A Tale of two States and their struggle with HIV

On the surface, Indiana and Florida could not be more different. Be it size (Florida is the 3rd most populous state, while Indiana is the 38th); location (Midwest vs Deep South) or diversity of the population (Indiana is 84.3% white while Florida is over 46% minority), one might assume their challenges to be very different. However, each state's struggle with their own outbreaks of HIV only serves to reminds us of power of one of the virus' closest allies; poverty.  

Most HIV activists agree that poverty plays a major role in the intransigence of the epidemic. According to the International Labor Office of UNAIDS: "HIV/AIDS is both a manifestation of poverty conditions that exist…, and the result of the unmitigated impact of the epidemic on social and economic conditions. HIV/AIDS is at the same time a cause and an outcome of poverty, and poverty is both a cause and an outcome of HIV/AIDS." So there is no coincidence that as each state struggles with growing poverty, so too has HIV increased. 

Much has been written about Indiana's HIV outbreak-largely because it seemed to come out of nowhere. Starting in February 2015 through April 2016, 190 cases have been documented. Long known as a religiously and socially conservative state, it seemed ill suited to generate headlines for one town, Austin (population 4,200) now has a higher incidence of HIV than "any country in Sub Saharan Africa." says CDC Director Tom Frieden. "They've had more people infected through IV drug use than all of New York City last year." Indiana's poverty rate of almost 21% is also above both the national average (15.9%) and for that of Midwestern states (14.1%) 

Florida too, has both soaring rates of poverty and HIV. Roughly 1 in 6 Floridians live in poverty and, according to the Business Insider, has three of the top 15 cities where poverty is increasing the fastest. Florida also has the highest number of new HIV diagnoses in the nation, with a 23% increase in 2015 alone. 

Despite the largely different primary modes of infection in Austin, Indiana and Florida (IV drug use vs MSM), both states' increases in HIV can be linked to a lack of sustained effort to promote safer sex. In Florida, prevention funding has been flat or cut, and still has prohibitions on talking explicitly about sexuality in sex education classes. Austin IN, like much of rural America, has few medical providers. There is only one doctor and the Planned Parenthood clinic in the county that used to provide HIV testing and referrals closed in 2013, as government funding declined. There is a great fear among HIV surveillance experts of a growing prevalence of HIV in many other rural counties- especially in the south- but also in areas such as Idaho, which had two rural outbreaks in 2008. 

The ongoing debates about income equality and jobs carry a much greater importance that just determining the type of housing in which one lives or the schools our children attend: it has a direct impact on our health. Poverty is the ultimate social determinant and until we have the will to aggressively address it, we will continue to have these pervasive health disparities, like HIV disease. In the meantime, we know what works against HIV. Access to HIV testing and treatment; condoms; needle exchange programs and prevention education can make a real impact on preventing or halting the outbreaks. When the Indiana state health department aggressively moved in and offered HIV testing and treatment as well as setting up a needle exchange in Austin, it effectively stopped its outbreak. Sadly however, "the horse was already out of the barn' and reactive policies are just that, often too little too late. 

State governments and health departments, such as those in Indiana and Florida need to shelve their conservative rhetoric and provide a real plan to prevent HIV infection and to address their burgeoning IV drug use epidemics. Otherwise, we will continue to see a resurgence of this eminently manageable disease, all over the country. 

35 Years of HIV/AIDS

June 5, 2016 represented a solemn birthday as HIV/AIDS turned 35. On July 3, 1981, the New York Times published a groundbreaking article about a rare and often fatal cancer called Karposi’s Sarcoma, which was found in 41 cases of homosexual men in California and New York; eight of the sufferers died less than 24 months after the diagnosis was made. Due to the rarity of the cancer, it was believed at that time that earlier cases might not have been detected. An astounding 71 million infections later, and with over 34 million deaths, the HIV/AIDS epidemic is second in lethalness to the Bubonic Plague of the 14th century, which is estimated to have killed 75 to 200 million people. I began working in the field of HIV/AIDS in 1987, six years after its coming out party. During that time, an HIV diagnosis seemed akin to a death sentence. There was so much that we did know about HIV, and there was only one medication available to specifically treat HIV/AIDS. The medication, called AZT, was prescribed in such toxic doses that many felt more ill from the AZT treatments than they did from AIDS. People were so desperate for something to extend their lives that they would have taken almost anything. Needless to say, a fair number of individuals and "clinics" began to pop up with "cures" for AIDS. While a cure has continued to elude us to this day, we have dozens of medications that have extended the lives of millions of people throughout the world. The challenge now is to provide access to these life preserving medications for all who need them, and to ensure (or facilitate) people taking them. Several years ago I had an opportunity to meet with a group of female HIV activists from South Africa. When I informed them that not everyone in the US with HIV were taking anti-retrovirals, they were stunned. It was their understanding that HIV medication was widely available, and that everyone who needed them were taking them. I explained that health insurance plans in some states provided limited coverage for certain medications, and that some people (as many as 19%) living with HIV were unaware of their infection. While they understood this, they could not understand how so many who were aware of their diagnosis and had access to medications were not on medication. Various studies have shown that as few as 30% of people living with HIV in the US have suppressed viral loads, the gold standard for HIV care. While viral load suppression has risen in HIV+ individuals in care, there remains an alarming number of individuals not receiving consistent HIV disease management (ex. in and out of care, or not in care at all). While we cannot cure HIV, we have built a better toolbox that can help keep people alive for a long time, and there are even more tools in the pipeline. In spite of the tools at hand, however, issues of poverty, homelessness, substance abuse, and mental illness continue to disproportionately impact those most at risk for HIV. Thus, our goal at year 35 of the HIV/AIDS epidemic is to get people into care, and to help them stay there.

