Women and hiv/AIDS
“Health inequalities are the sum total of all the other social inequalities.” William Julius Wilson
Fellow, Edmond J. Safra Center for Ethics, Harvard University, 2015-16
I am a political philosopher who studies how disparities in health contribute to and perpetuate social and political inequalities. In the mid-1990s, I introduced a course that I called “Women, Health, and Social Justice.” My aim was to investigate diseases and disorders to which women are disproportionately vulnerable, such as anorexia, breast cancer, depression, and so on, and to identify the social and environmental factors that contribute to illness. Once some of these social factors were understood, my students and I would evaluate public and governmental responses to women’s health crises.
I devoted one section of the course to sexual health issues. This is when I began to research hiv/AIDS rates among women, both in the U.S. and worldwide. Two aspects of this growing epidemic would typically surprise my students: that outside the U.S., rates among women were as high or higher than rates among men (see: amfAR: Statistics: Women and HIV/AIDS, AVERT: Women and HIV/AIDS , an article I shared with my students in 2004), and that, in some countries, marriage raises a woman’s risk of infection (for example, see: article on Malawi, and “Protecting Young Women from HIV/AIDS” ). Because the hiv/AIDS epidemic has been concentrated in the gay male population in the U.S., Americans associate this disease with men. Other faces of this disease include injection drug users and sex workers.
I remember one day in class, when I shared some research findings about married women, a student blurted out “I didn’t know my husband had AIDS until he died.” On another day, I remember a student throwing back her head and slamming her pen down on her desk. If straight, married women, who presumably were sexually monogamous and not injecting drugs were vulnerable, then what the hell was going on, my students wanted to know. One student asked me if I had more information that she could bring to her church. Hiv/AIDS rates were beginning to climb among African American women and Latinas, and there was little public discussion of this trend and a great deal of shame.
While there is more attention today to rates of hiv among women, many still see this as a “gay disease.” In response to an op-ed I wrote, I received numerous emails and readers’ comments alleging that the women who get infected have male partners who are gay or bisexual, and they have “gay sex” (i.e., anal sex). My students (who are mostly Latina and black) often ask if there are higher rates of injection drug use among blacks and Latinos, higher numbers of sex workers in these groups, and lower rates of condom use. All of these assumptions and stereotypes have been shown to be false (see national study of condom use rates , study showing black/white hiv/AIDS disparities cannot be explained by differences in drug or sexual behaviors . My students repeatedly overlook, and even resist, more obvious explanations. Instead, they elaborate the theories that have gained traction in our society, and then respectfully suggest that perhaps I’m not sufficiently acquainted with the “down low”, or with lifestyles that involve casual or commercial sex, and drugs.
When I ask my students to think beyond what they have been told about hiv/AIDS, and to think about how diseases spread, and about documented (rather than mythical) differences between ethnic groups, a different story about hiv/AIDS begins to emerge. One question I pose to my students is: with which partners is someone least likely to use a condom? The answer: spouses and steady boyfriends/girlfriends. Rates of condom use are not tied to ethnic or gender characteristics, but rather to types of social relationships and access to condoms. Long-term intimate partners often expect high levels of trust, which can make it difficult to adhere to using condoms. Teenagers and prison inmates might not have access to condoms when they need them. A second question I raise is: what socioeconomic differences have been documented among U.S. ethnic groups, and how might differences in wealth and poverty affect health outcomes? I ask my students to think through the impact such differences might have on access to health care and information, and thus on hiv/AIDS rates. A third question I ask is: how does the prevalence of an infectious disease in one’s community affect one’s risk? This is relevant even for STDs because people typically select sexual partners from members of their community, and so their chances of having a partner who is infected with hiv is greater if there is a higher hiv prevalence in their community. In other words, even when a person’s individual risk factors are similar to someone living in a community with low prevalence, living in a community with relatively high prevalence raises one’s risk.
