Kevin Fenton, MD, PhD, FFPHDirector

National Center for HIV/AIDs, Viral Hepatitis, STD and TB PreventionCenters for Disease Control and Prevention

Understanding HIV/AIDS in the context of the Black

Diaspora: An epidemiological framework

AIDS 2012HIV and AIDS in Context of the Black Diaspora

Regional SessionJuly 25, 2012

Understanding the Black diaspora

HIV/AIDS epidemic typologies, and their determinants, across the Black diaspora

Moving forward: Enhancing the HIV/AIDS prevention response within and across the Black diaspora

Overview

Disclaimer: The opinions expressed are those of the author and may not necessarily reflect the official position of the Centers for Disease Control and Prevention

The term “diaspora” refers to the movement, migration, or scattering of people away from an established or ancestral homeland (Cohen, 1997)

Between 1500 and 1900, approximately four million enslaved Black Africans were transported to island plantations in the Indian Ocean, about eight million were shipped to Mediterranean-area countries, and about eleven million survived the Middle Passage to the New World.

African (and to lesser extent Caribbean) immigration has become the primary force in the modern black diaspora It is estimated that the population of recent African

immigrants to the United States alone is over 600,000. There are significant populations of African immigrants in

many other countries around the world, e.g. UK and France.

The Black DiasporaHistoric origins and current drivers

TYPE I:Post-Slavery

Black Majorities

The Black DiasporaA descriptive typology

TYPE II:Post slavery,

Black Minorities

TYPE III:Post-

Colonialization Black Minorities

TYPE IV: Recent

economic and social migrants

Caribbean region

Populace mainly of African descent

Political, social power structures and networks largely governed by those of African descent

Social and economic trajectories heterogeneous and determined by economic, political and social

North, Central and South America

Populace mainly of European or Mixed descent with varied proportion of blacks

Political, social power structures and networks largely governed by ethnic majority

Civil rights heterogeneous

Western Europe

Populace almost entirely of European descent

Black migration in mid-late 20th Century

Political, social power structures and networks largely governed by ethnic majority

Civil rights influence minimal and heterogeneous

Western Europe, Canada, United States, Intra-Africa

Level of integration into society heterogeneous

Display general characteristics of economic migrants

Political, social power structures and networks largely governed by ethnic majority

Historic New

Indicator 2001 2011Number of adults and children living with HIV

210 000 230 000

Adult prevalence 1.0% 1.0%

New Infections (adults and children)

19 000 13 000

Number of deaths (adults and children)

18 000 10 000

TYPE I: Post-Slavery Black MajoritiesCaribbean Region: Trends in the HIV/AIDS epidemic, 2001-2011

Source: WHO/UNAIDS Source; UNAIDS World AIDS Day Report 2011; UNAIDS, Together We Will end AIDS 2012

The Caribbean has the second highest regional HIV prevalence after sub-Saharan Africa, although

the epidemic has slowed considerably since the mid-1990s.

Overall, unprotected sex between men and women—especially paid sex– is believed to be the main mode of HIV transmission in the Caribbean.

High HIV infection levels have been found among female sex workers in the region: 4% in the Dominican Republic, 9% in Jamaica and 27% in Guyana.

Sex between men is also a significant factor in several national epidemics with at least 12% of reported HIV infections in men estimated to have been caused by unprotected sex between men. The estimated HIV prevalence among MSM for 2005-2008 varied from 6.1% in

the Dominican Republic to 32% in Jamaica. Mobile and migrant populations as well as STI clinic attendees

also represent vulnerable groups with higher HIV prevalence relative to the general population.

TYPE I: Post-Slavery Black Majorities Caribbean Region: Epidemic Drivers

Source: UNAIDS Caribbean Fact Sheet, 2010; UNAIDS, The Status of HIV in the Caribbean

TYPE II: Post-Slavery Black MinoritiesAdults and Adolescents with HIV and Awareness of HIV Status, 2009, United States

Source: CDC. HIV Surveillance Report Supplemental Report Vol. 17, No. 3. June 2012.

Estimated number of HIV infected persons in US

1,148,200

Estimated number unaware of their HIV infection

207,600 (18%)

Estimated new HIV infections annually 48,100

Estimated number of blacks living with HIV

510,600

Estimated number of blacks unaware of their infection

99,200

Blacks represented approximately 14% of the U.S. population, but accounted for 44% of 48,100 estimated new HIV infections in the U.S. in 2009.

Of the 191,698 HIV diagnoses from 2007-2010, blacks accounted for 45% of the total, 62% of women, 64% of infections attributable to heterosexual contact, and 66% of children aged under 13 years.

Lifetime risk of HIV diagnosis for African Americans is 1 in 16 for men; and 1 in 30 for women

In 2009, the highest rate of deaths among persons diagnosed with HIV was for blacks, 29.3 per 100,000 population.

TYPE II: Post-Slavery Black Minorities HIV/AIDS Among Blacks in the United States

Source: Prejean et al, PLoS ONE 2011. CDC HIV Surveillance Report, 2010

Shortfalls in labor supply created by the post WWII economy provided the “pull” for migrant labor, while native workers moved to satisfy the demand for labor in more attractive jobs. Migrant workers filled their places as “replacement populations”

In Britain: The first large-scale migration of people of minority ethnic origin

came from the Caribbean shortly after WWII and during the 1950s. Immigrants from India and Pakistan arrived mainly during the 1960s. Many people from African-Asian descent came to the US as refugees

from Uganda during the 1970s Majority of Britain’s Black African communities arrived during the

1980s and 1990s

The recruitment of Black and Asian migrant workers in the 1950s and 1960s to the least desirable sectors of the British labor market set in motion a cycle of disadvantage, inhibiting opportunities of the migrants and their children.

