Using information from raw scientific data and published analytical studies, EJAF is able to set grant-making priorities that help ensure it is providing support both where it is needed most and where it is likely to be most effective in combating the HIV epidemic. For example, the numbers reveal that the HIV epidemics in the United States, Caribbean, and Latin America are not evenly distributed but instead concentrated in specific at-risk populations. Furthermore, studies can now point to specific interventions and policies that have been proven to effectively help prevent new HIV infections, increase access to HIV testing and treatment, and simultaneously promote broader health and human rights.
Gay men and HIV
More than half of all new HIV infections each year are among gay and bisexual men. These infection rates are driven by a combination of high-risk behavior, the high prevalence of HIV within the community, and the high likelihood of transmission during each unprotected sexual encounter. In the U.S., a recent government study found that one in five (19% of) gay and bisexual men in 21 major cities were infected with HIV, and nearly half (44%) were unaware of their infection. In Latin America and the Caribbean, HIV prevalence among gay men has been reported at rates surpassing 20% in countries as varied as Bolivia, Jamaica, and Mexico.
For gay men, especially those who are younger and living in economically marginalized communities, HIV rates can be reduced by improving access to information and opportunities to negotiate safer sex, safer drug use, and HIV treatment and care. This is accomplished in part by addressing inadequacies in health systems, directly confronting stigma and discrimination related to gender identity and sexuality, and building a community norm that places value on broader health (a gay men’s health agenda). Gay men’s health can be positively impacted by initiatives that promote and encourage healthy relationships, supportive communities and families, stable employment and housing, and freedom from stigma, discrimination, bullying, harassment, and physical violence.
Youth and HIV
One in four (24%) of all new HIV infections in the United States – more than 10,000 cases every year – are among young people age 13-24. Approximately 72% of those 13-24 year olds who are newly HIV-positive are infected through sex between men (i.e., they are young gay or bisexual men). Similar HIV statistics are reported in Latin America and the Caribbean. In national U.S. surveys, one in three American high school students reports being sexually active (defined as having had sex during the preceding three months), and, alarmingly, more than one third of sexually active high school students report not using condoms at last sexual intercourse.
For young people, rates of sexually transmitted infections can be reduced through sexual education, health services, social services (such as mental health counseling), and peer-based social support, but these programs don’t yet exist in the U.S. or in Latin America and the Caribbean at sufficient scale, quality, and sustainability. Youth, their parents, and their allies need to advocate for the quality and sustainability of sexual education, health services, and social support for underserved youth. In the U.S., there is an especially critical need for investment in programming led by and targeted to young gay men, since more than 70% of new HIV infections among people age 13-24 are among young men who have sex with men.
Black Americans and HIV
Approximately half of the HIV epidemic in the U.S. is among Black people, i.e. of African and/or Caribbean descent, with a disproportionate impact on Black gay men. Rates of HIV infection are higher among Black people than any other racial/ethnic/national group in the U.S., and a large proportion of the HIV epidemic among Black people is among Black gay men, which underscores the need for rights-based initiatives to address health disparities. For Black gay men, researchers note a need to improve HIV-related clinical practices specifically for those men, finding that HIV is frequently undiagnosed by healthcare providers even when men are engaged in care and have disclosed their sexuality to the provider.
Black-led rights-based initiatives are needed at a national, state, and local level to increase awareness in the African American community about HIV testing and treatment. These initiatives should be folded into the existing context of efforts to monitor the implementation of national healthcare reform, community mobilization on other health issues such as diabetes, hypertension and asthma, and broader community development in areas such as education, housing, and employment.
Prisoners and ex-offenders and HIV
Every year, approximately 171,000 (1 in 7) HIV-positive Americans pass in and out of U.S. correctional systems (federal and state prison, county jails, parole, and probation). The U.S. “war on drugs” and mandatory sentencing of drug charges has driven much of the increase in the number of prisoners over the past three decades.
