Forty years into the HIV epidemic, we have witnessed remarkable achievements. People living with HIV (PLWH) can thrive because of the availability of antiretroviral therapy (ART), with a lifespan like those without HIV. We learned that “U = U”; that is, we now know that PLWH whose HIV cannot be detected by laboratory testing cannot sexually transmit the virus to their partners. The advent of preexposure prophylaxis (PrEP) expanded biomedical HIV prevention tools, enabling people without HIV to protect themselves from infection. While we have the necessary HIV prevention and treatment tools to end the HIV epidemic, such a goal remains elusive. Unfortunately, these great achievements in research and practice have been accompanied by profound failures, including inequitable access to new HIV prevention and treatment options among African Americans.
Despite accounting for only 13% of the US population, African Americans comprise 42% of all new HIV diagnoses.1 For members of key subpopulations, the situation is even more dire; approximately half of African American men who have sex with men (MSM) are expected to contract HIV in their lifetime.1 Among all cisgender women, African Americans identifying as cisgender comprise 54% of new diagnoses, and African American transgender women comprise 46% of new diagnoses among all women.1 Compared with their peers from other racial/ethnic backgrounds, African Americans have lower rates of engagement in the HIV treatment continuum.1 In 2019 alone, for every 100 African Americans diagnosed with HIV, 74 received some HIV care, 56 were retained in care, and 61 were virally suppressed, indicating lower engagement than their White and Hispanic/Latino peers.1 While individual and social factors (e.g., HIV-related stigma, HIV knowledge, poverty, sexual risk) are frequently cited as the primary contributors to low engagement in the HIV prevention and treatment continuum, the spotlight on such factors masks the broader social, political, and economic conditions that generate and maintain observed racial disparities in HIV infections and related outcomes, such as structural racism and repeated exposures to racial trauma.2,3
In this article, we discuss the influence of structural racism (i.e., the way in which society promotes and sustains racial discrimination through larger systems and macro-level conditions that limit the opportunities, resources, power, and well-being of racial minorities) and racial trauma (i.e., the emotional injury resulting from exposure to various forms of racism, racial discrimination, and racial bias) on HIV-related outcomes among African Americans. We conclude with recommendations aimed at addressing these factors to end racial disparities observed in the HIV epidemic.
Structural racism is a key source of racial disparities in HIV-related outcomes2,4 and can occur in various social domains, including schools, corporations, legal systems, and health care. One of the most blatant and impactful examples of the influence of structural racism on HIV-related outcomes among African Americans was drug policy concerning controlled or illicit substances—policies that disproportionately targeted people of color.5 In 1971, led by then‒President Richard Nixon, the US federal government declared drug abuse “public enemy number one,” launching the War on Drugs—a federal campaign that sought to end the illicit drug trade in the United States, wherein the federal government budgeted billions for drug-control agencies, established harsh penalties for drug possession, and increased police presence in predominately ethnic minority communities.
Biases in the US drug policies and policing and sentencing practices led to harsher legal penalties for people of color who bought or sold drugs compared with their White peers; despite the similarities in illicit drug use between African Americans and White Americans,5 law enforcement agencies and state prosecutors inequitably targeted people of color for investigation and incarceration.5,6 Decades of failed policies and practices led to the mass incarceration of people of color, with incarceration of African American men skyrocketing. By 1980, the African American arrest rate for drug possession and drug sale was three times higher than for their White counterparts. Unfortunately, racial disparities in incarceration rates have worsened, with African American arrest rates being up to five times higher than for White Americans.7
The impact of the mass incarceration of African Americans on racial disparities in HIV-related outcomes is multilevel. At the individual and community levels, higher incarceration rates among African Americans disturbed sexual networks within the African American communities, limiting the pool of available sexual partners and increasing the likelihood of overlapping sexual partnerships, thereby increasing HIV risk.5 Moreover, stigma and employment practices limited opportunities for those who were formerly incarcerated, including access to health insurance, leading to social and financial stressors, all of which had generational impacts on families and entire communities.4,6,8 Together, these policies contributed to the rise in HIV infection and transmission in African American communities.9
