HIV/AIDS Disparities Among African-American Women in New York

Introduction

"About 30% of Hispanic and 20% of African-Americans lack a usual source of health care compared with less than 16% of European-Americans" (Agency for Healthcare Research and Quality, 2003). "Racial and ethnic disparities in health care, whether in insurance coverage, access, or quality of care, are one of many factors producing inequalities in health status in the United States" (Lillie-Blanton & Lewis, 2005, p. 1). No universally accepted definition of health disparities or health inequities currently exists; to some, disparities are simply differences in health processes or outcomes between population groups (Meyers, 2007).

"Clearly understanding racial and ethnic health disparities demands a careful examination of all groups in all societies in which such disparities exist" (Dressler, Oths & Gravlee, 2005, p. 233). Eliminating disparities in health and healthcare was a priority identified in the U.S. Department of Health and Human Services Healthy People 2010 initiative (Kilbourne, Switzer, Hyman, Crowley-Matoka & Fine, 2006).

This research report describes the current health situation and issues facing African-American women in New York City. After describing current health status — including population, birth rate, health indicators, and infant mortality — the focus turns to the major issue of HIV/AIDS. The central concern of the report is the racial and ethnic disadvantages, as well as discrimination, experienced by HIV-positive African-American women attempting to receive primary care treatment. It is challenging to eradicate these disparities for government and institutions partly because their causes are entangled with a controversial history of race relations in the United States. However, it is important to ensure greater fairness and accountability in the healthcare system for a growing regional base, including those who purchase, pay for, and provide health care (Lillie-Blanton & Lewis, 2005).

As much research has now been conducted on healthcare disparities, the focal point has shifted from assessing and documenting disparities toward exploring their roots and causes, as well as developing interventions to address them. James, Thomas, and Lillie-Blanton (2007) note that data remain incomplete for certain racial and ethnic subgroups, and for those who self-identify with more than one racial group. "Information that documents health care disparities is important to understanding where progress has been made and the challenges that remain" (James, Thomas & Lillie-Blanton, 2007).

Current Health Status: African-American Women in New York

Dressler, Oths, and Gravlee (2005) state that based on current investigation, comparatively little progress was made toward eliminating racial and ethnic inequalities among health status indicators over the previous decade. Progress toward the goal of eliminating health disparities will require more concerted efforts going forward. For HIV prevention to be successful in communities of color — such as Pacific Islanders, Hispanics, and/or American Indians — research must specifically target African-American communities as well.

In the New York metro area, the African-American population is larger than in any other city in the United States, at approximately 3.5 million — roughly 9% of the entire Black population of the country. Within New York City itself, there are approximately 2.4 million African-Americans, of whom women comprise 52% (CDC Health, United States Report, 2007).

Health statistics show that 18% of African-American women in New York City currently smoke, and 79% of those aged 20 years and above are overweight. Life expectancy has increased significantly from an average of 33.5 years in 1900 to 76.5 years today. Additionally, 41% of African-Americans in New York State have hypertension.

The overall infant mortality rate in the United States declined from nearly 100 deaths per 1,000 births in 1900 to 6.89 per 1,000 in 2000. However, the rate did not decline significantly between 2000 and 2005. It fell somewhat from 6.86 in 2005 to 6.68 in 2006, and the 2007 rate of 6.75 was not statistically different from the 2006 figure (Matthews & MacDorman, 2010). Substantial disparities in infant mortality among racial and ethnic groups have persisted — and in some cases widened — indicating that not all groups have benefited equally from social and medical advances. Data show that the highest infant mortality rate was among African-American women (13.35 per 1,000 live births), a rate 2.4 times that of non-Hispanic white women (5.58).

Racial and ethnic differences in infant mortality rates may partly reflect differences in maternal sociodemographic and behavioral risk factors. For example, infant mortality rates are higher than the U.S. average among infants born to mothers who are "teenagers, unmarried, smokers, have lower educational levels, had a fourth or higher order birth, or did not obtain adequate prenatal care" (Matthews & MacDorman, 2010).

"Medical care makes a limited contribution to population differences in health but may have a greater impact on the health status of vulnerable populations, such as African-American women with HIV/AIDS" (Williams, 2002, p. S43). Kilbourne et al. (2006) define health disparities as "observed clinically and statistically significant differences in health outcomes or healthcare use between socially distinct vulnerable and less vulnerable populations that are not explained by the effects of selection bias" (p. 2114). These observed differences represent inequalities or measurable gaps between groups. "These disparities in health outcomes or health status may be caused or exacerbated by patient, provider, or system-level factors that result in differential treatment" (Kilbourne et al., 2006, p. 2114).