My intellectually inquisitive students are generally not satisfied by these explanations. Nor should they be, because they don’t explain how prevalence rates for hiv/AIDS rose more quickly among low-income African Americans than in other low-income communities. Fortunately, two important factors that help explain the black/white disparity in hiv/AIDS rates in the U.S. have now been identified. One factor is the differential incarceration rates between black and white men (see: “The Effects of Male Incarceration Dynamics on AIDS Infection Rates among African American Women and Men” , “Incarceration, African Americans and HIV” ). The other factor is racial segregation and its impact on social networks (see: “Social Context, Sexual Networks, and Racial Disparities in Rates of STIs” “Ending the Epidemic of Heterosexual HIV Transmission Among African Americans”). These factors may also explain relatively higher hiv/AIDS rates among Latinos (compared to non-Hispanic whites), yet more studies need to be done on hiv/AIDS transmission in Latino communities, and such studies need to factor in the impact of immigration on these communities. Because the disparity in hiv/AIDS rates between Hispanic and non-Hispanic whites is not quite as large as between blacks and whites, and because there is not as much of a consensus about what social factors are contributing to elevated hiv/AIDS rates among Latinos, my research on the moral and political implications of hiv/AIDS disparities focuses mostly on differences between black and white communities in the U.S.
In the 1990s and early 2000s, the spike in hiv/AIDS rates among African American women was much less understood. The rate of hiv/AIDS among African American women is now 20 times higher than for non-Hispanic white women. My first classroom discussions began in the years just before effective drug therapies were introduced (around 1996) that could keep an infection from progressing to AIDS. Contracting hiv had generally been a death sentence until then. Sadly, an hiv diagnosis still leads to premature death for African American women, in many cases. (see: CDC: Leading Causes of Death in Black Females ). Some women do not know they could be at risk and therefore do not seek testing. Others get tested, once symptoms develop and they are forced to seek medical care, but then do not continue with their treatment, possibly due to the lack of health care insurance or an untreated mental health issue such as depression. For these and other reasons, rates of anti-retroviral therapy (ART) use, and accordingly viral suppression, are lower for African Americans than other groups (see kff.org: HIV Testing and Access to Prevention and Care ). Yet today, full and continuous viral suppression from ART not only prevents disease progression and premature death, but virally suppressed people are not infectious. (see: No partner infections with viral suppression , Viral Suppression May Bring HIV Transmission Risk Close to Zero ). To get more people tested and treated, we need to challenge the many myths and stigmas that attach to hiv, and also improve access to health care, including mental health care (see: HIV Care Continuum ).
One structural risk factor that puts black Americans at greater risk is relatively high levels of incarceration. Black men are incarcerated at six to seven times the rate as white men, and over 90% of those incarcerated in the U.S. are men. Black women are incarcerated at roughly four times the rate for white women (see “Incarceration, African Americans, and HIV” ). Prison conditions can increase a person’s risk for a number of reasons. First, hiv prevalence in our prison and jail population, including juvenile detention centers, is anywhere from three to five times higher than for those not incarcerated. Second, sex happens in prison, both consensual and non-consensual. This has little to do with the number of gay or bisexual men in prison, which is not significantly higher than outside. Prison sex is often about power relations among inmates (see: Prison Sexuality ). Some inmates use sex to intimidate and dominate others, and inmates with subordinate status use sex to obtain protection from inmates with greater social status or power. Most men who have sex with men inside prison choose women as sex partners when they are outside prison. Despite public knowledge about the sexual practices of inmates, less than one percent of prisons make condoms available to inmates. Third, injection drug use and tattooing take place in prison, while few prisons provide inmates with the means to obtain sterile needles. And fourth, inmates may be exposed to infected blood when violent fights erupt.
Health researchers do not know what percent of inmates become infected with hiv while in prison and what percent were infected before entering prison. STD testing when entering prison in the majority of states is voluntary, and there is very little follow-up STD testing before one is released (“Incarceration, African Americans, and HIV” ). Fear of acquiring a stigma by testing positive may be greater among inmates, and their expectation of getting appropriate medical treatment may be lower. Ironically, it may now be easier for some inmates to get on ART while inside prison, because outside they may not have access to health insurance and health care. This is in part due to job and housing discrimination that many former inmates face, and due to the ongoing high numbers of people who lack health insurance in the U.S., especially in states that have not expanded Medicare. Yet, until there is more STD testing upon entry and exit from prison, it is difficult to estimate the rates of hiv incidence (new infections) as opposed to prevalence (those living with hiv) inside our prisons, jails, and detention centers. Even if many inmates enter prison already infected, having a prison record decreases their chances of staying healthy and noninfectious upon release.
