AIDS in the Americas

AIDS is one of the most devastating diseases in human histry. The global count of people living with HIV/AIDS reached forty million by the end of 2004; millions more had already succumbed to the disease. Although HIV/AIDS is worldwide in its spread, it is not equally divided among the populations of the world.

The Distribution of AIDS in the Americas

One way of understanding the impact of the disease on populations of African descent in the Americas is by looking at the worldwide number of people living with HIV/AIDS disease along a continuum. At one end of the continuum is sub-Saharan Africa, which remains the region hardest hit by the disease, with approximately 25.5 million people now living with HIV/AIDS infection and an adult (ages 15–49) prevalence rate of 7.4 percent. Near the opposite end of the continuum falls North America, with about a million people living with HIV/AIDS and an adult prevalence rate of 0.6 percent, which is not significantly above that of Oceania, the region of the world with the lowest prevalence rate. Between these two epidemiological regions lie the island nations of the Caribbean, with under half a million cases and a prevalence rate of 2.3 percent. After sub-Saharan Africa, the Caribbean is now the second most intensely impacted region of the world. HIV/AIDS prevalence has grown rapidly in the Caribbean since the mid-1990s. Consequently, there were more cases of HIV reported in the Caribbean between 1995 and 1998 than from the early 1980s until 1995 (World Health Organization, 1998). AIDS has emerged as the leading cause of death in the English-speaking, African-American sector of the region among people fifteen to forty-four years of age.

These figures only give a broad sense of the extent and impact of the epidemic in the far-flung African-American populations of the New World. In Haiti, prevalence has surpassed 6 percent, the highest of any country outside of sub-Saharan Africa. Because of AIDS, life expectancy at birth in Caribbean countries like Haiti and Trinidad with majority African-American populations is projected by the year 2010 to be nine to ten years shorter than it would have been without the disease.

Other islands in the Caribbean with large populations of African descent have also developed significant AIDS epidemics. The Centers for Disease Control and Prevention (CDC) ranks the U.S. Virgin Islands, for example, fourth in the United States in AIDS incidence. Among women in the Virgin Islands, the AIDS-case rate of approximately 30 per 100,000 population is nearly three times the U.S. national rate (with 27 percent of AIDS cases and 47 percent of combined HIV/AIDS cases among women). By late 2000, there were over four hundred AIDS cases in the Virgin Islands; 54 percent of those with the disease had already died (Nelson, Todman, and Singer, 2005).

Based on frozen tissue samples, the oldest confirmed case of AIDS in the Americas was a fifteen-year-old African-American male from St. Louis who was hospitalized in 1968 with an aggressive form of Kaposi's sarcoma. Twenty years later, his stored serum specimens tested positive for HIV-antibodies (Gerry, et al., 1988). Today, the AIDS case rate (for all ages) per 100,000 population in the United States is 6.1 among white non-Hispanics compared to 58.2 among African Americans. HIV/AIDS is more prevalent among African Americans, and significantly so, than any other racial/ethnic population in the country, a pattern that holds across age and gender subgroups. Among men, for example, the AIDS case rate is over eight times greater among African Americans than among non-Hispanic whites (Centers for Disease Control and Prevention, 2003). Among women, the difference is even greater. In terms of actual number of cases, almost twice as many African Americans have contracted HIV/AIDS than non-Hispanics whites. Importantly, while the number of deaths among whites living with HIV/AIDS steadily fell from 1999 to 2003, among African Americans a clear trend has not emerged, with the number of deaths due to AIDS going up and down from year to year. Overall, however, while African Americans comprise about 12.3 percent of the U.S. population, from 1999 to 2003 they accounted for over 50 percent of the people who died of AIDS during those five years. By the end of 2003, almost 200,000 African Americans had died of AIDS. In other words, while compared to some other parts of the world the HIV/AIDS prevalence is low in the United States, HIV-related morbidity and mortality are notably concentrated in the African-American sector of the population. Moreover, in 2002 African Americans who died from HIV/AIDS had over ten times as many age-adjusted years of potential life lost before age seventy-five years as whites (Office of Minority Health, 2005).

