Human immunodeficiency virus (HIV) is credited with weakening a person’s immune system by killing crucial CD4+ T cells that fight off infections (CDC, 2019). If untreated, HIV can progress to the last and most serious form of HIV often referred to as Acquired Immune Deficiency Syndrome or AIDS. Some Americans are more likely to be at risk for HIV because of several factors, including their sexual behaviors, number of partners, where they live, stigma around their sexuality, and their access to medical care (CDC, 2019). The CDC reports that “38,281 people received an HIV diagnosis in the US during 2017 alone and that 1,140,400 people ages 13 and up were living with HIV at the end of 2016” (CDC, 2019). Of this number, homosexual, bisexual and men who have sex with men (MSM) account for 57% or about 648,500 cases (CDC, 2019). Among the 3 million HIV testing events reported to the CDC in 2015, the percentage of transgender people who received a new HIV diagnosis was more than 3 times the national average (CDC, 2015). These numbers show that the already underserved lesbian, gay, bisexual, transgender and queer (LGBTQ) community is one of the predominant groups of people at risk for HIV/AIDS infection and more education and resources should be dedicated to the LGBTQ community for the fight against HIV/AIDS. In 2015, Arizona ranked 15th among the 50 states in the number of HIV diagnoses with nearly 75% of the population diagnosed with HIV consisting of members of the LGBTQ community that year (AZDHS, 2017).
Men who have sex with men (MSM) are at an incredibly high risk for contracting HIV, especially MSM of African American and Hispanic descent (CDC, 2015). The homeless population and IV drug users are also at an increased risk for HIV/AIDS and often go undiagnosed for years as they may have limited access to healthcare or be unwilling to seek testing (CDC, 2015). In addition to MSM, the transgender community reported rates of HIV diagnosis at 2.6% compared to 0.9% for males and 0.3% for females (Levitt, et al., 2017). For this reason, the LGBTQ community and especially people of color (POC) within this community make up our primary target population as they are at increased risk for HIV/AIDS infection. According to the Arizona Department of Health’s State Prevention Plan, the state incidence rate is 11.4 per 100,000 people in Arizona with Maricopa county as high as 13.8 per 100,000 people (AZDHS, 2017). According to the same source, the Arizona state prevalence rate is 260 per 100,000 with Maricopa county as the highest again with 292 per 100,00 (AZDHS, 2017). It should also be noted that in Arizona, LGBTQ youth of color (aged 18-26) are at a disproportionately high risk for contracting HIV (AZDHS, 2017). Due to Phoenix being one of the largest cities in America with an incredibly diverse population, it is important to address HIV in our state as the magnitude of the problem is more severe than in a smaller and less diverse states.
Nature and Magnitude of the Problem
While HIV/AIDS morbidity rates are lower than the peak high in 2004 due to the antiretroviral therapy (ART), an alarming amount of people around the world are still being infected with this preventable disease (UNAIDS, 2019). It is estimated that about “1.8 million people worldwide became newly infected with HIV in 2017 which consists of about 5,000 new infections per day” (HIV, 2018). As of 2016, 708 new cases of HIV were found in Arizona for a total of 17,464 Arizonans confirmed to have HIV and even more not yet diagnosed (AZDHS, 2017). MSM account for 71% of all new HIV infections for males, while 51% of females had no risk reported making it hard to quantify the number of LGBTQ cases in females (AZDHS, 2017).
Another concerning aspect of HIV/AIDS is that a large number of people may be unaware of their status as symptoms may take years to surface (HIV, 2018). It is estimated that globally, 1 in 7 individuals with HIV don’t know they have it which means they aren’t accessing lifesaving treatments readily available (HIV, 2018). This problem is also extremely concerning as those people could be at risk for passing on the infection without realizing it (CDC, 2019). In the United States, talking about sex is a taboo topic and discussing sexually transmitted infections and testing status often doesn’t occur until after intercourse, if at all.
