't wanna see in myself. So, you know and I said, ‘You're crazy, I gotta do this. Everybody's watching.’ You know, and it was always about everybody. You know, pleasing everybody instead of dealing with inner self.” (Harlem, 38)

42. Black Masculinity “As being a young black male, if I would come and say something’s wrong with me. They [medical providers] would say, ‘Oh, look at this, you know they probably just hip-hoppin’ and screwin’ down and you know, smokin’ the blunts, and then he gonna come here, talkin’ about he sick.’ So its like I’m stereotyped already. And now if you say you’re gay, everybody can get the picture of the feminine, gay brother. So I guess it can come to the sexuality because they feel, ‘Oh, you must have been loose in the booty already.’” (Harlem, 19)

43. Religion/Spirituality “This one woman came up to me, she said “You ain’t been to church in 3 months, and I’ve seen you with some man, and I know he sleeps with men. What’s up with you?” And I said to her “Are any one of your 5 baby daddies saved?” I just wanna know. Everybody act like y’all aint never done nuthin wrong. To me, being gay and sleeping with a man, is no more, no different than me sleeping with a woman. Cause I’m not married so according to the bible, its all fornication. And that’s for him to judge me. People in church, they just get saved and quote-unquote, “get Jesus,” and they act like they just perfect.” (Rochester, 21)

44. Medical Culture “I was talking to her [the doctor] about the symptoms I was having. And she’s like, she asked me when the last time I had anal sex? And I told her like whenever it was. And she’s like, ‘Well, you know…,’ and this really surprised me, ‘Well, you know, the anus really isn’t made for that.’ And I was like, ‘Yeah, I know, but it’s a little too late.’ You know?” (Manhattan, 34)

45. Why is all this important? • 30% HIV prevalence for 23-29 year old BMSM in large metropolitan areas (YMS, 2001) • 14.7% HIV incidence rate (YMS, 2001) • 93% of HIV-infected BMSM not aware of their status (YMS, 2001) • 16% of lower income LA black men who are heterosexual admit anal sex with other men • Black women comprise 75% of the female AIDS cases in the United States (CDC, 2000) • BMSM who are “disclosers” have higher rates of unprotected anal sex (41% vs. 32%) and higher HIV prevalence than “nondisclosers” (24% vs. 14%) (YMS, 2003)

46. HIV, Statistics and Media Hype • No scientific studies on HIV and “down low” black men – NONE! • Few scientific studies on the social context of sexuality among black men (or women) • NY Times, Village Voice, Washington Post – “Down Low” experts • “Down Low” has become a catch phrase for self-marketing and promotion • The Culture of Fear – “Bowling for Columbine”

47. Real Topics on the “Down Low” • Child sexual abuse (male and female) • “Situational sex” • Gender and power dynamics in sex • Lack of condoms in prisons • Sexual prejudice in the Church • The mental health of black people in the United States

48. Conclusions • No Justification for “Down Low” • Sexuality is not as static as we think • Know your partner’s status • Treat everyone like they’re HIV positive until you know for sure • Assess your own risk based on your behavior, not who you are

49. Reconstructing HIV Prevention • HIV prevention for the entire black community • Start addressing our mental health • Scrap the overemphasis on “Down Low” • Focus on HIV risk behavior • More qualitative research to compliment the statistics • Realistic assessment of role of churches • Emphasize women’s resiliency factors • Redefining gender roles

50. Contact Information • David Malebranche, MD, MPH • dmalebr@emory.edu • (404) 616-0347 wk • 69 Jesse Hill Jr. Drive • Atlanta, GA 30324