Barack Obama stood, jacket off and sleeves rolled, shouting into his mic and straining to be heard over the roaring crowd that turned up to welcome him back to Kenya. It was August 26, 2006, and the world was already watching.
The young senator was just a few months away from launching his improbable bid to become the 44th president of the United States, and he needed to demonstrate his ability to walk on the global stage. So he’d chosen a swing through Africa as his first major diplomatic foray, with a grand return to his father’s homeland as the highlight. The trip would be roundly praised. He’d be warm, but also challenging. He’d make a bold statement against corrupt government in African nations. And he’d offer his family as a deeply personal example of leadership in the fight against HIV.
“One of the reasons that we’re here today,” Obama began, having quieted the crowd gathered around him in front of a tiny mobile clinic, “is because HIV and AIDS have ravaged the community.” His visit to Kenya had just begun and he’d decided to use this welcoming moment, in which thousands thronged the streets, to send a pointed message about ending AIDS. He told the crowd that he and his wife, Michelle, were about to take HIV tests—and if they could do it, so could everyone else present. “I am so happy now because I know the status of my wife and I,” Obama declared after the test. “We are both negative, and I can take control of my family and all tasks that lie ahead of me.”
Just over two years later, those tasks are greater and graver than anyone ever imagined. President Obama now faces crises ranging from a global economic collapse to a rapidly destabilizing environment. But the challenge he chose to highlight that Saturday afternoon in Kenya has also grown more urgent, including right here in the United States.
Over the past eight years, America has rested on the AIDS treatment successes of the previous decade, turning its focus solely abroad while assuming a domestic victory it has not yet won. The result, as the Black AIDS Institute outlined in our 2008 report, Left Behind: Black America—A Neglected Priority in the Global Epidemic, is a black epidemic that looks more and more similar to those in places like Kenya. From rural Alabama to densely packed Oakland, California, the black American epidemic’s breadth and complexity mirrors that of poor communities throughout sub-Saharan Africa.
During his presidential campaign, Obama signaled that he understands the tangled up crises that have produced the epidemic in black neighborhoods, and he vowed not to shrink from that reality if elected. “When we are impoverished,” he said during a primary debate at Howard University, “when people don’t have jobs, they are more likely to be afflicted not just with AIDS, but with substance abuse problems, with guns in the streets. So it’s important for us to look at the whole body here.”
His campaign platform included a plan he argued would do just that. Complex, big picture analysis like the one Obama offered at Howard too often becomes an excuse for inaction in the face of tough problems; it’s a trap that many people in all walks of life have fallen into when confronted by HIV. But Obama’s potential is to spring policymakers from this trap and end Washington’s three-decade-old vacillation between ignoring the problem and groping for a quick fix to it.
From Bad to Worse
The year 2008 was chocked full of bad news, far too much of it as predictable and preventable as it was devastating. AIDS was no different.
For many Americans, the news got lost amid the uproar over soaring gas prices and plummeting 401Ks. But the summer of 2008 marked a similarly grave turn for the health of black neighborhoods: The U.S. Centers for Disease Control and Prevention, or CDC, announced that the American AIDS epidemic is at least 40 percent larger than previously believed.
Nearly a decade ago, the CDC began developing a new system for monitoring the American AIDS epidemic. For years, HIV tests could determine only whether the virus was in a person’s blood, not how long it had been there. That meant researchers couldn’t differentiate a new infection—say, one that’s six months old—from an old infection—one that’s six years old. And as a result, they couldn’t detect with precision how fast or slow the virus was spreading, only how fast or slow health workers were diagnosing its spread.
A new testing technology, however, now allows the CDC to essentially time-stamp an infection. “It’s like shifting from standard-view to wide-screen HD TV,” quipped CDC’s HIV and STD prevention director Kevin Fenton in explaining the technology to reporters. And using that sharper vision, CDC’s number crunchers went back and developed new estimates for the annual growth of America’s epidemic. The results, published in the August 6, 2008, issue of the Journal of the American Medical Association, were arresting.
Since the early 1990s, the CDC had estimated that 40,000 Americans were newly infected each year. We now know that America has never logged fewer than 50,000 new infections a year. That low mark came in the early 1990s, where it stayed until the late 1990s, when infections began ticking upward. From that point forward, between 55,000 and 58,500 Americans have contracted HIV every year; in 2006, the most recent data available, the CDC found 56,300 new infections.
The study confirmed what we already knew about where all those new infections are being found: Among black people, from all walks of life, and among gay and bisexual men of all races. In 2006, black Americans accounted for 45 percent of new infections, though we’re just 13 percent of the overall population. Gay and bisexual men were 53 percent of infections that year.
