Roadblocks to HIV Screening, Treatment, and Care in Black Communities
Much of the disproportionate impact of HIV, and subsequent high demand for Ryan White-funded services among African-Americans reflects the socioeconomic drivers found within their communities. David J. Malebranche, an assistant professor of medicine at Emory University’s School of Medicine who has a joint appointment with the Rollins School of Public Health in Atlanta, Georgia, says a combination of socioeconomic factors, from lack of insurance to limited health literacy, has helped perpetuate HIV in the Black community. “Take lack of education and employment, displacement, homelessness, powerlessness, trading sex for money—and then throw HIV in the mix—and it’s going to be an explosion” of health disparities and HIV infection.
Also added to the “mix” is poverty, with over one-fifth of African-Americans living below the Federal Poverty Level (FPL).14 This reflects, in part, the economic downturn in 2008 and resulting unemployment experienced nationwide. The recession has devastated African-American communities, which have experienced rates of unemployment nearly twice the national average of 8.8 percent.15,16 As a result, nearly 21 percent of Blacks report living without health insurance, which has seriously undermined health outcomes and fueled health disparities, such as disproportionate rates of heart disease and diabetes, as well as HIV/AIDS, in Black communities.17 As one HIV provider in New York City explains, “HIV medications and hospitalizations are expensive. And unfortunately when you are Black and poor, whether you are a man or a woman, it is just one of the things you have to deal with and manage.”
African-American women and gay Black men have been particularly hard hit by HIV, though they experience slightly different barriers to care. According to the CDC, most Black women diagnosed with HIV/AIDS live in poverty, which severely undermines their ability to seek HIV services.18 The story of Delores, an African-American woman living with HIV, is typical of many African-American women learning their status for the first time:
I was poor, and at that time, I was using drugs and having sex to both feed my habit and keep a roof over my head. I didn’t think about the risk of AIDS—I thought about the next fix, and what I had to do to survive. I didn’t do anything about it at first, including use condoms, or get into care for two years.
It was not until she got into treatment for her drug addiction, with the help of a Ryan White-funded provider, that she could even accept that she had AIDS. Unfortunately, too many Black women enter HIV care too late. HIV/AIDS has been one of the leading causes of death since 2000 for African-American women ages 10 to 54.19 In 2011, HIV/AIDS was the number one cause of death among Black women ages 35 to 44.20,21
The internalized stigma and stress experienced by many PLWHA are often heightened among African-American women already stressed by the daily responsibilities of caring for children and other family members. It is not uncommon for providers to report that HIV-positive Black mothers often defer medical appointments and purchasing medications to ensure their family’s needs are met. Much of this selflessness is driven by cultural norms of “collective responsibility,” in Black communities, which designates African-American women as caretakers of children, their partners, and their extended family and community members.22