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Abstract
African Americans make up only 12% of the United States population, but they have the highest HIV rates of all races and ethnicities, accounting for over 46% of all HIV diagnoses (CDC, 2013). HIV is the fifth leading cause of death in African American men and seventh among African American women (Kaiser Family Foundation, 2014). There are a variety of factors that result in higher rates of HIV transmissions among African Americans, including social, cultural, economic, environmental, and political causes. Traditionally, health promotion and disease prevention interventions were focused on individual patients and were not necessarily based on the broader social and cultural contexts of scientific research principles.
Identifying and targeting interventions that coincide with the needs of multiple populations such as men who have sex with men, intravenous drug users, and young people who are marginalized and discriminated against, is difficult. Stigmatized populations are often hidden and difficult to reach (UNAIDS, 2013). Therefore, approaches to reducing HIV and AIDS prevalence must be multi-faceted and multi-leveled. Current literature suggests that successful health promotion, disease prevention, and treatment efforts, including medication regimens, should be based on demographic data and epidemiological concepts such as population-level assessments of disease burden, risks, and outcomes (Dorrucci, 2010). In order to achieve more favorable outcomes, protocols and clinical practice guidelines should be based on random control studies (RCTs) that examine patterns and the distribution of the principles of HIV/AIDS in high-risk populations and certain geographical regions locally, nationally, and globally. Furthermore, interventions should include biomedical, behavioral, and social services with a focus on quality of life.
A number of studies have examined contributing factors to the high prevalence of HIV/AIDS in African Americans, such as discrimination and stigma, homophobia, poverty and sexual relationships, unemployment, lack of access to healthcare, and the high cost of HIV/AIDS treatment. Fear of stigma and discrimination and widespread perceptions about the escalating rates of HIV/AIDS in African Americans and the misconceptions about routes of transmission are barriers that impede dialogue, create barriers to accessing key populations, and derail early preventive measures and treatment (CDC, 2013).
Incarceration can also play an integral role in discrimination and stigma. In mid-2013, African Americans accounted for more than 36% of prison inmates and 65% of prison deaths (in 2007) from AIDS-related illnesses, which provide another avenue for HIV transmission (CDC, 2012). Homosexuality is highly stigmatized in the African American community with the majority of African American churches preaching that homosexuality is a sin (McCree, Jones, & O’Leary, 2010). As a result, African American men may prefer to keep their sexuality a secret.
A cause and effect relationship oftentimes exists between poverty and sexual relationships. According to a recent article, twenty eight percent of African American families live in poverty (Avert, 2014). African Americans often live in heavily populated residential areas where high-risk sexual behavior and drug abuse is prevalent. This is known as 'residential segregation' and accounts for the high rates of HIV infections in these communities (Avert, 2014).
Unemployment is another issue that many African Americans and other minorities may encounter. In the workplace, people living with HIV/AIDS may suffer stigma in the form of social isolation or ridicule from their employers and/or co-workers or may fear discriminatory practices such as termination (CDC, 2013). Without a job or underemployment, the high costs of treatment increases the likelihood that African Americans may delay treatment until they are seriously ill. Unfortunately, unaware of their status, many have engaged in unprotected sexual acts with multiple partners by this time. Health care providers must address these missed opportunities to decrease racial disparities (CDC MMWR, 2010).
Lastly, another contributing factor to the rising prevalence of HIV/AIDS in African Americans is lack of access to healthcare. After an AIDS diagnosis, survival and death rates are higher among African Americans than other racial and ethnic groups due to poor access to health care (CDC, 2013). People who live in poverty often have state-funded insurances such as Medicaid or Medicare while others are uninsured altogether. In July 2010, the National HIV/AIDS Strategy underscored these facts in HIV treatment in the Affordable Care Act. In 2014, these changes expanded Medicaid eligibility and provided protection to people with pre-existing and chronic illnesses such as HIV/AIDS (U. S. Department of Health & Human Services, 2014).
In order to make a significant difference in the escalating rates of HIV and AIDS in African Americans, the DNP educated nurse practitioner may serve in various roles, including clinician, educator, consultant, collaborator, researcher, and legislator. In these multiple roles, the nurse practitioner can advocate for change at the local, state, national, and even global levels; appeal to community leaders, faith-based organizations, and key institutions that help mold and reinforce societal norms and values; work collaboratively with other disciplines to address the multiple factors such as stigma and discrimination, poverty, unemployment, and housing; and advocate legislatively with policymakers to pass laws that increase awareness of HIV/AIDS and pinpoint contributing factors that play an integral part in this epidemic.
Epidemiological Basis for Preventive Strategies
Primary prevention – Clinician and Educator. The nurse practitioner should conduct individual and group screenings and prevention programs in churches and other common meeting places for African Americans.
Secondary prevention – Consultant and Collaborator. Health care practitioners should provide routine screenings on high-risk persons and institute the early initiation of antiretroviral therapy based on current research, including random controlled trials; conduct widespread social marketing and advertising campaigns that target churches and other heavily populated African American organizations; serve as consultants for patients and other disciplines, and conduct educational programs for peers and other community providers (Grant et al., 2010; Thigpen et al., 2011).
Tertiary prevention – Researcher and Legislator. Providers should remain in constant contact with health care facilities and community organizations and implement changes based on evaluations and current epidemiological research which include, but is not limited to, qualitative and quantitative population-based studies; actively participate in legislative policies, serving as an advocate, so that changes can be made locally, nationally, and globally (CDC, 2013)
References
CDC (2012). Estimated HIV incidence in the United States, 2007–2010. HIV Surveillance Supplemental Report, 17(4). Retrieved from http://www.cdc.gov/hiv/pdf/statistics_hssr_vol_17_no_4.pdf
CDC (2013). HIV Surveillance Report, 23. Retrieved from
http://www.cdc.gov/hiv/topics/surveillance/resources/reports
Dorrucci, M. (2010). Epidemiology of HIV. Update. Recenti Progressi in Medicina, 101(1), 12-15.
Grant, R. M., Lama, J. R., Anderson, P. L., McMahan, V., Liu, A. Y., Vargas, L.,…Goicochea, P. (2010). Pre-exposure chemoprophylaxis for HIV prevention in men who have sex with men. New England Journal of Medicine, 363(27), 2587-2599. doi: 10.1056/NEJMoa1011205
HIV & AIDS among African Americans (2014). Avert. Retrieved from http://www.avert.org/about-avert.htm
Kaiser Family Foundation (2014, April 25). Black Americans and HIV/AIDS. Retrieved from http://kff.org/hivaids/fact-sheet/black-americans-and-hiv-aids/
McCree-Hubbard, D., Jones, K. T., & O’Leary, A. (Eds.). (2010). African Americans and HIV/AIDS: Understanding and addressing the epidemic. Springer: New York. doi: 10.2174/1874613601206010098
Thigpen, M. C., Kebaabetswe, P. M., Smith, D.K., Segolodi, T. M., Soud, F. A., Chillag, K.,…Paxton, L. A. (2011, July 17-20). Daily oral antiretroviral use for the prevention of HIV infection in heterosexually active young adults in Botswana: Results from the TDF2 study. International AIDS Society: 6th IAS conference on HIV pathogenesis, treatment, and prevention.
UNAIDS (2013). 2013 UNAIDS report on the global AIDS epidemic. Global Report. Retrieved from https://www.issuu.com/unaids/docs/20140716_unaids_gap_report
U.S. Department of Health & Human Services (2014, November 21). Affordable Care Act and HIV/AIDS. AIDS.gov (Blog). Retrieved from
http://www.aids.gov/federal-resources/policies/health-care-reform/