The impact of structural racism on HIV risk and transmission extends to the health care system. Previous research, for example, has linked poor health care quality to provider and systemic biases, including HIV-related stigma.10 Personal or vicarious experiences of racism, discrimination, and stigma within such systems has been linked to health care disengagement, including with preventive and HIV care.11,12 A study among African American women living with HIV, for example, found that perceptions of structural racism and discrimination in HIV care settings contributed to skepticism or distrust of medical advice and mistrust in the health care system.13
Taken together, structural racism operates through various social systems, including policy and health care provision, and has harmed generations of people of color by limiting access to HIV prevention and treatment resources, and exacerbating personal and communal experiences of racism and discrimination, leading to experiences of racial trauma.14
Racial trauma can result from both direct and vicarious experiences of racism12 and has been linked to psychological distress.14 To our knowledge, there are no studies exploring the effects of racial trauma on HIV risk behaviors. However, exposure to racial discrimination has been linked to poor HIV-related outcomes.15 One study, for example, linked more experiences with racial discrimination to greater engagement in risky sexual behaviors among heterosexual African American men.15
In addition to affecting engagement in risky sexual behaviors, racial trauma may also have an impact on engagement in HIV care. One study among African American MSM living with HIV, for example, found that participants reporting greater experiences of discrimination because of their HIV status, race, and sexual orientation were less likely than their peers with fewer reports of discrimination to adhere to their ART regimens over six months.16 In a recent study among older African Americans, experiences of HIV-related stigma and discrimination were linked to greater odds of medication nonadherence.17 Moreover, a recent meta-analysis found increased odds of ART nonadherence among PLWH with trauma-related histories than their peers without trauma histories.18
Although such studies are unable to infer causation, they do suggest that experiences of racial discrimination could have an impact on sexual behavior, though the nature of this link requires further investigation. As interest in the effect of structural racism and racial trauma on HIV outcomes continues to grow, more research is also needed to understand the impact of racial trauma on HIV outcomes among people of color.
While there is no singular solution for eliminating the racial disparities observed in HIV infections, efforts to end the HIV epidemic must include multilevel approaches aimed at dismantling structural racism and addressing racial trauma. We make the following recommendations for public health practice and research: Provide HIV prevention services in correctional settings, Address implicit bias and discrimination in health care, Prioritize health equity and community engagement, and Incorporate racial trauma healing into interventions.1. 2. 3. 4.
Federal and state policies related to drug possession have led to higher rates of incarceration among African Americans. With correctional facilities being recognized as potential entry points for HIV prevention and treatment strategies,19,20 greater efforts are needed to ensure equitable access to biomedical prevention and treatment tools both during and after incarceration. Although condoms are widely known as effective HIV-prevention tools, they are often inaccessible because of concerns about encouraging sexual activity, a myth that has been repeatedly debunked. Providing condoms in correctional facilities could reduce HIV transmission in those settings20 and prepare individuals who are released to adopt such practices while in the community. Like condom distribution, offering PrEP in correctional facilities could also reduce HIV transmission risk.
HIV testing and screening practices within correctional facilities vary from state to state. Some facilities only offer testing at the request of an inmate or during the intake process. Public health practitioners and scholars have advocated universal HIV testing and screening procedures, which could increase early detection of HIV and improve linkage to HIV care within correctional systems.19 One policy, opt-out HIV testing, has been linked to increased rates of HIV testing among incarcerated populations compared with opt-in approaches.20
In addition to obtaining resources within correctional facilities, access to resources in the community must also be addressed. Decarceration, which involves releasing incarcerated persons with nonviolent offenses, is a strategy for reducing racial inequities in incarceration. Although this strategy could reduce racial disparities in disproportionate rates of incarceration, we need to concurrently implement strategies that also reduce HIV transmission risk. While access to HIV treatment within prisons is often required by federal or state policies or both, formerly incarcerated people often lose access to HIV treatment upon release, as they often face challenges with securing follow-up care because of economic and employment instability.9,21 These challenges create barriers for continuing HIV care and accessing ART. Legislation focused on criminal justice reform and decarceration should address systematic factors that interrupt HIV care, such as affordable housing, under- or unemployment, and failure to expand Medicaid access. As such, criminal justice reform could improve access to re-entry programs, which assist formerly incarcerated populations with linkage to support services, including mental health treatment, employment and housing, and health care.