AIDS also has reached significant levels among Brazilians of African descent. The first reported case of AIDS in Brazil was diagnosed in 1983. During the 1990s Brazil emerged as the epicenter of HIV/AIDS in South America with just under sixty percent of all AIDS cases in Latin America and the Caribbean combined. Cumulative AIDS cases passed a quarter of a million in 2003, with an adult prevalence rate for HIV/AIDS of 0.7 percent. Infection is not generally dispersed in the population but rather is concentrated among those who are twenty to thirty-five years of age and belong to at least one of four groups: men who have sex with men, sexually transmitted disease patients, commercial sex workers, and injection drug users. The latter two groups, in particular, tend to be poor, and they disproportionately comprise darker skinned Brazilians. Although the proportion of HIV/AIDS cases among women is rising—especially among those who have male sex partners who engage in high-risk behaviors—rates of infection are significantly higher among men (U.S. Agency for International Development, 2004).

BlackAIDS.org

According to the BLACKAIDS.org website, the Black AIDS Institute is the "first black HIV/AIDS policy center dedicated to reducing HIV/AIDS health disparities by mobilizing black institutions and individuals." The group's motto is "Our People, Our Problem, Our Solution."

The AIDS epidemic has had a disproportionate impact on black communities. As early as 1983, African Americans, who represented over 13 percent of the population, accounted for more than a quarter of reported AIDS cases. Now, African Americans account for greater than 50 percent of all new HIV infections in the United States. BlackAIDS.org is making an effort to reduce this trend.

The site focuses on global coordination and is a sort of alternative news center. Policymakers and other influential people who shape the general consciousness are interviewed. Every week new stories are featured and columnists' perspectives are offered, all centering around this topic. The goal is to educate people and to investigate stories that the mainstream media might have a tendency to overlook. Also of interest is a section devoted to arts addressing HIV. BlackAIDS.org is an excellent tool for anyone serious about learning more on this epidemic and its effect on African Americans.

AIDS as a Syndemic: The Political Economy of Suffering

AIDS does not exist in isolation from other diseases or from a social and political economic environment that shapes the general health, access to food and shelter, and availability of medical treatment. To help frame this critical biosocial, perspective medical anthropologists introduced the concept of "syndemic" in the mid-1990s (Baer, Singer, and Susser, 2003; Singer and Clair, 2003). While biomedical understanding and practice, traditionally, have been characterized by the tendency to isolate, study, and treat diseases as if they were distinct entities that existed separate from other diseases and independent of the social contexts in which they emerge, a syndemic model focuses on trying to understand social and biological interconnections as they are shaped and influenced by inequalities within society. At its simplest level, the term syndemic refers to two or more epidemics (i.e., notable increases in the rate of specific diseases in a population), interacting synergistically with each other inside human bodies and contributing, as a result of their interaction, to excess burden of disease in a population. The term syndemic refers not only to the temporal or locational co-occurrence of two or more diseases or health problems, however, but also to the health consequences of the biological interactions among copresent diseases, such as between HIV and tuberculosis. HIV-positive individuals infected with TB are a hundred times more likely to develop an active disease than those who are HIV-negative, and TB is disproportionately prevalent among African Americans. In Jamaica this interrelationship of diseases has been found increasingly among children, with TB severity being greatest among children who are co-infected with HIV (Geoghagen, et al., 2004). Similarly, research has shown both that individuals co-infected with hepatitis (HCV) and HIV have higher HCV viral loads than those infected with only HCV alone and that African Americans have significantly higher HCV loads among co-infected individuals than do whites, suggesting important interrelations between copresent diseases and the differential consequence of co-infection across race/ethnicity (Matthews-Greer, et al., 2001).

