Medical Examiner

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.

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.

Then there’s the much ballyhooed “down low” phenomenon. Some men on the DL are becoming infected by anal intercourse with men and then spreading the infection to their female partners, a transmission route that became widely discussed earlier this year with the publication of J.L. King’s On the Down Low: A Journey Into the Lives of “Straight” Black Men Who Sleep With Men. But the great unknown is how frequently this occurs, and whether it’s truly different in blacks versus whites or Hispanics.

Because of a flurry of media coverage about the DL link, including an Oprah show featuring King and a New York Times Magazinestory, many who study AIDS in the black community cringe at its mention. “I’m sick of hearing about it,” says Victoria Cargill, an epidemiologist at the Office of AIDS Research at the National Institutes of Health. Cargill, who also works at a clinic in poor, black Southeast D.C., says the high prevalence of HIV/AIDS in women can clearly be attributed to a host of factors that have nothing to do with the DL. “I’m not saying it doesn’t exist, but if we start adding up how many people this affects, this is the eye of the needle,” says Cargill. “Let’s start talking about the needle.” CDC epidemiologist Greg Millett says that when it comes to the DL phenomenon, there simply are more questions than answers. “The truth is there are very few studies that deal with bisexual black men and even fewer that deal with the down low,” says Millett, who has put together a provocative PowerPoint presentation on the topic.

A fascinating CDC study published last year specifically looked at men who have sex with men and do not disclose their sexual orientation versus those who do disclose. The study recruited participants from only six gay bars (which already tilts the results away from DL men who may not go to gay bars), but the findings were startling. More black men were nondisclosers (18 percent)—that is, on the DL—than white men (8 percent), and all nondisclosures reported having more sex with women than with men. But nondisclosers of all races were also less likely to be infected with HIV than disclosers, and black nondisclosers in particular reported significantly less unprotected anal intercourse with men than did black disclosers. Several other recent studies have found higher proportions of bisexual black men than white men, but it’s unclear whether how much of an HIV “bridge” they are to black women.

Phill Wilson, executive director of the Black AIDS Institute in Los Angeles, suggests, rather, that the single biggest driver of the heterosexual spread to black women is the incarceration of black men. “The prison industry in America is an almost exact replication of the mining industry in South Africa, where you take large groups of men and move them from their families for an extended period of time,” says Wilson. As studies conducted in South Africa have shown, men who leave their homes for the mines often have new sexual partners—as do the women they leave behind. The increased sexual mixing spreads HIV in both the migrant men and their regular partners. When they return home, the men may infect their regular partners—or vice versa. This pattern of sexual networking is called concurrent partnering, which means that relationships overlap, and there’s nothing that HIV likes more.

Wilson and others argue that with so many men cycling in and out of the African American community, women end up at a greater risk because of similar disruptions of sexual networks and the resultant concurrency patterns: They mix with new partners when their men leave and often reunite with them when they are released. Incarceration also exposes many men to anal sex, whether by coercion or choice, and injection-drug use, the two most efficient ways to spread HIV. And if the locked-up man was the main wage earner, poverty can be a factor, too.

One superb study of concurrency in African Americans in rural North Carolina found that 53 percent of the men and 31 percent of the women reported concurrent partners during the preceding five years. Interestingly, 80 percent of the men in the study who said they had been incarcerated for more than 24 hours reported having had concurrent partners within five years; that percentage plummeted to 43 percent if a man had not been locked up for a day or longer.

Equally important, black women have a small pool of black men to choose from at any given time. “African American women are the only group in the United States where there are fewer men than women,” says Gail Wyatt, an associate director of the AIDS Institute at the University of California, Los Angeles. “The availability of a partner who shares the same values is much less likely. The women are more likely to be educated than their partners. They’re more likely to be employed.” As a result of the shortage of black men, black women are vulnerable to becoming involved with men who are engaging in risky behaviors that they don’t know about, whether it be having unprotected sex with other partners, female or male; visiting sex workers; or injecting drugs.

The muddy truth is that the high rate of HIV infection and AIDS among African American women is due to a combination of all these factors. “It’s a perfect storm of issues,” says NIH’s Cargill.

And there’s one more factor to consider, says Wilson: Politicians ignore this population. “It’s both a cause and a symptom of the problem that our government really is not interested in the health and well-being of black people and in particular black women,” says Wilson. “How is it that Dick Cheney can tell you how many machine guns are in Baghdad, but doesn’t have a clue about issues that are killing black women a stone’s throw from his office?”

Gwen Ifill, for her part, received so many queries about this particular question that she wrote out a response, refreshingly candid, that her publicist gave out to people who inquired. “I have to say I was surprised that neither the Vice President nor the Senator had an answer on this,” wrote Ifill. “As a black woman, I also found it depressing. The good news is that, in the feedback I have gotten since the debate, folks got that. These debates have been very useful for smart and involved likely voters. They have gotten to see what these folks do, and don’t, care about.”