Black Women and HIV: What
you should know
David J. Malebranche
Assistant Professor
Emory University
Division of General Medicine
Agenda
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HIV 101
HIV Transmission
Behavioral Risk for HIV
Current HIV Treatment Guidelines
Black Women and HIV
“Down Low” Men and HIV
Conclusion/Questions
HIV 101
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Immune System Review
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Bone Marrow: creates immune cells
Thymus: produces mature T cells
Spleen: blood filter for foreign material and
stimulator of immune response
Lymph nodes: filter for lymphatic fluid, which
carries foreign material
HIV 101 (cont’d)
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Immune System Cells
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T cells
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CD4 – coordinates immune response **
CD8 – kills viruses, tumors and parasites and suppresses
immune response
NK cells – kills foreign invaders and infection
B cells – produces antibodies (proteins) to fight
infection
Polymorphonuclear leukocytes (PMNs) – trap and
digest foreign material and infections
Antigen presenting cells (APC)
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Macrophages
Dendritic cells
HIV and the Immune System
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HIV decreases CD4 T-cell count
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Peripheral destruction
Decreased production/maturation in thymus
Two in HIV progression:
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CD4 count (normal count 600-1500)
Viral load (amount of virus in bloodstream)
Train analogy
HIV Transmission
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Vaginal/Anal sex
IV Drug Abuse
Vertical Transmission (during birth)
Breast feeding
Oral Sex?
Kissing?
Biting?
Saliva, Tears, Sweat?
Co-factors in Behavioral Risk
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Mental Health – Depression, Anxiety, etc.
Sexually Transmitted Infections – Herpes,
Syphilis, Gonorrhea, Chlamydia
Circumcision – increased risk for men
Media – blaming the victim
Poor risk assessment
Denial – risk behaviors, drug use, sexuality
Protecting Yourself from HIV
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Mental Health – you’re not “crazy”
Education - Know your risk!
Abstinence
Have your sexual partners tested
Condoms
Microbicides - 2007
Post-exposure prophylaxis (PEP)
Sperm Washing – before becoming pregnant
Condoms
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Latex – best protection
Polyurethane – for those with latex allergy
Lambskin – porous; not the best barrier
Breakage rate – 2%
>90 - 98% effectiveness preventing:
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Pregnancy
Gonorrhea/Chlamydia
HIV
Not as effective against Syphilis, HPV (warts)
and HSV (herpes)
Acute Retroviral Syndrome
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Flu-like illness – fever, muscle aches, sore
throat, swollen lymph nodes
2-8 weeks after HIV exposure
Rash distinguishes it from the flu
HIV Antibody test often negative
HIV viral load & glycoprotein testing
30 – 70% of those infected will have this
syndrome
HIV Testing Methods
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Elisa Test – sensitive test (low false
negative rate) – blood test
Western Blot – specific test (low false
positive rate) – blood test
Orasure – Q-tip swab in mouth
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Rapid results
Routine lab results
When to Start Antiretroviral
Therapy?
CD4
COUNT
PLASMA
< 5000
< 350
350-500
> 500
Advise
Therapy
Consider
Therapy
Defer
Therapy
HIV RNA
LEVEL
5000 –
50,000
Advise
Therapy
Advise
Therapy
Consider
Therapy
> 50,000
Advise
Therapy
Advise
Therapy
Advise
Therapy
HIV Medications
NUCLEOSIDE REVERSE
TRANSCRIPTASE INHIBITORS (NRTIs)
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These drugs work by blocking Step 4, where the HIV genetic
material is converted from RNA into DNA. Approved drugs in this
class include:
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AZT (Zidovudine, Retrovir®)
ddI (Didanosine, Videx®) **
ddC (Zalcitabine, Hivid®)
d4T (Stavudine, Zerit®)
3TC (Lamivudine, Epivir®) **
Abacavir (Ziagen®)
Tenofovir (Viread) **
FTC (Emtriva, Emtricitabine) **
Combivir (AZT/3TC combination)
Trizivir (AZT/3TC/Abacavir combination)
Side Effects - NRTIs
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Common
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Headaches
Nausea
Diarrhea
Serious
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Pancreatitis – inflammation of pancreas (All)
Lactic Acidosis – body burns fat(All)
Hypersensitivity – allergic reaction (Ziagen)
Peripheral Neuropathy – nerve burning (Zerit, Videx)
Anemia, Neutropenia – low blood counts (AZT)
HIV Meds (cont’d)
NON-NUCLEOSIDE REVERSE
TRANSCRIPTASE INHIBITORS,
(NNRTIs)
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These drugs blocks the same step of the life cycle (step
4), but in a different way. Three NNRTIs have been
approved:
 Nevirapine (NVP, Viramune®)
 Delavirdine (DLV, Rescriptor®)
 Efavirenz (EFV, Sustiva®)
Side Effects - NNRTIs
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Common
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Elevated Liver Enzymes