Black Gays in ‘Urgent Need’
The most dramatic news from the 2008 CDC studies involved what public health workers call “men who have sex with men,” a term that encompasses everyone from those who identify as gay to those who have occasional homosexual relationships. Conventional wisdom had held that, while more people were getting infected every year, the pace at which those new infections occurred wasn’t quickening. The CDC’s new testing technology allowed researchers to prove this assumption deeply wrong among gay and bisexual men. “Infections have in fact been rising among men who have sex with men,” said Fenton in August, “since the early ’90s.”
And they’ve been rising most sharply among young black men. In 2006, the CDC has discovered, black men between the ages of 13 and 29 accounted for more new HIV infections among gay and bisexual men than any other race or age group. And more than half, or 52 percent, of all black gay and bi men infected that year were under 30 years old.
Overall, 63 percent of all black male infections were found among men who have sex with men in 2006. “These data,” Fenton concluded, “point to an urgent need in this population.”
For years, public health watchers have worried about “HIV prevention fatigue” among young gay men. But we now know that the rapid growth of infections among young men is unique to blacks. Among whites, for instance, new infections were more evenly spread, with men in their 30s and 40s accounting for the largest share, while men under 30 accounted for just 25 percent of new infections.
So why does it appear young white gay men are avoiding the pitfalls of their elders while young black men are not?
That is yet another unanswered question about the black AIDS epidemic. CDC officials theorized during the rollout of the agency’s September 2008 report that black gay youth are more likely to have sex with older men, and thereby put themselves at greater risk. Other researchers have noted that, like blacks overall, young black men who have sex with men choose sex partners from within smaller pools of people and, thus, once HIV is introduced it spreads quickly.
One thing that seems clear is that young black gay and bisexual men do not perceive themselves to be at great risk for HIV, which in turn may make them less likely to learn their HIV status and to take steps to protect themselves or their sex partners. In a dramatic June 2005 study, the CDC found nearly half of the black gay and bisexual men it tested were HIV positive; roughly two-thirds of them had not been diagnosed. An older CDC study, conducted in the 1990s, found that 90 percent of the twenty-something black gay and bisexual men who tested HIV positive hadn’t considered themselves to be at risk.
But there is also research suggesting that this disconnect between actual and perceived risk isn’t entirely made up. It appears that young black gay and bisexual men do not think they are at greater risk for HIV because they aren’t doing things they’ve been told would put them at greater risk. CDC researcher Greg Millet, who is both black and gay, has culled several studies to illustrate this fact. Young black men who have sex with men are less likely to have unprotected anal sex of any sort than either their white or Latino counterparts, Millet says, and they are no more likely to have unprotected anal sex as the receptive partner (HIV is transmitted far easier as the receptive partner than as the inserting partner in anal and vaginal sex). They are also far less likely to use crystal meth, cocaine, injection drugs—even “poppers.” And they are no more likely to work as prostitutes.
Black Women and STDs
The CDC’s 2008 reevaluation of the epidemic’s scope in America also reinforced what we know about racial disparities among women. Although the majority of new HIV infections among blacks in 2006 were found among men who have sex with men, blacks were again far overrepresented among women who contracted the virus. Just over 60 percent of women infected in 2006 were black, who had a rate of new infection that was almost 15 times as high as their white counterparts.
CDC offered no new information about the forces driving the racial disparity among women. But a separate study, in the spring of 2008, reaffirmed at least one major cause that has received far too little attention within the black community: the high prevalence of undiagnosed and untreated STDs, which greatly facilitate HIV transmission.
Since the turn of the millennium, far too many conversations about the racial disparity in HIV infections among women have been dominated by speculation over their relationships with closeted gay men—popularly known as men “on the down low.” And research does suggest that black men who have sex with men are greatly less likely to identify as gay or bisexual than their white peers or to disclose their sexual orientation, regardless of the identity or terminology they use for it. However, there appears to be little link between this fact and their HIV risk.
In fact, men who identify themselves as “gay” are both more likely to report behavior that puts them at risk for HIV and are more likely to be HIV positive than men who have sex with men but do not identify as gay. The same dynamic is true among men who do not disclose their sexual orientation—they are both less likely to be HIV positive and less likely to take sexual risks with their male partners than men who are “out.”
Yet, the conversation about “down low” men has deeply overshadowed the far more crucial one about STD testing and treatment among both black women and black men. HIV requires a route of entry to a person’s blood stream—something that is actually relatively difficult for the virus to find. Certain types of sex offer more ready entry points than others—the vaginal and anal canals, for instance, offer HIV far more access than the penis does. But STDs make everything much easier, because they both create breaks in the skin and increase the density of cells that HIV targets.