Implicit bias—a form of bias that occurs automatically and unintentionally that affects judgments, decisions, and behaviors—is common among health care providers and threatens equitable access to HIV prevention and treatment services. Previous research observing PrEP uptake among African Americans, for example, linked health care provider decision-making regarding the appropriateness of PrEP to racism and both implicit and explicit biases against patients.22
While there are ongoing efforts to address implicit bias in health care, including revisions to the curricula in training programs, statewide mandates requiring implicit bias training to meet continuing education requirements for some health care professionals, and the implementation of structural competency training, which seeks to educate providers on the role of structural racism on racial health disparities, the long-term effectiveness of such programs is unknown. Moreover, there are often unclear metrics applied toward measuring the effectiveness of such programs, as the field is still evolving in this area; we need validated tools and standardized constructs to enable cross-comparisons and evaluation.
Health communication campaigns aimed at increasing engagement in the HIV prevention and treatment continuum can impact one’s attitudes, beliefs, willingness to change, and behavioral intentions.23 HIV prevention and treatment messaging should not only address individual behaviors but also reach further, challenging social and cultural norms that lead to high-risk behaviors.23 To do so, we must engage key populations in the research, development, implementation, and dissemination of novel interventions that could lead to structural changes, including economic and housing development. Engaging affected populations in HIV research could facilitate the development of culturally relevant messages with a higher likelihood of community buy-in and acceptance,24 which could provide evidence for the need for policy changes that could have an impact on social and cultural norms.
In addition to engaging members of key populations in public health practice and research, increasing representation of African Americans within HIV care and research can also improve HIV outcomes. Previous research, for example, has shown that patients receiving care from providers with the same racial identity reported a more positive experience in health care and more effective communication with their health care provider. However, structural racism within academic admissions affects diversity in this field, with many scholars advocating structural change by establishing pipeline programs for people of color, implementing antiracism curricula, utilizing more holistic approaches to application review for academic admissions, and developing initiatives aimed at mentoring and supporting trainees of color within professional health programs.
For many African Americans, experiences of racism, discrimination, and bias are unavoidable facets of life. These experiences, however, are linked to poor health outcomes, including trauma and psychological distress.25 Among African Americans living with HIV, experiences of racism and trauma can intersect with stigma and discrimination associated with their HIV status and sexual orientation, among other socio-structural determinants.3 Completely eliminating all forms of racism from our society, however unlikely, will take time. As such, we must ensure that African Americans are able to cope with these unfortunate and unjust burdens. Within mental health treatment interventions, incorporating racial trauma healing into HIV prevention and treatment interventions may be a necessary step toward supporting African Americans at elevated risk of contracting HIV or currently living with the virus.
Racial trauma healing describes a therapeutic process that implements strategies aimed at helping people of color heal from traumatic racial experiences. For example, Metzger et al. shared several approaches for addressing racial trauma among African Americans receiving mental health treatment, including integrating racial socialization—the process of transmitting cultural attitudes, behaviors, perceptions, and values to help African American adolescents manage racial discrimination and racism—into evidence-based psychotherapies.25 Specifically, the researchers proposed adaptations to trauma-focused cognitive behavior therapy that would include racial socialization and suggested that clinicians use culturally relevant communication approaches (e.g., poetry and music) rather than the general storytelling that is recommended to encourage youth to share their experiences with racism and discrimination, exploring how they contribute to current challenges and ways to overcome them. Among African Americans living with HIV, incorporating racial trauma healing into mental health treatment may support retention in HIV care and ART adherence by providing strategies for coping with intersecting trauma and stressors that could disrupt health care engagement.
Ending racial disparities observed in HIV-related outcomes requires us to focus our efforts on addressing structural racism and reducing the impact of racial trauma on populations affected by HIV. Incorporating racial socialization and healing into HIV prevention and treatment efforts may provide tools for coping with stressors, thereby improving HIV outcomes. This could also reduce mistrust among African Americans living with HIV and medical providers and reduce interruptions of HIV care thereby improving ART uptake and adherence. Still, efforts are needed to diversify the field of HIV prevention and treatment, enabling more scholars of color to be leaders in addressing the racial HIV disparity. We posit that addressing structural racism in these suggested ways will allow us to combat disparities in HIV outcomes that disproportionately impact African Americans.
ACKNOWLEDGMENTS
T. D. Ritchwood’s effort was supported by (1) career development awards from the National Institute of Mental Health (K08MH118965) and the Duke Center for Research to Advance Healthcare Equity, which is supported by the National Institute on Minority Health and Health Disparities under award U54MD012530, and (2) other support from the Duke University Center for AIDS Research, a National Institutes of Health (NIH)-funded program (5P30 AI064518).
Note. The content of this article is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.
CONFLICTS OF INTEREST
The authors have no conflicts to declare.