Know what you are talking about

I was recently asked if I felt that we, in the black community, could now decelerate our efforts to fight HIV due to so much progress with treatment. My answer, quite to the questioner’s surprise, was a resounding NO! Her question was predicated on the belief that the black community had previously issued a 'call to arms' and had mobilized, much like the LGBT community had in the 80's and 90's, to educate our community and advocate for more funding. It is downright depressing to think that the black community might be breathing a collective sigh of relief and backing off on whatever feeble efforts we are able to marshal, believing that we have won something. Has progress been made? Absolutely. Are we out of the woods yet? Absolutely not. Two recent reports have demonstrated that we still have a long way to go. While HIV has continued to wreak havoc on the black community (representing 44% of new HIV cases), the landscape is even bleaker for black gay and bisexual men in the United States. According to the Centers for Disease Control (CDC), one half of black MSM (men who have sex with men) “will be diagnosed with HIV in their lifetime” if current trends continue. To put this another way, if America’s black gay and bisexual men comprised a nation unto themselves, that nation would soon have the world’s highest rate of infection — twice as high as its closest rivals in Sub-Saharan Africa (CDC). If this isn't dire enough, the average survival time for African-Americans with AIDS is lower than for other racial or ethnic groups despite dozens of effective medications including a HIV prevention pill (PrEP). The main reason for this seems to be inconsistent treatment. From 2011 to 2013, only 38 percent of black HIV patients received consistent treatment, whereas about 50 percent of whites and Hispanics with the virus had continuous care (CDC's Feb. 4th Morbidity and Mortality Weekly Report). This disparity is consistent with the statistics regarding viral suppression, which is the gold standard for HIV care. In general, it is understood that the lower the amount of HIV virus in one’s blood, the lower the risk of opportunistic infections and the greater the life expectancy. Only about 25 percent of people living with HIV in the United States have achieved viral suppression, with African Americans being the least likely to do so at a rate of 21% compared to 26% among Hispanics and 30% of whites. Additionally, the 25-34 age group (one of the hardest hit among black MSM) is the least likely to have achieved viral suppression compared to other age groups, with only 15 percent of individuals 25-34 reaching this goal. The causes for this include the usual suspects of poverty, substance abuse, lack of access to health care, homophobia, stigma, etc. But, and back to my original premise, I have NEVER seen a true sense of urgency in the black community about HIV/AIDS. Oh sure, the Congressional Black Caucus has successfully fought for more money to address HIV in black and brown communities. Many black churches, civic and fraternal organizations have stepped up, and even a few celebrities have raised their voices (as well as money) for and about this epidemic. Our President has even released comprehensive HIV strategies, with specific objectives and time-frames. Nevertheless, we continue to get caught up in stereotyping and conspiracy theories that undermine the severity and urgency of this issue. I cringe when I read statistics about the terrible impact in black gay and bisexual men, because I know that gives our community more 'cover,' enabling us to bask in the warm waves of the delusion that HIV/AIDS is someone else's problem. We can no more stop HIV infection by building imaginary walls between ourselves and people who, well, are not 'like us' (gays and bisexuals), as we can stop terrorism and immigration by building brick and mortar walls. There is no simple solution to this. But, for starters, I suggest that we take the time to learn more about it. Something I hear over and over in my conversations about HIV/AIDS is that people don’t realize ‘how bad it is,’ despite the wealth of information available. I can't help but think about the words of two truly different, yet wise, black men. Chris Rock tells us (and I paraphrase) that books are like Kryptonite to black folks, and if you want to hide something from us, put it in a book. On a more serious note, President Obama, speaking to the 2016 graduating class at Rutgers University, said that “ignorance is not a virtue…It's not cool to not know what you are talking about. That's not keeping it real or telling it like it is. That's not challenging political correctness. That's just not knowing what you are talking about." Before we start dismissing HIV as only a “gay disease” or believing that there’s this secret cure for rich people, open a book or a suitable internet page (try the CDC.gov for starters) and begin to know what you are talking about.