What aspect of the HIV/AIDS epidemic among black Americans is of particular concern to you?

The epidemic thrives on stigma

I think HIV/AIDS thrives on stigma. The more stigmatized a group is, the less likely it is that HIV/AIDS will be talked about in that group. The result will be people engaging in high-risk behavior.

HIV itself is stigmatizing and the behaviors involving sex and drugs associated with HIV transmission are stigmatizing. Of course, those behaviors are stigmatized in every population in the country, but it may be true that it is more so in the black community. This has helped to keep HIV underground where it thrives.

As a country, we have not shown much of an appetite for public campaigns about sexuality. It forces the society, as well as civic and religious leaders, to deal with stigmatized behaviors in a public way, and I do not think a lot of them have the stomach for that.

That said, I think it cannot help but improve the situation to have a black president in office. We have somebody in a position of great influence who can speak with some personal insight into the challenges that HIV represents in the black community. We have always known that we needed better relationships with black churches and community leaders, and that holds true still. I think those relationships will improve with the new administration.

Current CDC recommendations for opt-out HIV testing for all individuals aged 13 to 64 years old is good start, but I think the next step should involve a more coordinated way to reach out and bring more people into care. There are still several hundred thousand people in this country with HIV who have not been diagnosed or given access to treatment. Many of those individuals are in stigmatized groups, including the MSM community. This is preventing us from accurately estimating infection rates and effectively dealing with the epidemic.

There is a sense that a number of black men are having sex with men and women. Unless we are willing to openly discuss some of the uncomfortable topics involved in this and other areas of the HIV epidemic, we will continue to find it difficult to gain traction in any aspect of the fight. Confronting these issues head-on in a systematic way could be extremely helpful in facilitating the kind of communication it will take to eliminate stigma.

Paul Volberding, MD, Professor and Vice Chair of the University of California San Francisco Department of Medicine and an Infectious Disease News editorial board member.

Health care disparities are top concern

Disparities in the health care system are a serious concern. Despite the large number of uninsured black Americans, the problem of disparity is not limited to one of access or no access. There is evidence that disparities exist even among the insured.

The problem can be divided into two broad categories: institutional disparities and individual disparities.

Many health care agencies are open 9:00 to 5:00 with no weekend or evening hours. This forces many working people to choose between taking time off and seeing a doctor. For those that do decide to take the time off, transportation becomes an issue. In economically depressed regions, health care centers are often few and far between. For those that have their own transportation, parking costs are an issue. Co-pays are an issue. These are factors built into the health care institution that select out certain kinds of people.

The individual disparities are more difficult to pinpoint. There is a degree of medical mistrust of health care providers among ethnic minorities. We have seen evidence of providers giving different information to different populations. Providers can make judgments about the ability of a patient to comprehend advice, and their recommendations for medication or additional care reflect these judgments. Providers may make judgments about patients who are homeless or have been incarcerated.

We have seen situations where minorities are seen by nurses when doctors are available. Sometimes the length of time a doctor spends with a patient is insufficient and sometimes the things said by the doctor are insufficient or inappropriate. There is evidence that different kinds of people get different kinds of care. We still have a big gap in services provided.

On yet a more personal level, even the body language and vocabulary used by providers might be off-putting to certain populations. Patients may feel scrutinized simply by the way they are greeted or treated by their doctor. When issues of race and prejudice may come into play, bedside manner becomes an important factor. Xenophobia still exists. We have some well-entrenched attitudes and beliefs that are present in the health care system as well.

Attempts have been made to assess the level of ethnocentricity among health professionals, but it proved nearly impossible to gauge. Doctors would not self-evaluate for having ethnocentric ideas, either in their own beliefs or in their approach to treating patients.

But the message to providers needs to get out: Anyone who is not providing the same level of care to all patients should get additional information about how certain attitudes and behaviors can push people out of the health care system.

The good news is that we can train providers on cultural competence and diverse populations and how to prevent ethnocentric attitudes from impacting their practice. With appropriate guidance, I think this is something that could be easily remedied or overcome.

Gail E. Wyatt, PhD, Associate Director of the UCLA AIDS Institute and Professor in the Department of Psychiatry and Biobehavioral Sciences.