Health disparities in HIV based on race and ethnicity have been with us since the start of the epidemic. Community-based advocacy to address such disparities is equally long-lived. The year 2020, however, brought these inequities to levels of public prominence never seen before. The two epochal events that brought about this shift were the COVID-19 epidemic that began with the 2020 New Year, and the murder of George Floyd, a Black man, at the hands of white police officer Derek Chauvin in Minneapolis on May 25. Here, we look at how disparities based on race and ethnicity have shaped the HIV epidemic for 40 years, as well as how the understanding of these disparities, and the societal response to them, has changed in the era of George Floyd and COVID-19.
The concept of syndemics in HIV and COVID-19
Like the HIV epidemic, the COVID-19 pandemic emerged against a backdrop of disparities in healthcare access, health outcomes, and social determinants of health. In the past two decades, the concept of syndemics has been used to explain health disparities in HIV, and the same concept has quickly emerged as a useful lens of analysis for COVID-19. The term “syndemic” was coined in the mid-1990s by Merrill Singer, a medical anthropologist at the Hispanic Health Council in Hartford, Connecticut. It refers to a complex of two or more medical conditions or social determinants of health that overlap and interact in a synergistic manner, each fueling the other in a vicious cycle of cause and effect. In a seminal 1996 article, Singer conceptualized the close interconnections among violence, substance use, and HIV. Rather than separate conditions, Singer conceived of substance abuse, violence, and HIV as a closely interrelated complex of health and social crises that take an ongoing and significant toll on the lives and well-being of affected communities. Singer coined the acronym SAVA (substance abuse, violence, and AIDS) to underscore the connections among these public health crises. The violence referred to in the concept of the SAVA syndemic takes many forms, including gang violence, violence in jails and prisons, intimate partner violence, child abuse, and violence against sex workers, among others.
Social determinants of health
Writing about COVID-19–related health disparities, Clare Bambra and colleagues in the United Kingdom note that non-white racial and ethnic groups, people living in poverty and related forms of socioeconomic deprivation, and people in marginalized groups such as the homeless or unstably housed, incarcerated people, and street-based sex workers generally have a greater number of coexisting non-communicable diseases (NCDs). Moreover, non-infectious health conditions among these groups are often more severe and occur at a younger age. This includes higher rates of almost all of the known underlying clinical risk factors that increase the risk of severe illness and death from COVID-19. These conditions include hypertension, diabetes, asthma, chronic obstructive pulmonary disease (COPD), heart and cardiovascular disease, liver disease, renal (kidney) disease, cancer, obesity, and smoking. These inequalities in chronic conditions, Bambra and colleagues point out, arise as a result of inequalities in exposure to social determinants of health such as working conditions, unemployment, access to essential goods and services, housing, and access to healthcare.
Overlapping disparities in HIV and COVID-19
In October 2020, the O’Neill Institute for National and Global Health Law at Georgetown University published a report on the overlapping health disparities associated with HIV and COVID-19. The limited data available indicate that people living with HIV (PLWH) who are on effective antiretroviral therapy (ART) have the same risk for COVID-19 as people who do not have HIV. But as COVID-19 made its way across the country in the first months of 2020, it soon became apparent that people of color were disproportionately affected, and that there was considerable overlap between the communities bearing most of the brunt of COVID-19 and HIV.
The role of systemic racism
These disparities are largely driven by the effects of structural or systemic racism. According to the authors of the O’Neill Institute report, Jeffrey S. Crowley and Sean E. Bland, systemic racism encompasses a broad range of disadvantages embedded in public policy, law, government, and culture. Systemic racism is also manifested in, and influenced by, social determinants of health, which include such areas as education, employment, the healthcare system, housing, income and wealth, the physical environment, public safety, social environments, and transportation, among other factors.
Rather than separate conditions, Singer conceived of substance abuse, violence, and HIV as a closely interrelated complex of health and social crises that take an ongoing and significant toll on the lives and well-being of affected communities.
Experts writing over the past 18 months have identified factors contributing to increased vulnerability both to COVID-19 and to HIV. For example, Tonia Poteat and colleagues point to the high rates of pre-existing medical conditions, the fierce resistance to Medicaid expansion in the South, the lack of access to testing in low-income neighborhoods, and an over-representation among the essential workforce as factors that explain elevated risks for COVID-19 among people of color throughout the United States. These same factors also contribute to poor HIV-related health outcomes. Indeed, since Poteat and colleagues published their commentary in the spring of 2020, we have entered the era of COVID-19 vaccines, and here have seen disparities that closely parallel the disparity in access to, and uptake of, ART for HIV.