Morever, a person who has an STD and is also HIV positive is far more infectious than one who only has HIV. An HIV positive man with gonorrhea, for instance, has a concentration of HIV in his semen that is 10 times higher, as a median, than his counterpart who has only HIV.
As a result of these factors, the presence of an STD makes a person as much as five times more likely to contract HIV when she or he encounters it.
And in 2006, black Americans had higher rates of all STDs than their peers. Black women were 16 times more likely to have syphilis than white women, 15 times more likely to have gonorrhea and seven times more likely to have Chlamydia.
Here again, young people are of particular concern. In March, at the CDC’s annual HIV and STD prevention conference in Atlanta, the agency released a stunning study showing that half of black teenage girls have had a sexually transmitted infection.
Obama and HIV Prevention
In all of this, from syphilis and Chlamydia to HIV, public health officials have stressed and re-stressed the need for more people to get tested. That’s part of what made Barack and Michelle Obama’s dramatic, personal example in Kenya so significant. CDC stresses that roughly a quarter of Americans who are HIV positive don’t know it and the agency believes a lopsided share of new infections stem from that fact.
But in the course of his presidential campaign, Barack Obama also made some pointed policy commitments related to preventing HIV’s further spread. Most significantly, he declared his support for comprehensive sex education in public schools and vowed to “pursu[e] a strategy that relies on sound science and builds on what works.”
The Bush administration offered vigorous support for abstinence-only sex education, which bars educators from discussing safer sex tools like condoms. According to the Sexuality Information and Education Council of the United States (SEICUS), a sexual health research and advocacy group, the fiscal year 2007 federal budget included $176 million for abstinence-only programs, and Washington had spent $1.5 billion on these programs since 1996. Yet, study after study has proven them to not only fail in keeping students from having sex, but also to disseminate dangerous and inaccurate information. The body of evidence against abstinence-only is so great that, according to SEICUS, 25 states had refused to accept the federal money as of August 2008.
The incoming Obama administration and Democratic Congress can take a simple, direct step toward ending HIV’s spread by turning off the federal spigot for abstinence and directing funds to support locally designed, comprehensive sex education.
More broadly, the new administration and Congress can make real change by putting meaningful money into the CDC’s woefully underfunded prevention work.
And the CDC has indeed targeted its domestic HIV prevention and research funds at black Americans. According to CDC, 49 percent of that budget goes to programs working in the black community—reflecting the fact that 45 percent of new infections are in black America. That means CDC spent just under $369 million on black-specific prevention and research in fiscal year 2008. The agency has vowed to direct still more funds toward black-focused prevention work as they become available. It says that 63 percent of the prevention dollars newly available in fiscal years 2006 and 2007 went to programs targeting black Americans.
The problem is that even targeting the whole of CDC’s paltry HIV prevention budget toward black communities wouldn’t do the job. The CDC’s annual HIV-prevention budget has never topped $800 million—a fraction of what the U.S. spends on the Iraq war in a week. Indeed, the prevention budget peaked in fiscal year 2001, at the Bush administration’s start, with just $767 million. It has declined or remained flat every year since then. The only area of the prevention budget that has increased in recent years is that for testing, though even that money has actually come from moving cash out of other piles, according to the Community HIV/AIDS Mobilization Project.
Few genuine stakeholders inside or outside of government would argue that this funding history reflects the need. In September 2008, the House Committee on Government Reform and Oversight reacted to the summer’s news about the epidemic’s growth by holding the first ever oversight hearing on HIV prevention in the U.S. CDC Director Gerberding testified that her agency should spend $1.6 million this year on HIV prevention—more than double the current budget—and $4.8 billion over the next five years. “Not only do we need to expand what we know can work, we’ve got to find new things,” Gerberding told Congress, according to press reports. “The research for new tools is a very important part of it.”
The cost of not investing in prevention is far greater than the funding Gerberding requested. As outlined in a report Gerberding submitted to the House committee, the costs of medical care and early death are estimated to be over a $1 million for every person living with HIV. “Put another way,” the report expains, “56,300 new HIV infections each year may cost the nation over $56 billion.”
Meanwhile, the number of people getting infected—particularly in black neighborhoods—has climbed each year that the prevention budget has stagnated and declined. That trend will continue in the first year of the Obama administration, and in every subsequent year, if the new president does not recognize AIDS as a similarly pressing priority as the economy and the environment. If, however, President Obama offers the same sort of political leadership as he displayed in his personal life during his Kenya visit, he can change the course of this epidemic.