In the United States, it was estimated that about 1,122,900 adults and adolescents were living with HIV at the end of 2015 and about 162,500 or 15% had yet to get a formal diagnosis (CDC, 2019). Shockingly, young people with HIV (ages 13-24) were the most likely to be unaware as an estimated 51% didn’t know their HIV status (CDC, 2019). Some of this may in part be due to the fact that minors may be resistant to talk to their parents about their sexual activity and may not feel comfortable requesting to see a doctor to be tested for sexually transmitted infections (STIs) such as HIV. In addition, once someone is confirmed to have HIV, they will need a lifetime of medication and monitoring, and the cost of care may become burdensome over time, especially for people who are under or uninsured. The social determinants of health tell us that people who are considered to be minorities often have less access to health care which seems to be true for people of color within the LGBTQ community.
Risk factors for HIV/AIDS amongst the LGBTQ community consist of unsafe sexual practices, multiple sexual partners, not getting tested for HIV, partaking in IV drug use, and homelessness (CDC, 2019). A recent study stated that the LGBTQ community is at an increased risk for “homelessness, joblessness, depression, stigma and may practice risky sexual and non-sexual behaviors as a form of escapism and avoidance of financial pressure and other stressors” (Levitt, et al, 2017). Due to the stigma surrounding LGBTQ lifestyles, many individuals may delay or avoid seeking treatment and may feel uncomfortable discussing their sexual practices with healthcare providers. As mentioned previously, MSM are at especially high risk for HIV/AIDS as they may have multiple partners, practice risky sexual behaviors, or delay seeking medical care due to stigma or fear of violence against them. This population should get tested frequently in addition to using condoms, discussing their HIV status with partners, and abstaining from IV drug use and needle sharing. While many health services are not typically inclusive of the LGBTQ community, certain clinics have LGBTQ specific screenings and services where individuals can seek treatment and prevention methods.
Health, Economic, and Social Consequences
The health consequences of HIV can be catastrophic on an individual and population level. HIV targets the immune system making the affected individual susceptible to a variety of illnesses that may become fatal (CDC, 2019). People with HIV/AIDS are susceptible to opportunistic infections due to their weakened immune systems such as “Herpes Simplex Virus (HSV, Lymphoma, Tuberculosis, Cervical Cancer, Pneumonia, Salmonella, and Toxoplasmosis of the Brain” (CDC, 2015).
Economically, as of 2015, the lifetime treatment cost of HIV was estimated at $379,668 (in 2010 dollars) (CDC, 2015). In 2016, the CDC provided the state of Arizona with $6,279,621 to combat HIV and provide effective prevention methods, comprehensive disease monitoring, and program evaluation (CDC, 2019).
The main social consequence surrounding HIV is the overwhelming stigma associated with the disease. This stigma prevents many people from seeking testing or treatment and ultimately has a tremendous negative impact on the overall health and wellbeing of the affected individual. Several studies have found the internalized homophobia has adverse consequences for mental and physical health and is negatively associated with self-esteem and self-efficacy (Huebner, 2002). A recent study found that the LGBTQ community and people of color face numerous sociocultural barriers resulting in discrimination related to race, ethnicity, socioeconomic status, gender identity, and sexual orientation (Levitt, et al., 2017). An HIV diagnosis is also required to be reported to the state health department and once de-identified, it must be passed on to the CDC (CDC, 2015). While these measures are intended to help track the HIV epidemic, they can deter people from visiting their healthcare provider and delay seeking treatment for fear of a breach in confidentiality. For this reason, it is essential that healthcare providers develop a trusted rapport with their patients and convey the importance of getting tested and seeking treatment for the individual and their partner or partners.
Action Steps to Address the Problem
HIV antiretroviral pre-exposure prophylaxis (PrEP) is an extremely effective method of HIV prevention for populations at risk for HIV, including MSM and members of the LGBTQ population (Grant et al., 2010). A recent study of PrEP efficacy among MSM found that steadfast adherence to PrEP reduced HIV acquisition by 86%, yet the same study found that “there is less than 50% awareness of PrEP amongst racially diverse samples of MSM” (Dolling et al., 2016; Fallon et al., 2017). In addition, once someone thinks they may have been exposed to HIV, it is imperative to seek treatment as soon as possible. Antiretroviral therapy or ART is an effective way to reduce the amount of HIV in the body to a low level which keeps the immune system working and prevents illness (CDC, 2019). Medications aside, there are numerous health behaviors at-risk individuals can adopt to reduce the likelihood of contracting HIV. LGBTQ individuals should practice safe sex, practice monogamy or have only a few trusted and tested sexual partners if possible, in addition to using condoms and getting tested regularly. Needle exchange programs and increased sexual education are also great measures to reduce HIV incidence in the United States (CDC, 2019).