Racial segregation as a risk factor for HIV and COVID-19
Gregorio Millett, MPH, a prolific and influential epidemiologist who worked in the Obama White House and is now vice president and director of public policy at amfAR, recently wrote about differing HIV and COVID-19 outcomes and service delivery by race and ethnicity, and the crucial role of racial segregation in housing and homeownership. Using publicly available data from the U.S. Census Bureau, Millett and colleagues divided U.S. counties into quintiles by percentage of non-Hispanic white residents, and examined per capita (basically, on average per person) diagnoses of HIV and COVID-19. Their study found that HIV diagnoses decrease as the proportion of white residents increase across U.S. counties, with COVID-19 diagnoses following a similar pattern. Moreover, the study found that, compared to primarily non-Hispanic white counties in the U.S., fewer COVID-19 diagnoses have occurred in primarily white counties throughout the duration of the COVID-19 pandemic. As Millett and colleagues point out, other data contribute to the conclusion that racial segregation plays a part in disparate rates of infection and outcomes both for HIV and COVID-19. One recent study showed an association between redlining practices in Chicago and greater COVID-19 mortality in primarily Black neighborhoods. In another study, racial segregation accounted for 19% of HIV infections among Black people who inject drugs (PWID) compared to 3% of HIV infections in white or Latinx PWID. In addition, a study in New York reported that 65% of Black men diagnosed with HIV and 68% of new HIV diagnoses among Black men occurred in specific ZIP codes.
As Crowley and Bland note, researchers consistently observe racial and ethnic health disparities across many health conditions in the U.S. When it comes to HIV, the greatest disparities are for men who have sex with men (MSM) and transgender women. Across all risk groups, however, Black and Latinx people have a higher burden relative to non-Hispanic whites and other groups. They point to common factors that increase risk for HIV and COVID-19, including racism, trauma, poverty, stigma, residential segregation, housing insecurity (including both less access to housing and greater housing density), less access to health care and preventive services, incarceration, and immigration status.
George Floyd rekindles the racial justice movement
Within hours of George Floyd’s murder at the hands of Minneapolis police officer Derek Chauvin, demonstrators began flooding streets in cities and towns across America, demanding an end to police violence against Black Americans in what became the largest mass protest movement in U.S. history. The slogan Black Lives Matter, which had emerged in 2013 after the acquittal of George Zimmerman in the shooting death of Trayvon Martin 17 months earlier, became the mantra of a nation grappling with Mr. Floyd’s death. Over the next year, calls for racial justice grew to a scale not seen in the U.S. since the civil rights movement of the 1960s. And by most accounts, this incarnation of racial justice activism was more diverse and inclusive than any previously seen—a reflection, it would seem, of social, cultural, and demographic changes that had emerged during the first decades of the twenty-first century.
When it comes to HIV, the greatest disparities are for men who have sex with men (MSM) and transgender women. Across all risk groups, however, Black and Latinx people have a higher burden relative to non-Hispanic whites and other groups.
This resurgence of racial justice activism emerged in the midst of the COVID-19 pandemic, which had already begun to focus renewed attention on the health dimensions of the racial inequities that run throughout American history. Indeed, people of color were hardest hit not only by the health crisis itself, but by the economic devastation that came in the wake of the coronavirus. In addition, the murder of George Floyd occurred within months of the officer-involved deaths of Ahmaud Arbery and Breonna Taylor. For a time, at least, white Americans displayed previously unseen levels of support for the Black Lives Matter movement, identified racial discrimination as a major problem, and acknowledged that excessive police force disproportionately impacted Black people in this country.
Biden commits to racial equity in public health
On the campaign trail in 2020 and upon entering the White House in 2021, Joe Biden made addressing systemic racism one of his administration’s four major priorities, and promised to center racial equity throughout his agenda, from combatting COVID-19 and revitalizing the economy to addressing climate change. In doing so, Biden make frequent reference to the murder of George Floyd, to the national reckoning with systemic racism, and to the centrality of racial equity to his agenda. This commitment has played out most noticeably in the rollout of the vaccination effort. While journalists continue to ask Biden’s press secretary, Jen Psaki, to explain the lower rates of vaccination among people of color compared to whites, it seems clear that the administration’s vaccination infrastructure, strategy, and tactics have consistently been designed and implemented with racial equity front and center.
Signaling commitment to race and HIV with key appointments
In addition to vaccination policies and other COVID-19–related strategies that appear to deliver on the administration’s promise of centering racial equity, Biden has shown his commitment with several key appointments. Biden appointed Marcella Nunez-Smith, MD, MHS, an expert and leader in health equity research at Yale, to co-chair the Biden-Harris transition’s COVID-19 advisory board, and then selected her to lead his administration’s COVID-19 Equity Task Force.