Upon release from prison, most black men return to communities that are predominantly African American. Because viral levels rebound quickly when someone stops taking ART (see: AIDSinfonet: Treatment Interruptions ), short interruptions in health care, at a moment when one is reuniting with family and friends, facilitates the transmission of hiv to one’s sex partners. Former inmates, who are already confronted with serious social challenges and stigmas, are unlikely to discuss with family, friends, and future intimate partners their sexual encounters with men, or their needle sharing habits, while behind bars. Heterosexual men, in particular, may be less inclined to be transparent about their sexual contact with men while in prison with future female partners and with health providers. In addition, some studies suggest that high rates of incarceration have substantially reduced the numbers of adult men in African American communities. This presents a number of challenges for maintaining relationships with families and adult partners, and it significantly reduces the number of potential partners for adult heterosexual women. Because of the low sex ratio of men to women, black women are more likely to enter “high-risk relationships”—relationships with men who are at high risk for hiv due to their history of incarceration, drug habits, or number of concurrent sexual partners (see “Association of Sex Ratios and Male Incarceration Rates with Multiple Opposite-Sex Partners” , “The Effects of Male Incarceration Dynamics on AIDS Infection Rates among African American Women and Men” ). Some researchers speculate that black women are not only more likely than other women to enter relationships with men at elevated risk for hiv, but they may be willing to engage in more risky behaviors in order to maintain these relationships. Black women experience a shortage of available partners due to high incarceration rates, but also due to the racism they confront in dating markets, and this in turn diminishes their negotiating power in their social relationships with men.
In addition to the social factors that increase the vulnerability of black women to hiv, women are, in general, more biologically vulnerable than men, in that a man is more likely to transmit hiv to a woman than vice versa (see: “Rethinking Gender, Heterosexual Men, and Women’s Vulnerability to HIV/AIDS” ). This has to do with a variety of factors, including the potential viral load in semen, a woman’s exposure to semen during penetrative sex (compared with a man’s exposure to vaginal secretions), and the sensitivity of the vaginal tissues exposed. The CDC reports that, for black women with hiv, 87% were infected through heterosexual sex. Of course, this is not to blame black men for transmitting hiv to black women. All of us engage in behaviors that put us at risk for illness and other misfortunes and, as individuals, the level of risk taking by African Americans in regard to hiv exposure is no higher than for other groups.
One study shows that “White young adults in the United States are at elevated STD and HIV risk when they engage in high-risk behaviors. Black young adults, however, are at high risk even when their behaviors are normative.” (http://www.ncbi.nlm.nih.gov/pubmed/17138921 ) What this means is that black Americans, as a group, are experiencing higher rates of hiv/AIDS compared to other groups because of structural or environmental factors, and not because of higher levels of individual risk taking within this group. For instance, the same rates of condom or drug use can produce different outcomes in social environments with different levels of hiv prevalence. Moreover, when people who have the same degree of tolerance for risk as others are put in environments where they cannot protect themselves, they may get harmed. Black men are at greater risk for hiv/AIDS not because of higher rates of closeted bisexuality (the “down low” hypothesis) or other individual risk factors, but due to systemic features in our society—in particular, higher rates of incarceration and the conditions of prison life in the U.S.
Unfortunately, the current methods for gathering and presenting health statistics perpetuate the misunderstanding that the men most at risk for hiv are gay or bisexual. The CDC and other research agencies gather health statistics for “men who have sex with men” (MSM), and many are under the impression that this group consists of gay and bisexual men. But MSM includes heterosexual men who have had sexual contact with men. What is relevant for gathering health data in most contexts is a person’s behavior rather than one’s psychological disposition or social identification (i.e., sexual orientation). Moreover, the CDC presents statistics on MSM and on heterosexual men, which suggests that these categories are mutually exclusive, although they are not. In this context, “heterosexual” means something like men who do not report any sexual contact with men during some time period. White, Black, Hispanic/Latino MSM have the highest numbers and rates of infection (see: “New HIV Infections in the U.S. for the Most-Affected Subpopulations”), but this includes men who report some sexual contact with men, including those who identify as heterosexuals. So this category can include men who have been incarcerated and who identify and live as heterosexuals outside of prison. Some commentators refer to sex in men’s prisons as “situational homosexuality,” but this too can obscure the factors that shape behavior and its consequences. Rather than contrast “heterosexual men” with MSM, the CDC should use as the contrasting category “men who have sex exclusively with women.” Such men are at lower risk for hiv, due to the lower probability of transmission from women to men, and also because such men are less likely to have been incarcerated.
