By Kurt C. Organista
Thirty years into the epidemic I remain struck by is how HIV continues to exploit our country’s entrenched social, cultural, and economic cleavages — almost to the point of appearing to be a homophobic, racist, sexist, and transphobic virus! Latinos now rank second to African Americans in their disproportionately high rates of AIDS cases: 50% & 20%, respectively, despite only composing 13% & 15% of the US population. Consider for example that 75% of AIDS cases in the US are among men who have sex with men (MSM), and the same is true within US Latino population. Women continue to be primarily infected by male sex partners, and African American women and Latinas are, respectively, 20 times and five times more likely to become infected than their white female counter-parts.
While research on transgendered people is nascent, preliminary studies suggests alarming rates of between 8% & 78% in male-to-female transgendered people of color! The latter should not surprise us considering the additive risks inherent in the multiple marginalities experienced by transgendered people who frequently face rejection from family, community, peers, and school while young, followed by job discrimination while transitioning into adulthood. Survival sex and alcohol and substance use are not uncommon responses to such rejection.
HIV/AIDS continues to exact tremendous cost in human lives and dollars. Globally we have lost 25 million people to AIDS, with over 40 million currently infected with HIV. 1.2 million are infected in North America with Africa (26 million) and China (8.3 million) sharing the global burden. The US spends over 27 billion dollars annually on HIV/AIDS: 52% on HIV/AIDS care and treatment, 25% on the global epidemic, 11% domestic HIV research, 10% domestic cash/housing assistance, and 3% on domestic HIV prevention.
Interestingly, of the 3 billion dollars allocated to HIV research annually, over 80% is spent on biomedical research including vaccine and anti-retroviral medication (ARVM) development, and more recently PREP and PEP (pre-exposure & post-exposure prophylaxis or ARVM treatment). The latter have been shown to actually prevent HIV transmission in sero-discordant couples when the infected partner takes enough medication to render viral loads undetectable (PREP), or when those exposed to HIV (e.g., nurses encountering infected needle stick) are promptly treated with ARVM. While PREP is being celebrated (e.g., Science magazine’s 2011 breakthrough of the year), concern is growing regarding its effectiveness outside of the research lab. Similar concerns abound regarding the heavy emphasis on biomedical solutions to HIV, or the growing conviction that HIV/AIDS is not 80% a biomedical problem, and 20% social problem, as the HIV research budget implies.
While we applaud ARVM for transforming HIV infection from a death sentence to something akin to a chronic disease, it’s sobering to consider that 80% of those infected globally have no access to these miracle drugs. And while we anxiously look forward to an HIV vaccine, we should recall that it was promised back in the mid-1980s by then president Regan’s Secretary of Health, Margaret Hecker. Further, the main concern with depending on PREP as a quasi-magic bullet is this:
Social problems require social solutions and HIV/AIDS is at least 50% a social problem. Structural-environmental (including cultural, social, interpersonal, and situational) factors compose the many contexts of HIV risk, and produce and reproduce risky situations and environments for US Latinos. Consequently, structural-environmental solutions are proposed and tested, including scaling up community and cultural resources with the power to mitigate harsh living and working conditions in which HIV risk and other health and social disparities fester. Some of the exciting community-based interventions for preventing HIV risk in diverse Latino populations include: community engagement and AIDS activism to prevent risk in LGBT Latinos; facilitating discussions about HIV and sex in Latina mother and daughter dyads; local, state, and international infrastructure to address the basic human needs of transgendered Latinas, and immigration reform migrant laborers).
In closing, we need to continue investing in prevention research that is not only biomedical and behavioral but structural-environmental in its attention to the complex context of HIV risk and prevention for Latinos and other populations.
Kurt C. Organista, PhD, is Professor at the School of Social Welfare, University of California, Berkeley and the editor of HIV Prevention With Latinos: Theory, Research, and Practice.