Beyond the notion of disease clustering in a social location or population and the biological processes of interaction among diseases, the term syndemic also points to the determinant importance of social conditions in disease interactions and consequences. As Farmer (1999, pp. 51–52) has emphasized, "the most well demonstrated cofactors [for HIV] are social inequalities, which structure not only the contours of the AIDS pandemic but also the nature of outcomes once an individual is sick with complications of HIV infection." Living in poverty, for example, increases the likelihood of exposure to a range of diseases, including HIV. Also, poverty and discrimination place the poor at a disadvantage in terms of access to diagnosis and treatment for HIV, as well as ability to adhere to treatment plans because of structurally imposed residential instability and the frequency of disruptive economic and social crises in poor families. Haiti is by far the most impoverished country in the Americas, and it is not coincidental that it is the country in this hemisphere that has been hardest hit by AIDS thus far.

In multiethnic New World countries, racism is another critical social condition that appears to contribute to higher levels of HIV risk and infection among peoples of African descent. In Brazil, for example, while race-based oppression is denied officially and at the popular level, studies show that "the structures of racism are present in everyday experience" (Goldstein, 2003, p. 105). Consequently, writing of internalized racism in Brazil, Neusa Santos Souza (1983), notes that dark-skinned Brazilians commonly feel inferior and ugly because of all of the subtle reminders to which they are subjected each day that whiteness equals beauty. Internalized racism, no less than open color-based discrimination, is linked with heightened levels of HIV risk and infection (Baer, Singer, and Susser, 2003). Ultimately, such social factors as poverty, racism, sexism, and marginalization may be of far greater importance in HIV morbidity and mortality among people of African descent than the nature of the human immunodeficiency virus. Overall, populations of African descent in the Americas encounter HIV/AIDS not as a single life-threatening disease but as part of a set of interacting diseases and toxic social conditions with a resulting significant toll on their health and well-being.

AIDS Stigma: AIDS and Accusation

Goffman (1963) first defined stigma as the negative image that a social collectivity creates of a person or group based on some physical, behavioral, or social attribute that is perceived to diverge from established group norms. More recently, Link and Phelan (2001, p. 365) offered a definition of stigma in terms of "status loss and discrimination that lead to unequal outcomes" and argue that "stigmatization is entirely contingent on access to social, economic, and political power that allows the identification of differentness, the construction of stereotypes, the separation of labeled persons into distinct categories, and the full execution of disapproval, rejection, exclusion, and discrimination." Notably, this definition emphasizes the centrality of political economy in the emergence and distribution of stigma. Health-related stigma, in short, tends to reinforce other axes of social inequality.

AIDS stigma has had a significant impact on HIV-infected individuals of African heritage. At the national level AIDS stigma has been tied to efforts to blame AIDS on people of African origin, especially Africans and Haitians (Farmer, 1992). Such accusation is unsubstantiated by any research, as AIDS is a disease capable of infecting all humans and is impervious to ethnic or national boundaries. Stigma has also been significant at the individual level. A study among HIV/AIDS infected Haitian-American women, for example, found that they perceived five areas of AIDS-stigmatization in their lives: rejection by the dominant society, self-doubt, diminished self-esteem, stress in intimate relationships, and rejection by other Haitians within their community (Santana and Dancy, 2000). Comparative research on African-American women in the southern United States who were in treatment for either HIV or breast cancer found that reported levels of hope were significantly lower for those with HIV,

as were their assessed coping skills, affirming the damage done by AIDS stigma (Phillips and Sowell, 2000).

Various researchers have asserted that AIDS-related stigma functions as a barrier to HIV-infected individuals voluntarily seeking counseling and testing. Research in rural Haiti, however, suggests that the introduction of high-quality HIV care can lead to a significant reduction in stigma and to increased rates of HIV testing (Castro and Farmer, 2005). Rather than stigma, these researchers argue, it is logistic and economic barriers that primarily determine who will access available HIV services. This finding further affirms the importance of understanding AIDS stigma in terms of the prevailing structures of social and economic inequality.