If incarceration rates are an important part of the story behind the hiv/AIDS epidemic in African American communities, how is it that gay men have had higher rates of hiv/AIDS without disproportionately high incarceration rates? The second structural factor I mentioned above that helps to explain this is social segregation. When groups are socially segregated, whether by choice or not, their members form networks of friendship and intimacy within relatively small and insular networks. Members of such groups are more likely than members of less segregated communities to have a former or current sex partner in common. If an STD is introduced into such a network of sexual partners, then it will spread among the members of that community more quickly than to people outside that community (see: “How do sexual networks affect HIV/STD prevention?” , “Understanding Disparities in the HIV Epidemic” ).
In the U.S., hiv/AIDS outbreaks first showed up in various socially segregated and sexually insular gay communities, although outside the U.S. this was not the case. The growing prevalence rates of hiv among gay men, combined with the greater biological vulnerability of men who have sex with men, can explain much of the disparity in hiv/AIDS rates between gay and straight men. A man who is anally penetrated by another man during sex is at a higher risk for hiv (some researchers estimate the risk is double or more) for much of the same reasons as women who are vaginally penetrated by men. The so-called “passive” party is more exposed to the bodily fluids of his partner, and semen can have a relatively high viral load compared to other bodily fluids. Moreover, anal tissues, like those around the vagina and cervix, are less impervious to viruses than other areas of the body. Another risk factor for gay men is that they may have more concurrent sex partners, on average, than heterosexual men, or be with a partner who has concurrent sex partners.
Like gay men, African Americans often live in socially segregated and sexually insular communities. This factor, combined with the greater biological vulnerability of women to an hiv infection, helps to explain how hiv spread more quickly among black women than among other groups of women, as hiv prevalence rates climbed in their community. Moreover, due to the destructive impact of hyperincarceration on both healthy sex ratios and stable adult partnerships, heterosexual black men may have more concurrent sex partners, on average, than white heterosexual men. In addition, formerly incarcerated men often face job and housing discrimination, which constrains their access to health care and networks of social support that facilitate continuous treatment for illness. Untreated men who are hiv-positive are more infectious and more likely to transmit the virus to a partner. In short, both social segregation and hyperincarceration help to explain disparities in hiv rates between African Americans and other groups, and between black and white women.
Understanding both the social and biological determinants of disease should help us design better policies for addressing public health crises, such as hiv/AIDS. There are some large and long-term changes that our society needs to make, such as reducing incarceration rates and ending racially unjust practices that lead to police profiling, biased sentencing, and racial segregation. Unfortunately, these changes will not happen over night, and the hiv/AIDS crisis demands more immediate action. Fortunately, there are some effective interventions that can quickly be introduced, such as expanding Medicaid in all states, and signing up inmates for Medicaid before they leave prison. In addition, we can augment and strengthen re-entry programs for inmates, so that inmates who are hiv-positive have continuous access to ART and medical providers who are experienced in hiv care. Furthermore, much more can be done inside prisons, such as ramping up STD testing upon entry and before release from prison, and insuring that prisons provide adequate care for hiv-positive inmates. Also, all prisons need to make condoms available to inmates and initiate needle exchange programs, similar to those in place outside prison.
Prisons and jails need to do a much better job of protecting the basic human rights of those in their custody, and this includes protecting them against sexual assault and other forms of physical and psychological violence. Incarcerated persons have had their liberty taken away from them. There is no justification for forcing people in jail or prison to live under conditions where they cannot protect their mental and physical health. Such conditions not only reflect societal neglect and the abuse of power by state officials, but misguided and unjust forms of punishment. It is the responsibility of all citizens to insure that the rights of all are respected, including those who are in some form of detention. Harsh and unjust punishments not only destroy the health and lives of those who are arrested and convicted of crimes, but they also unfairly burden the communities to which they return. Incarceration rates in the U.S. quadrupled during the same decades that the hiv/AIDS epidemic skyrocketed in African American communities. The relationship between these sad developments, as well as our failures in correcting long-term patterns of racial segregation, are a significant part of the picture that explains how black disadvantage is maintained. We now need to take both short- and long-term steps to reverse these developments in our country.