TYPE III: Post-Colonialization Black MinoritiesBritain’s Black and Ethnic Minorities

Source: UN; IOM

The prevalence of diagnosed HIV in black African and black Caribbean communities in England is estimated to be 3.7% and 0.4% respectively, compared to 0.09% among whites.

New diagnoses among black Caribbeans remained low (189 in 2007), representing 3% of new diagnoses in 2007. Twenty-seven percent of HIV diagnoses among black Caribbeans were late.

In 2007 black Caribbeans accounted for over a quarter (26%) of heterosexually acquired gonorrhoea diagnosed in a sample of genitourinary medicine clinics in England and Wales.

TYPE III: Post-Colonialization Black MinoritiesBritain’s Black and Ethnic Minorities

0

10

20

30

40

50

60

70

80

90

100

HIV Gonorrhoea Syphilis Chlamydia Population

New

dia

gnos

es (%

)

Black African

Black Caribbean

All other ethnicities

White

Proportions of new HIV, gonorrhoea, syphilis and chlamydia diagnoses among heterosexuals of different ethnic groups, UK*, 2007.

Migrants are defined as ‘any person who lives temporarily or permanently in a country where he or she was not born, and has acquired significant social ties to this country’.

Approx. 3.1% of worlds population – 214 million – were international migrants in 2010 (IOM)

Patterns of migration affected by political tensions, war, economic and environmental crises.

Migration has implications for public health including provision of HIV services, cultural competence of interventions, and understanding epidemic impact and trajectories

TYPE IV: Recent Social and Economic Migrants

Global impact of migration

Source: UN; IOM

TYPE IV: Recent Social and Economic MigrantsHIV/AIDS in European Region

PortugalFinlandIcelandEU/EEA

GermanyNetherlands

SloveniaGreece

NorwayLuxembourg

IrelandMalta

SwedenUnited Kingdom

Belgium

0tan25a5660250tan28a5660280tan29a566029

0tan2a566020tan8a566080tan9a56609

0tan11a5660110tan12a5660120tan13a566013

0tan16a5660160tan24a566024

0tan29a5660290tan29a5660290tan29a566029

0tan5a56605

%

Source: ECDC and WHO

Percent of HIV cases originating from countries with generalized epidemics among all heterosexual cases, 2010

An estimated 100,013 black adults and adolescents were diagnosed with HIV infection in 33 states for which country of birth information was available

Of these, 12% were foreign-born Most were from the Caribbean (54%) and Africa (42%)

A higher percentage of the foreign-born black individuals was female than were the native-born

The foreign-born black individuals were was more likely to have HIV attributable to heterosexual contact than were the native-born individuals

The foreign-born black individuals were more likely than the native-born to be diagnosed with AIDS within 1 year of their HIV diagnosis The foreign-born, however, were more likely to survive 1 year

or 3 or more years after their diagnosis

TYPE IV: Recent Social and Economic Migrants Epidemiology of HIV diagnoses among native-born and foreign-born black people, 33 U.S. states, 2001-2007

Source: Satcher Johnson, Public Health Reports, 2010

Typology Location HIV Prevention ApproachTYPE I:Post-Slavery Black Majorities

Caribbean Region

• Economic and leadership sustainability• Focus on MARPs• Address stigma, social and legal issues• Strengthen CBO, Faith response

TYPE II:Post slavery, Black Minorities

North, Central and South America

• Community mobilization and engagement

• Address social and structural determinants

• Healthcare access, utilizationTYPE III:Post-Colonialization Black Minorities

Western Europe • Community engagement• Address social and structural

determinants• Healthcare access, utilization

TYPE IV: Recent economic and social migrants

North America, Western Europe, Oceana, Africa

• Programs for migrant populations• Healthcare access, utilization• Address criminalization

Enhancing HIV prevention across the DiasporaTypology-specific considerations

Gaps in information. Still relatively few studies on the black diaspora and HIV. Surveillance systems are inconsistent. Data reporting not systematic and tied to solutions.

Lack of standardization. A major methodological challenge is terminology used to describe “migrant” in many settings. May include short or long term; transit or settled populations; multi-generational migrants.

Inconsistent policies. Heterogenous national policies and response to HIV prevention treatment and care and support observed across jurisdictions. Especially seen with the way migrant populations are managed.

Obstacles at service delivery level. In many countries administrative barriers to HIV prevention, treatment and care remains a challenge – both for migrant as well as established populations.

Enhancing HIV prevention across the DiasporaAddress critical needs

Members of the black diaspora have been and remain disproportionately affected by the HIV/AIDS pandemic

A complex array of behavioral, healthcare and social and structural determinants continue to drive HIV within Black communities

Turning the tide within the Black diaspora will require greater awareness, focus, and commitment to engaging and responding to communities needs

Summary

Thank YouKevin A. Fenton, MD, PhD, FFPH

Centers for Disease Control and Prevention404-639-8000

Email: kif2@cdc.gov Twitter: CDC_DrFenton

Web: www.cdc.gov/nchhstp