The Other 20 Percent
According to the Centers for Disease Control and Prevention (CDC), women account for 20% of new HIV infections in the United States. In 2011, of all women living with HIV, only 45% were receiving care and only 32% were reported to have achieved viral suppression. Furthermore, evidence shows that not all women living with HIV are receiving the care they need. Specific risks exist for each group of ethnic/racial minority women. These need to be addressed by gender specific and culturally tailored program modeling. The following brief summaries detail considerations for HIV prevention needs among groups of ethnic/racial minority women.
Estimates of New HIV Infections in the United States for the Most-Affected Subpopulations, 2010
HIV and African American Women
African American women with heterosexual contact were the fourth largest group for new infections when compared to all other groups by race/ethnicity, gender and transmission category. For all newly diagnosed HIV cases among women, 64% were African American.
Variables for the high rate of HIV transmission include:
- poverty with related lower quality of health care access;
- untreated sexually transmitted infections (STIs) that increase access to the bloodstream;
- existing high prevalence of HIV among those in the community;
- stigma, homophobia, negative perceptions of HIV testing; and
- lack of awareness of infection status.
HIV and Latina/Hispanic Women
Latina/Hispanic women accounted for 15% of newly diagnosed HIV infections among women in 2010 with 86% of transmission due to heterosexual contact. In 2013, HIV was the eighth leading cause of death for Latinos/Hispanics aged 25 to 34.
Transmission risks for HIV infection include:
- unprotected sexual contact with partners of unknown risk behavior and HIV status;
- high rates of STIs including chlamydia, gonorrhea, and syphilis;
- cultural gender roles and norms that add to stigma and fear of testing;
- poverty with significant unstable migration patterns and lower educational factors; and
- language barriers that prevent timely access to information and treatment.
HIV and Asian American Women
While Asian Americans only make up 2% of newly HIV diagnosed cases, the HIV incidence rate has unfortunately kept pace with the overall census population growth of 43% in the United States. Asian American females made up 16% of diagnosed cases of the total Asian American HIV population with 94% of infection due to heterosexual transmission.
Transmission risks for HIV infection include:
- existing undiagnosed HIV status of 22% of Asians living with HIV;
- cultural factors such as language barrier, stigma, unstable migration patterns and gender roles that discourage negotiation skills in sexual relationships;
- limited research on targeted prevention and behavioral intervention programs; and
- the low recorded rate of HIV cases may not reflect the actual prevalence due to misidentification of race/ethnicity, and therefore may lead to underestimation of infection and service need.
HIV and American Indians and Alaska Native Women
American Indians and Alaska Natives (AI/AN) living with HIV had the highest transmission rate of infection due to injection drug use (IDU). For AI/AN women, 69% reported infection due to heterosexual contact while 29% were due to IDU.
Transmission risks HIV infection include:
- lack of identified HIV infection status with 18.9% estimated to be undiagnosed;
- prevalence of STIs with AI/AN having the second highest rates of chlamydia and gonorrhea;
- cultural based stigma for AI/AN gay and bisexual men combined with limited access to education and testing;
- significant cultural diversity of tribal groups with distinct languages, beliefs and practices;
- poverty and socioeconomic issues related to education, employment, and housing;
- historical factors contributing to the mistrust and under-utilization of health services;
- younger individuals' rates of alcohol and drug use contributing to high rates of risk behaviors; and significant lack of data to inform service need and effective programming.
Program Planning and Evaluation
Careful design of innovative treatment models must address the various cultural factors uniquely impacting each dynamic HIV positive ethnic group. Also, comorbid conditions, such as mental health and substance addiction disorders increase the risk correlated with HIV prevalence. It's important to assess the service population's risks to develop a targeted approach to address information dissemination and engagement strategy as well as to successfully implement solutions for cultural variables that encourage early testing and decrease high-risk behaviors. Research also indicates regional geographical differences with engagement and retention in care for HIV treatment. Careful planning is necessary for addressing the variable regional patterns for engagement and retention in care to effectively manage the early stages of treatment and follow-up, and to improve overall treatment outcome. Gender differences for transmission risks and evidence-based practices, such as trauma-informed care, must be blended into the clinical practice protocol and evaluation design. Trauma-informed care, in particular has been shown to be most needed to address the high rate of trauma experiences for women living with HIV. One must selectively choose interventions that are flexible and sensitive to the cultural context of the service population to weave in healthy practices that speak to informed choice and positive awareness of self-care. For a true "lessons learned" model reflecting best practices and innovative care, an evaluation of the service model allows replication of those that show impactful engagement and improved health outcomes. When successfully implemented, evaluation is not just a set of numbers, but opens a wider door to treatment access by improving care. For HIV prevention among minority women, it is essential to have a wider door to treatment access and improved care.
Additional SAE Resources
SAE's summaries and podcasts on the newest SAMHSA funding opportunities on HIV prevention:
- SAMHSA TCE-HIV: Minority Women
- SAMHSA HIV Capacity Building Initiative
SAE's Issue Briefs:
- Trauma-Informed Care And Planning An Evaluation
- Advances in HIV Prevention that Work!