To head the Centers for Disease Control and Prevention (CDC), Biden chose a renowned HIV expert, Rochelle P. Walensky, MD, MPH. In a statement marking the 40th anniversary of the report on Pneumocystis pneumonia in five previously healthy young gay men in Los Angeles in the Morbidity and Mortality Weekly Report (MMWR), Dr. Walensky underscored the disproportionate impact of HIV on specific communities, even in the face of extraordinary progress towards ending the HIV epidemic in the U.S. in recent years. Walensky notes that, while annual HIV infections in the U.S. decreased 73% from 1981 to 2019, some 37,000 people continue to be newly diagnosed with HIV each year. “Disparities in diagnoses and access to treatment and prevention persist,” Walensky said. “Over half of new HIV infections are in the South, and new infections remain high among transgender women, people who inject drugs, and Black/African American and Hispanic/Latino gay and bisexual men.”
Fauci personifies link between HIV and COVID-19
Perhaps the most dramatic symbol of the Biden administration’s commitment not only to racial equity, but also to ending both the COVID-19 pandemic and the HIV epidemic, and to maintaining a fundamental commitment to science and fact-based decision making, is his reappointment of Dr. Anthony Fauci to head the National Institute of Allergy and Infectious Diseases (NIAID), a position Fauci has held under presidents both Democratic and Republican since 1984. The ACT UP activists who confronted Fauci at the NIH in October 1988 ended up being given a literal seat at the table—the table in Fauci’s conference room—later meeting with him regularly over red wine at the home of Fauci’s deputy, James C. Hill, PhD, a gay man with a townhouse on Capitol Hill, where the virologist and the street activists would plan how to incorporate people with AIDS in the planning and execution of clinical trials for AIDS drugs.
Whither health equity?
At the annual meeting of the Presidential Advisory Council on HIV/AIDS (PACHA) in March 2021, Gregorio Millett gave a presentation on achieving health equity in HIV and COVID-19. Millett pointed out that both HIV and COVID-19 disproportionately impact communities of color, and stated that COVID-19 is part of a syndemic (alongside HIV, opioids, and hepatitis C) that magnifies health inequities by race. He noted that, while we are on track to end the HIV epidemic among white Americans, it will take much longer to end HIV in Black and Brown communities, due to COVID-19-related delays in implementing a national HIV strategy that is based on maximizing access to, and uptake of, HIV testing, treatment, and prevention by members of highly-affected communities, including people of color, where the impact of the lingering HIV epidemic is currently greatest.
Millett also discussed possible ways forward, including Medicaid expansion (which is currently gaining popularity in the states where it was initially rejected by governors and legislatures), ramped up HIV testing programs, and the use of algorithms and guidelines to address health inequities. Millett advocates declaring racism a public health issue, since that would allow it to be surveilled by the CDC, and “What gets measured gets managed.”
Social determinants of health associated with greater HIV burden in Black and Brown communities have re-emerged in the wake of COVID-19, with disproportionate COVID-19 cases, hospitalizations, and deaths in communities of color.
In a 2020 commentary, Millet discusses why both COVID-19 and HIV remain prevalent in communities of color in the U.S., and explains the implications of these disparities for ending the HIV epidemic. As Millet notes, a recent report by the National Academy of Sciences estimated that as much as 70% of health outcomes are due to health access, socio-economic factors, and environmental conditions. Millett states that social determinants of health associated with greater HIV burden in Black and Brown communities have re-emerged in the wake of COVID-19, with disproportionate COVID-19 cases, hospitalizations, and deaths in communities of color.
“Just as HIV research expertise paved the way for a COVID vaccine, local and community efforts to address HIV disparities have also been instrumental in predicting and suggesting ways to address COVID-19 disparities,” Millet said in comments provided for this article. “These range from identifying the scope of the problem and ways to address it through national and local strategies; to engaging most-impacted communities as equal partners to find viable solutions; and finding ways to guarantee access to new health innovations for marginalized groups in the U.S. and abroad.”
“COVID-19 might temporarily set back our efforts to end HIV (and magnify racial disparities), but it will only strengthen the resolve of our community (advocates, scientists, and providers) to fight harder,” Millett insisted. “That is what we did in the 1980s and 1990s, and that is what we are going to do today and into the near future.”
Michael Broder is a gay, white, poz, Jewish, male, late-Boomer Brooklyn native (b. 1961). Columbia undergrad, MFA in creative writing from NYU, and PhD in classics from the CUNY Graduate Center. He tested HIV-positive in 1990, and started doing AIDS-related journalism while collecting unemployment insurance in 1991. He lives in Bed-Stuy with his husband and several feral backyard cats.