Rash
Headache
Nausea/Vomiting
Serious
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Dreams, Hallucinations, Mood Swings (Sustiva)
Severe rash with blistering (Viramune, Rescriptor)
HIV Meds (cont’d)
PROTEASE INHIBITORS (PIs)
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These drugs block Step 7, where the raw material for
new HIV virus is cut into specific pieces. Six protease
inhibitors have been approved:
 Saquinavir (SQV, Invirase® and Fortovase®)
 Indinavir (IDV, Crixivan®)
 Ritonavir (RTV, Norvir®) – “boosted” regimens
 Nelfinavir (NFV, Viracept®)
 Amprenavir (APV, Agenerase®)
 Kaletra (ritonivir/lopinavir)
 Atazanavir (Reyataz)
Side Effects - PIs
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Common
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Diarrhea
Nausea
Headaches
Fatigue
Rash
Liver irritation
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Serious
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Kidney Stones
(Crixivan)
Fat deposits/wasting
Diabetes (high blood
sugar)
High Cholesterol
Bone damage
HIV Meds (cont’d)
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FUSION INHIBITORS
These drugs block Step 2, blocking HIV’s ability to infect
healthy CD4 cells by adhering to its outer membrane.
One fusion inhibitor has been approved:
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Fuzeon (Enfuvirtide) – administered as a twice
daily subcutaneous injection
Side Effects – Fusion Inhibitors
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Injection site reactions
Allergic reactions
Pneumonia
Leg and foot nerve pain
Insomnia
Depression
Constipation
Pancreas problems
Initiation of Antiretroviral
Therapy
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2 NRTIs and 1 NNRTI
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D4T/3TC and Sustiva
Combivir and Kaletra
2 NRTIs and 1 PI or “boosted” PI
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Combivir and Viracept or Crixivan
Combivir and Kaletra
What’s the best regimen to start with???
Vertical Transmission
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HIV transmission from mother to child
25 – 30% HIV transmission risk to infant
without treatment
Treatment
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AZT – reduces transmission from 27% to 10%
compared to placebo
Viramune – reduces transmission from 21% to
12% compared with AZT
HIV and Black Women
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Statistical disclaimer – be critical thinkers
Greatest risk factors
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38% through heterosexual sex
25% through IVDU
“Significant” number of black women
contract HIV through sex with IVDU
64% of HIV infections among all U.S.
women in 2001
Why are infections occurring??
The “Down Low”
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What does Down Low mean?
Who is more at risk for HIV – “Down Low”
men or “Gay” – identified men?
The meaning of “Down Low”
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Secretive
Undercover
Discreet
An R. Kelly Song
A homosexual black man who doesn’t identify as
“gay”
A homo “thug”
A married or coupled heterosexual man who has
sex with men on the side
Deconstruction
Black Masculinity
Two main roles during slavery:
1. Physical labor
2. Breeding
Theatrical Movie Stereotypes
Athletes
Hip Hop Artists
Criminals
Black Masculinities Combined
“GAY”
The social construction of “gay”
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Rainbow flags
Pink triangles
Pride Marches
“Will and Grace”
“Queer as Folk”
“Queer Eye for the Straight Guy”
Homophobia vs. “Gay-o-phobia”
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Religion
Culture
Gender Role Conflict
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“Occurs when rigid, sexist, or restrictive gender roles
result in personal restriction, devaluation, or violation of
others or self.”
Gender-Role Conflict Scale (GRCS) – 37 item scale
1. Success, Power and Competition
2. Restrictive Emotionality
3. Restrictive Affectionate Behavior between men
4. Conflicts between Work and Family Relations
(O’Neil et al., 1986)
So What is “Down Low” in the
context of HIV prevention?
Battle of the brainwashing and
discrimination
Black Masculine Stereotypes
Vs.
“Gay” Stereotypes
“Down Low” relation to HIV
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Myths:
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More promiscuous than heterosexual or “gay” men
alone
More likely to have unprotected sex
More likely to have HIV
Reality:
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Potential mode of HIV transmission to black women
(and other black men)
Thirty-three percent of black men with HIV contract it
from IV drug use
Qualitative Research
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8 Focus Groups
81 self-identified BMSM
Atlanta, NYC and Upstate NY
NYC Dept. of Health, Columbia University
and New York State Black Gay Network
$25 participant compensation
Support from AIDS Education Training
Center (AETC)
Racial Stress
“Being a black man is a hard struggle. Not just being gay,
being straight – being a general black man is an
everyday struggle. I don’t care how you put it, white
America either wants me in a cell or a grave.”