"A large body of evidence documents pervasive racial and ethnic health disparities in diagnosis and treatment of minority persons once they enter the U.S. health care system" (Williams, 2002, p. S43). These disparities span various facets of care, ranging from technology to basic diagnostic and treatment interventions, including healthcare coverage (e.g., Medicare and Veterans Affairs), disease progression (e.g., HIV/AIDS stages), and medical facility access (e.g., primary care facilities; Williams, 2002).

Minority women face many challenges in accessing medical care, including availability of services and insurance coverage. Williams (2002) stated that minority women are less likely to be insured and more likely to have public health coverage, which is limited in the scope of treatment and services it provides.

Evidence from Literature

The widening gap in health disparities is receiving increased national attention. A vast literature documents substantial racial, ethnic, and socioeconomic differences in health status, treatment, access to services, and health outcomes (DeLoach, 2003). HIV health disparities continue to afflict the African-American female community. The research reviewed here attempts to understand the lived experiences of African-American women with HIV/AIDS in order to help bridge the gap in racial and ethnic health disparities within medical and primary care settings. The reasons behind these disparities are complex and include poverty, discrimination, inadequate access to healthcare, distrust of medical services and physicians, and high-risk behaviors. Stigma and discrimination remain heavily present in urban communities in relation to HIV/AIDS.

There are also significant gaps in patient-provider communication and trust within the primary care setting. Armstrong, Ravenell, McMurphy, and Putt (2007) noted that "adding to concerns about the overall decline in trust is the recognition that distrust may be particularly prevalent among racial and ethnic minority groups" (p. 1283). Potvin, Gendron, Bilodeau, and Chabot (2005) argue that the first challenge in overcoming health disparities in the primary care setting is to formulate a program theory that accounts for the social determinants of health and the mobilization of diverse factors for social change.

These findings can help local community and state health organizations establish more effective treatment and prevention programs geared toward African-American women, especially young African-American females living with HIV/AIDS. In many communities, a lack of information about the epidemic feeds stigma and bias against people living with HIV/AIDS. Effective health communication efforts regarding treatment and prevention programs are key components to reducing HIV/AIDS rates within minority communities.

Conclusion

Sutton et al. (2009) declared that challenges still remain in properly addressing factors that continually contribute to the problems of HIV/AIDS health disparities in the United States; some of the contributing factors include socio-cultural factors such as poverty, low literacy, stigma, unemployment, homelessness, racism, homophobia, and being underinsured or uninsured, which decreases access to acceptable health care. The U.S. Department of Health and Human Services (2010) stated that women with HIV infection face great difficulty finding healthcare and bear a heavy burden of caring for children; they typically lack adequate social support and face other problems that may interfere with their ability to access or adhere to treatment.

Lyles et al. (2007) reported that the CDC's HIV/AIDS Prevention Research Synthesis Team performed a systematic analysis of literature on HIV behavioral interventions in the United States from 2000 to 2004, seeking evidence of efficacy in reducing HIV risk. "Most of the best-evidence interventions are directly applicable for populations in greatest need of effective prevention programs; however, important gaps still exist" (Lyles et al., 2007, p. 133). More community health partnerships and programs should be established to help alleviate health barriers and improve health equity. Addressing the issues that increase the spread of HIV/AIDS among African-Americans in the United States will require collaboration from federal, state, and local health agencies and organizations (Sutton et al., 2009).

According to Sutton et al. (2009), new opportunities are being presented through the Routine HIV Screening Coverage Act in the 111th Congress:

"This bill would require health insurance plans to cover routine HIV tests under the same terms as other routine health screenings and would allow for broader compliance with the 2006 recommendations for routine HIV screenings in health settings. Efforts that increase alignment of best public health practices with executive-branch goals will improve overall HIV prevention and intervention synergy and will enhance our ability to stop the ongoing spread of HIV disease within African-American communities." (pp. S356–S357)

A joint effort by various HIV stakeholders, along with the National AIDS Strategy movement by the Office of National AIDS Policy at the White House, will aid in combating the spread of HIV/AIDS within African-American communities in the United States (Sutton et al., 2009).

The Minority AIDS Initiative, managed by the Department of Health and Human Services, serves as a resource for HIV/AIDS prevention, research, and treatment by providing targeted federal funding to reduce HIV/AIDS disparities among African-Americans and other communities of color at high risk for HIV (Sutton et al., 2009). Sutton et al. (2009) described the initiative's role as follows:

"The Minority AIDS Initiative objectives are used to address high-priority HIV prevention, research, and treatment needs in highly affected communities of color. The Minority AIDS Initiative was officially made into law when it was incorporated in the Ryan White Treatment Modernization Act passed by Congress in 2006. Today the Minority AIDS Initiative continues to try to bridge the gap in HIV preventive and medical service delivery by providing services to underserved communities, empowering local community-based providers to implement specific interventions to reach their communities, and supporting research in these disproportionately affected communities." (p. S352)