Conspiracy Theories: AIDS and Defensive Accusation

The flip side of AIDS stigma and blame is found in popular ideas about AIDS as a government conspiracy to exterminate people of color. A telephone survey of five hundred African Americans, for example, found that a significant proportion, especially men, held AIDS conspiracy beliefs (Bogart and Thorburn, 2005). Similar findings have been reached in door-to-door surveys with African-American populations (Klonoff and Landrine, 1999). Notably, those who embraced this perspective are much more likely to have negative attitudes about condom use and inconsistent condom use patterns, suggesting that belief in conspiracy theories is a barrier to AIDS prevention. Such attitudes are believed to have their origin in a defensive response to a long history of racial discrimination in health care as well as in medical research, including the infamous Tuskegee syphilis study of 1932 to 1972.

Coping with AIDS: The Range of National Responses

National responses to AIDS have varied considerably. Some predominant black nations, like the Bahamas, have demonstrated considerable success in responding to the epidemic. In 1994 the Bahamas recorded just over seven hundred new cases of HIV infection; by 1999, by contrast, the annual number of new cases was about half this level. The mortality rate for AIDS also fell by about half during this period as well (Baer, Singer, and Susser, 2003). Brazil, after an initial hesitation, has also demonstrated an effective response to AIDS. In the early 1990s Parker (1994, p. 28) noted that the "history of the epidemic in Brazil has been marked by the relative failure of government authorities to develop cohesive policies and programs." Consequently, the World Bank predicted that by the year 2000 there would be 1.2 million people infected with HIV in Brazil. Instead, a significant change in governmental response, including guaranteeing AIDS care, the manufacture and broad distribution of AIDS medicines, and the emergence of an aggressive community-based response to the epidemic, resulted in only about half as many infections as had been expected by the turn of the twenty-first century.

In the United States, in 1998 the CDC released findings on the distribution of HIV/AIDS that revealed significantly disproportionate rates of infection among African Americans. In response, the Congressional Black Caucus requested the Secretary of the Department of Health and Human Services to declare the HIV/AIDS epidemic in the African-American community a "public health emergency." Instead, the government announced a comprehensive new initiative to improve the nation's effort to prevent the spread of AIDS in African-American and Latino communities and to enhance the level of care provided to people of color living with the disease. While new levels of funding were made available to state and city departments of public health and community-based organizations to implement AIDS prevention in communities of color, the epidemic has continued to have far greater impact among people of African descent than among the rest of the U.S. population. Even more drastic is the case of Haiti, which, because of continued political and economic crises, has not been able to sustain an effective national AIDS prevention program, resulting in a continued out-of-control AIDS epidemic.

Future of a Health Crisis

The AIDS epidemic has exacted an enormous toll on populations of African descent throughout the Americas, especially among people of childbearing age and the young. While the predominant mode of viral transmission has been through sexual contact, especially heterosexual contact, rates of infection have also been high among men who have sex with men, and, in some areas, injection and noninjection drug users. National responses have varied, and while the AIDS epidemic has not been effectively controlled in any country, coordinated government/community responses have been able to slow the rate of new infections in some countries or with some at-risk populations. Research on mathematical modeling of the epidemic in English-speaking Caribbean nations suggests that if the incidence of HIV cases is not reduced, it will lead to negative growth (i.e., falling gross domestic product rates) in future years (Nicolls, et al., 1998). Such a drop will lower the ability of countries to respond to the epidemic, further accelerating the negative health and social effects of HIV/AIDS in a potentially disastrous downward spiral. Relatively successful responses to the epidemic, as seen in the cases of the Bahamas or Brazil, or even Haiti on a limited scale, suggest alternative, less dismal futures for the epidemic.

See also Mortality and Morbidity

Bibliography

Baer, Hans, Merrill Singer, and Ida Susser. Medical Anthropology and the World System. Westport, Conn.: Praeger, 2003.

Bogart, L., and S. Thorburn. "Are HIV/AIDS Conspiracy Beliefs a Barrier to HIV Prevention Among African Americans?" Journal of Acquired Immune Deficiency Disease 38, no. 2 (2005): 213–218.

