The Changing Face of HIV

Thirty years after the virus changed sexual politics and sexual health forever, the face of HIV/AIDS is no longer what it used to be. Although men who have sex with men (MSM) remain the largest single affected community, representing more than half of all new HIV infections, the virus has also become a serious threat to African Americans, Latinos, and residents of the southern United States.

According to the Center for Disease Control, approximately 1.1 million people in the U.S. are living with HIV. An estimated 50,000 are infected every year, a number which has remained fairly stable since the mid-1990s but represents a significant improvement from roughly 130,000 a year at the epidemic's height in the 1980s.

"Our reporting is better these days," said Dr. Marjorie Hill, CEO of the Gay Men's Health Crisis, a leading provider of HIV/AIDS prevention, care and advocacy. "One might think 30 years ago the epidemic was all gay men, and even 30 years ago that was not true."

Men who have sex with men, although comprising a smaller majority of HIV infections than they did at the epidemic's height, represent an increasing number of new infections, due in large part to a significant increase in transmission among young black MSM. But sex between MSM is far from the only way the virus is transmitted. Heterosexual transmission is responsible for 27 percent of new infections, followed by injection drug use, which causes 9 percent of new infections.

Dr. Hill said, "If one pretends that only gay men have to worry about the virus, women are not going to have important conversations with their partners. The truth is, the demographic that is at risk for HIV is people who are sexually active. A lot of people are having sex. Transmission is not about sexual orientation, it's about sexual activity."

Among the groups disproportionately impacted by HIV are ethnic and racial minorities. African Americans account for the highest number of new HIV infections, followed by Latinos. Although only 14 percent of Americans are black, 44 percent of new HIV infections occur in the black community.

Latinos, meanwhile, account for 16 percent of the U.S. population but 20 percent of new HIV infections. Socioeconomic factors such as lack of access to health care, discrimination and poverty may contribute to placing people of color at greater risk of contracting the virus than white people.

"Social drivers have always been the root cause of HIV," said Dr. Hill. "Poverty, homophobia, sexism, racism -- those factors have always been very highly correlated with HIV incidence. Unfortunately, African Americans experience a higher impact of racism and higher economic challenges. Latinos are disproportionately impacted for similar reasons, and because of immigration and language obstacles."

Transgender people too are disproportionately affected by HIV. Although the group is too small to represent a significant fraction of all HIV infections, an estimated 28 percent of trans women are HIV-positive.

Half of New HIV Infections Come from Southern U.S.

Geography also has an impact on an individual's risk of contracting the virus. The Southern U.S. contains only 37 percent of the country's population, but accounts for roughly half its new HIV infections. The South is the geographic region with the highest number of new infections, although the prevalence of AIDS diagnoses is higher in the Northeast. Both those regions have seen a decrease in new infections in recent years. The Midwest is the only region of the U.S. in which transmission increased between 2007 and 2010. Throughout the country, HIV is most prevalent in densely populated urban areas.

According to the Southern HIV/AIDS Strategy Initiative (SASI), the HIV-related death rate, as well as the incidence of HIV-related morbidity, is highest in the southern states. These states also have some of the highest poverty levels in the country, and a report from SASI indicates that, "states with the lowest incomes have the greatest HIV case fatality rates." In addition, the majority of African Americans -- the ethnic group most affected by the virus -- live in the South, and are disproportionately likely to be living in poverty.

The cultural conservatism of the South may be another factor in that region's high HIV incidence. A combination of inadequate sex education and stigmatization of behaviors that can lead to infection, such as homosexual sex and injection drug use, may lead to a lack of awareness of prevention strategies and a greater risk of transmission.

"Many people living with HIV are already in marginalized groups in this country -- men who have sex with men, injecting drug users, sex workers, etc.," said Carolyn McAllaster of SASI. "And these groups are particularly stigmatized in the South, in the Bible Belt."

"There's a lesson that sometimes it seems like we must keep re-learning," said James Loduca of the San Francisco AIDS Foundation. "HIV thrives in the margins. Whenever you have a community or a population marginalized and isolated, their HIV risk increases significantly, which is why we need to focus on bringing people in from the margins."

Because of the diversity of the communities involved and the methods of transmission, HIV and AIDS prevention is not a simple task, but comprises varying methods of outreach and education.

"A tension exists for the work of organizations like ours," said Loduca. "Destigmatizing HIV, to ensure people are treated with the dignity they deserve, is of paramount importance. HIV stigma can be a barrier to preventing new infections. At the same time, we need to similarly communicate to young people that HIV is manageable, but it is still a very serious disease that you don't want to get."

According to Dr. Hill, "Making a community a safe and comfortable space for people who are affected by HIV goes a long way in terms of managing the epidemic. The more supported individuals are, the more likely they are to succeed in health promotion activities."

"Knowledge and information have always been the best weapons against infection," said Loduca. "We need to have honest conversations with yourself and others about behaviors that can increase risk."

"Just like HIV started one person at a time, it's going to end one person at a time," he added.