For HIV-positive ex-offenders, programs offering intensive case management and other social services help people access and remain in HIV-related health care, as well as mental health services, addiction services, and stable housing. During recent years, state corrections agencies have expressed an increased interest in prisoner re-entry programs because they promise to be less expensive than recidivism and incarceration costs. However, people who are incarcerated or recently released report a continued lack of HIV prevention support inside correctional institutions and inadequate health services and support on the outside. Improving state policies and programs for ex-offenders, specifically to ensure continuity of health care along with mental health services, addiction services, and housing, will therefore be a crucial part of the national effort to end new HIV infections and new cases of AIDS in the United States.
Injection drug users and HIV
HIV infections due to injection drug use now account for an estimated 10% of all HIV infections in the United States, down from an estimated 25% of all infections in 2000. Even though these numbers are moving in the right direction, approximately 5,000 people become newly infected each year due to risks encountered in injection drug use. These 5,000 infections are entirely preventable, and therefore entirely unacceptable.
For injection drug users, data has shown that sterile injection equipment exchanges and associated harm reduction counseling and support programs reduce risks of HIV transmission. Harm reduction programs are recognized as an important way to stop injection-related HIV infections and provide a low-threshold entryway into drug treatment, counseling and interventions for sexual risk reduction, support for HIV treatment access and use, and other health and economic interventions.
Policies and HIV
In the U.S., 1.2 million people are living with HIV, and approximately 48,000 Americans are newly infected each year. One in five Americans who have HIV – 220,000 people – are unaware of their infection. Approximately 427,000 Americans are accessing HIV treatment, while more than 150,000 others should be accessing treatment but aren’t. And unfortunately, only 25% of people living with HIV (a total of 329,000 people) have successfully responded to HIV treatment with a suppressed HIV viral load.
In Latin America, 1.4 million people are living with HIV. Approximately 456,000 people are accessing HIV treatment, but more than 250,000 others are in need. Several countries, such as Argentina, Brazil, Cuba, Dominican Republic, and Mexico, have made considerable progress in scaling up HIV prevention and treatment. Other countries, particularly in Central America and the Andean region, are lagging behind.
In the Caribbean, 240,000 people are living with HIV. Approximately 75,000 people are accessing HIV treatment; more than 50,000 others are in need. Half of the Caribbean HIV epidemic is in Haiti, where 120,000 people are living with HIV. More than 29,000 Haitians are now accessing HIV treatment, but at least 30,000 others are in need.
Data show that HIV treatment can benefit anyone with a CD4 count of below 500, and also that treatment likely helps people living with HIV prevent onward transmission to their sexual partners. Studies in several countries now suggest that a scale-up of comprehensive HIV interventions, centered around regular HIV testing and expanded HIV treatment in specific locations and populations, can achieve sustained decreases in new HIV diagnoses and AIDS-related illnesses.
The challenges of appropriate scale-up of HIV testing, treatment, and health care reforms are not evenly distributed. In the U.S., Latin America, and the Caribbean, there are HIV epicenters where infrastructure and political will are not strong, particularly in the Southern U.S., Puerto Rico, other major U.S. urban centers, Haiti, and countries of Central America and the Andean region.
In July 2010, the United States issued a National HIV/AIDS Strategy which committed to specific actions aimed at reducing new HIV infections, increasing access to care and improving health outcomes for people living with HIV, reducing HIV-related health disparities, and achieving a more coordinated national response to the HIV epidemic. In June 2011, a U.S. National Prevention Strategy called for states to strengthen HIV and sexually transmitted infection testing, ensure that resources are targeted to communities at highest risk, and use social marketing, support services, and policies to increase the number of people tested and linked to care for HIV. Unfortunately, these initiatives are not yet funded at a sufficient scale, and all of these efforts are facing major budget cuts at both the federal and state level.
Advocacy is needed to fight budget cuts to the national and local programs that have shown promise in engaging people in HIV testing and treatment. These programs include efforts funded in part by the U.S. Centers for Disease Control and Prevention (CDC), Ryan White CARE Act, and Medicaid and Medicare programs, including the AIDS Drug Assistance Program (ADAP) and Medicaid Title X (through which an estimated one million people get HIV testing each year). U.S. healthcare reforms through the Patient Protection and Affordable Care Act are intended to address some of the gaps in health promotion and care, but these reforms will not be fully implemented until 2014. Continued advocacy will be necessary to ensure that all health reform policies and programs are sufficiently implemented and funded, especially in the U.S. South.