In Arizona, the Southwest Center for HIV and TERROS, Inc. have interventions designed specifically for the LGBTQ community in order to reduce the number of HIV cases in Arizona. “Healthy Relationships” is a five-session intervention for small groups of infected or at-risk individuals focused on gaining skills related to disclosure of HIV status to loved ones, needle sharing partners, and educating the population about safer sexual behaviors (CDC, 2015). This intervention is primarily focused on “Men who have Sex with Men (MSM), Injection Drug Users (IDU), homeless persons, young adults, and Black women and their partners” (AZDHS, 2017). Maricopa county has also partnered with Maricopa Medical Center (MIHS) to create an opt-out HIV testing policy and is helping MIHS provide Antiretroviral Treatment and Access to Services (ARTAS) to people with HIV in Arizona (AZDHS, 2017). This program is incredibly important as it helps link medical care to medical treatment services for individuals in an attempt to lower transmission rates in Maricopa County where the incidence and prevalence of HIV is the highest in Arizona (AZDHS, 2017).
In summary, increased education about safe sex practices, PrEP and ART amongst the LGBTQ community should be implemented specifically targeting LGBTQ people of color in Arizona. In addition to the LGBTQ community, the homeless population and IV drug users are also at increased risk for HIV/AIDS and should also be targeted with increased education measures and provided access to resources such as regular and free HIV testing, free HIV management visits, and have access to PrEP in shelters and rehabilitation clinics regardless of their insurance status (Fallon et al., 2017).
- Arizona Department of Health Services (2017). 2014-2017 Arizona Jurisdiction HIV Prevention Plan. Retrieved April 18, 2019 from https://www.azdhs.gov/documents/prevention/tobacco-chronic-disease/hiv-prevention/community-planning/AZHIVPreventionPlan.pdf
- Center for Disease Control. (2019, January 29). HIV/AIDS. Retrieved March 16, 2019, from https://www.cdc.gov/hiv/statistics/overview/ataglance.html
- Centers for Disease Control and Prevention. (2015, November). HIV surveillance report, 2014, Vol. 26. Retrieved September 27, 2016, from http://www.cdc.gov/hiv/library/reports/surveillance/
- Dolling, D. I., Desai, M., McOwan, A., Gilson, R., Clarke, A., Fisher, M., … Nardone, A. (2016). An analysis of baseline data from the PROUD study: An open-label randomised trial of pre-exposure prophylaxis. Trials, 17, 163. doi:10.1186/s13063-016-1286-4
- Fallon, S. A., Park, J. N., Ogbue, C. P., Flynn, C., & German, D. (2017). Awareness and acceptability of Pre-exposure HIV prophylaxis among men who have sex with men in Baltimore. AIDS and Behavior, 21(5), 1268–1277. doi:10.1007/s10461-016-1619-z
- Grant, R. M., Lama, J. R., Anderson, P. L., McMahan, V., Liu, A. Y., Vargas, L., & Glidden, D. V. (2010). Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. The New England Journal of Medicine, 363(27), 2587–2599. doi:10.1056/NEJMoa1011205
- HIV.gov. (2018, February 21). What Are HIV and AIDS? Retrieved March 16, 2019, from https://www.hiv.gov/hiv-basics/overview/about-hiv-and-aids/what-are-hiv-and-aids
- Huebner, D. M., Davis, M. C., Nemeroff, C. J., & Aiken, L. S. (2002). The impact of internalized homophobia on HIV preventive interventions. American Journal of Community Psychology, 30(3), 327-348.
- Levitt, H.M., Horne, S.G., Freeman-Coppadge, D. et al. AIDS Behav (2017) 21: 2973. https://doi.org/10.1007/s10461-017-1774-x
- UNAIDS. (2019, January 10). Global Statistics. Retrieved March 16, 2019, from https://www.hiv.gov/hiv-basics/overview/data-and-trends/global-statistics