Castro, Arachu, and Paul Farmer. "Understanding and Addressing AIDS-Related Stigma: From Anthropological Theory to Clinical Practice in Haiti." American Journal of Public Health 9, no. 1 (2005): 53–59.

Farmer, Paul. AIDS and Accusation: Haiti and the Geography of Blame. Berkeley: University of California Press, 1992.

Farmer, Paul. Infections and Inequalities: The Modern Plagues. Berkeley: University of California Press, 1999.

Garry, R., M. Witte, A. Gottlieb, M. Elvin-Lewis, M. Gottlieb, C. Witte, S. Alexander, W. Cole, and W. Drake. "Documentation of an AIDS Virus Infection in the United States in 1968." Journal of the American Medical Association 260, no. 14 (1988): 2085–2087.

Geoghagen, M., J. Farr, I. Hambleton, R. Pierre, and C. Christie. "Tuberculosis and HIV Co-infections in Jamaican Children." Journal of West Indian Medicine 53, no. 5 (2004): 339–345.

Goffman, Irving. Stigma. Englewood Cliffs, N.J.: Prentice Hall, 1963.

Goldstein, Donna. Laughter Out of Place: Race, Class, Violence and Sexuality in a Rio Shantytown. Berkeley: University of California Press, 2003.

Klonoff, E., and H. Landrine. "Do Blacks Believe That HIV/AIDS Is a Government Conspiracy Against Them?" Preventive Medicine 28, no. 5 (1999): 451–457.

Link, B., and J. Phelan. "Conceptualizing Stigma." Annual Review of Sociology 27 (2001): 363–385.

Matthews-Greer, Janice, Gloria Caldito, Sharon Adley, Regina Willis, Angela Mire, Richard Jamison, Kenny McRae, John King, and Wun-ling Chang. "Comparison of Hepatitis C Viral Loads in Patients with or without Human Immunodeficiency Virus." Clinical Diagnosis and Laboratory Immunology 8, no. 4 (2001): 690–694.

Nelson, Agatha, Patricia Todman, and Merrill Singer. "The>Risks of Paradise: Project RARE and the Fight against AIDS in the U.S. Virgin Islands." In Communities Assessing Their AIDS Epidemics: Results of the Rapid Assessment of HIV/AIDS in U.S. Cities, edited by Ben Bowser, Ernest Quimbey, and Merrill Singer. Lanham, Md.: Lexington Books, 2005.

Nicholls, Sheldon, Roger McLean, Karl Theodore, Ralph Henry, and Camara Bilali. Modeling the Macroeconomic Impact of HIV/AIDS on the English Speaking Caribbean: The Case of Trinidad and Tobago and Jamaica. St. Augustine, Trinidad and Tobago: University of the West Indies, 1998.

Office of Minority Health. Health Disparities Experienced by Black or African Americans—United States. Morbidity and Mortality Weekly Report 54, no. 1 (2005): 1–3.

Phillips, K., and R. Sowell. "Hope and Coping in HIV-Infected African-American Women of Reproductive Age." Journal of the National Black Nurses Association 11, no. 2 (2000): 18–24.

Santana, M., and B. Dancy. "The Stigma of Being Named 'AIDS Carriers' on Haitian-American Women." Health Care for Women Internationally 21, no. 3 (2000): 161–171.

Singer, Merrill, and Scott Clair. "Syndemics and Public Health: Reconceptualizing Disease in Bio-Social Context." Medical Anthropology Quarterly 17, no. 4 (2003): 423–441.

Souza, Neusa Santos. To Become Black or the Vicissitudes of Identity in Upwardly Mobile Black Brazilian. Rio de Janeiro, Brazil: Graal, 1983.

U.S. Agency for International Development. Country Profile: HIV/AIDS, Brazil. Washington, D.C.: USAID, 2004.

World Health Organization. Database on Violence among Women. Geneva, Switzerland: WHO, 1998.

merrill singer (2005)