(Rochester, 21)
“Because we’re black, we all have the same face. So when
you approach somebody, they think that you’re going to
automatically cross them in a very aggressive,
intimidating way. You’re black first.” (Atlanta, 33)
“For me, whether it’s sexuality or just gender, its always
gonna be an issue of race. I’m gonna be seen as a black
man.” (Albany, 42)
Gender Role Expectations
“You know, that's the way I was brought up. Grow up,
go to high school, go to college, marry a woman… Then
you have children. And you had a house, the dog, and I
grew up like that, and I did that. I did the marriage
thing, and the children, and the wife. You know, but
that's because that's what was instilled in me. And I
remember on my wedding day my big brother said to
me, he said, ‘You know you don't have to do this.’ He
saw something in me I didn't wanna see in myself. So,
you know and I said, ‘You're crazy, I gotta do this.
Everybody's watching.’ You know, and it was always
about everybody. You know, pleasing everybody instead
of dealing with inner self.” (Harlem, 38)
Black Masculinity
“As being a young black male, if I would come and
say something’s wrong with me. They [medical
providers] would say, ‘Oh, look at this, you know
they probably just hip-hoppin’ and screwin’
down and you know, smokin’ the blunts, and
then he gonna come here, talkin’ about he sick.’
So its like I’m stereotyped already. And now if
you say you’re gay, everybody can get the
picture of the feminine, gay brother. So I guess
it can come to the sexuality because they feel,
‘Oh, you must have been loose in the booty
already.’” (Harlem, 19)
Religion/Spirituality
“This one woman came up to me, she said “You ain’t been
to church in 3 months, and I’ve seen you with some
man, and I know he sleeps with men. What’s up with
you?” And I said to her “Are any one of your 5 baby
daddies saved?” I just wanna know. Everybody act like
y’all aint never done nuthin wrong. To me, being gay
and sleeping with a man, is no more, no different than
me sleeping with a woman. Cause I’m not married so
according to the bible, its all fornication. And that’s for
him to judge me. People in church, they just get saved
and quote-unquote, “get Jesus,” and they act like they
just perfect.” (Rochester, 21)
Medical Culture
“I was talking to her [the doctor] about
the symptoms I was having. And she’s
like, she asked me when the last time I
had anal sex? And I told her like
whenever it was. And she’s like, ‘Well,
you know…,’ and this really surprised
me, ‘Well, you know, the anus really
isn’t made for that.’ And I was like,
‘Yeah, I know, but it’s a little too late.’
You know?” (Manhattan, 34)
Why is all this important?
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30% HIV prevalence for 23-29 year old BMSM in large
metropolitan areas (YMS, 2001)
14.7% HIV incidence rate (YMS, 2001)
93% of HIV-infected BMSM not aware of their status
(YMS, 2001)
16% of lower income LA black men who are
heterosexual admit anal sex with other men
Black women comprise 75% of the female AIDS cases in
the United States (CDC, 2000)
BMSM who are “disclosers” have higher rates of
unprotected anal sex (41% vs. 32%) and higher HIV
prevalence than “nondisclosers” (24% vs. 14%) (YMS,
2003)
HIV, Statistics and Media Hype
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No scientific studies on HIV and “down low”
black men – NONE!
Few scientific studies on the social context of
sexuality among black men (or women)
NY Times, Village Voice, Washington Post –
“Down Low” experts
“Down Low” has become a catch phrase for selfmarketing and promotion
The Culture of Fear – “Bowling for Columbine”
Real Topics on the “Down Low”
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Child sexual abuse (male and female)
“Situational sex”
Gender and power dynamics in sex
Lack of condoms in prisons
Sexual prejudice in the Church
The mental health of black people in the
United States
Conclusions
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No Justification for “Down Low”
Sexuality is not as static as we think
Know your partner’s status
Treat everyone like they’re HIV positive
until you know for sure
Assess your own risk based on your
behavior, not who you are
Reconstructing HIV Prevention
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HIV prevention for the entire black community
Start addressing our mental health
Scrap the overemphasis on “Down Low”
Focus on HIV risk behavior
More qualitative research to compliment the
statistics
Realistic assessment of role of churches
Emphasize women’s resiliency factors
Redefining gender roles
Contact Information
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David Malebranche, MD, MPH
dmalebr@emory.edu
(404) 616-0347 wk
69 Jesse Hill Jr. Drive
Atlanta, GA 30324