1. Kevin Fenton, MD, PhD, FFPH Director National Center for HIV/AIDs, Viral Hepatitis, STD and TB Prevention Centers for Disease Control and Prevention Understanding HIV/AIDS in the context of the Black Diaspora: An epidemiological framework AIDS 2012 HIV and AIDS in Context of the Black Diaspora Regional Session July 25, 2012

2.  Understanding the Black diaspora  HIV/AIDS epidemic typologies, and their determinants, across the Black diaspora  Moving forward: Enhancing the HIV/AIDS prevention response within and across the Black diaspora Overview Disclaimer: The opinions expressed are those of the author and may not necessarily reflect the official position of the Centers for Disease Control and Prevention

3.  The term “diaspora” refers to the movement, migration, or scattering of people away from an established or ancestral homeland (Cohen, 1997)  Between 1500 and 1900, approximately four million enslaved Black Africans were transported to island plantations in the Indian Ocean, about eight million were shipped to Mediterranean- area countries, and about eleven million survived the Middle Passage to the New World.  African (and to lesser extent Caribbean) immigration has become the primary force in the modern black diaspora  It is estimated that the population of recent African immigrants to the United States alone is over 600,000.  There are significant populations of African immigrants in many other countries around the world, e.g. UK and France. The Black Diaspora Historic origins and current drivers

4. TYPE I: Post-Slavery Black Majorities The Black Diaspora A descriptive typology TYPE II: Post slavery, Black Minorities TYPE III: Post-Colonialization Black Minorities TYPE IV: Recent economic and social migrants Caribbean region Populace mainly of African descent Political, social power structures and networks largely governed by those of African descent Social and economic trajectories heterogeneous and determined by economic, political and social Caribbean region Populace mainly of African descent Political, social power structures and networks largely governed by those of African descent Social and economic trajectories heterogeneous and determined by economic, political and social North, Central and South America Populace mainly of European or Mixed descent with varied proportion of blacks Political, social power structures and networks largely governed by ethnic majority Civil rights heterogeneous North, Central and South America Populace mainly of European or Mixed descent with varied proportion of blacks Political, social power structures and networks largely governed by ethnic majority Civil rights heterogeneous Western Europe Populace almost entirely of European descent Black migration in mid- late 20 th Century Political, social power structures and networks largely governed by ethnic majority Civil rights influence minimal and heterogeneous Western Europe Populace almost entirely of European descent Black migration in mid- late 20 th Century Political, social power structures and networks largely governed by ethnic majority Civil rights influence minimal and heterogeneous Western Europe, Canada, United States, Intra- Africa Level of integration into society heterogeneous Display general characteristics of economic migrants Political, social power structures and networks largely governed by ethnic majority Western Europe, Canada, United States, Intra- Africa Level of integration into society heterogeneous Display general characteristics of economic migrants Political, social power structures and networks largely governed by ethnic majority

5. Indicator20012011 Number of adults and children living with HIV 210 000230 000 Adult prevalence1.0% New Infections (adults and children)19 00013 000 Number of deaths (adults and children) 18 00010 000 TYPE I: Post-Slavery Black Majorities Caribbean Region: Trends in the HIV/AIDS epidemic, 2001-2011 Source: WHO/UNAIDS Source; UNAIDS World AIDS Day Report 2011; UNAIDS, Together We Will end AIDS 2012 The Caribbean has the second highest regional HIV prevalence after sub-Saharan Africa, although the epidemic has slowed considerably since the mid-1990s.

6.  Overall, unprotected sex between men and women—especially paid sex– is believed to be the main mode of HIV transmission in the Caribbean.  High HIV infection levels have been found among female sex workers in the region: 4% in the Dominican Republic, 9% in Jamaica and 27% in Guyana.  Sex between men is also a significant factor in several national epidemics with at least 12% of reported HIV infections in men estimated to have been caused by unprotected sex between men.  The estimated HIV prevalence among MSM for 2005-2008 varied from 6.1% in the Dominican Republic to 32% in Jamaica.  Mobile and migrant populations as well as STI clinic attendees also represent vulnerable groups with higher HIV prevalence relative to the general population. TYPE I: Post-Slavery Black Majorities Caribbean Region: Epidemic Drivers Source: UNAIDS Caribbean Fact Sheet, 2010; UNAIDS, The Status of HIV in the Caribbean

7. TYPE II: Post-Slavery Black Minorities Adults and Adolescents with HIV and Awareness of HIV Status, 2009, United States Source: CDC. HIV Surveillance Report Supplemental Report Vol. 17, No. 3. June 2012. Estimated number of HIV infected persons in US 1,148,200 Estimated number unaware of their HIV infection 207,600 (18%) Estimated new HIV infections annually48,100 Estimated number of blacks living with HIV510,600 Estimated number of blacks unaware of their infection 99,200

8.  Blacks represented approximately 14% of the U.S. population, but accounted for 44% of 48,100 estimated new HIV infections in the U.S. in 2009.  Of the 191,698 HIV diagnoses from 2007-2010, blacks accounted for 45% of the total, 62% of women, 64% of infections attributable to heterosexual contact, and 66% of children aged under 13 years.  Lifetime risk of HIV diagnosis for African Americans is 1 in 16 for men; and 1 in 30 for women  In 2009, the highest rate of deaths among persons diagnosed with HIV was for blacks, 29.3 per 100,000 population. TYPE II: Post-Slavery Black Minorities HIV/AIDS Among Blacks in the United States Source: Prejean et al, PLoS ONE 2011. CDC HIV Surveillance Report, 2010

9.  Shortfalls in labor supply created by the post WWII economy provided the “pull” for migrant labor, while native workers moved to satisfy the demand for labor in more attractive jobs. Migrant workers filled their places as “replacement populations”  In Britain:  The first large-scale migration of people of minority ethnic origin came from the Caribbean shortly after WWII and during the 1950s.  Immigrants from India and Pakistan arrived mainly during the 1960s.  Many people from African-Asian descent came to the US as refugees from Uganda during the 1970s  Majority of Britain’s Black African communities arrived during the 1980s and 1990s  The recruitment of Black and Asian migrant workers in the 1950s and 1960s to the least desirable sectors of the British labor market set in motion a cycle of disadvantage, inhibiting opportunities of the migrants and their children. TYPE III: Post-Colonialization Black Minorities Britain’s Black and Ethnic Minorities Source: UN; IOM

10.  The prevalence of diagnosed HIV in black African and black Caribbean communities in England is estimated to be 3.7% and 0.4% respectively, compared to 0.09% among whites.  New diagnoses among black Caribbeans remained low (189 in 2007), representing 3% of new diagnoses in 2007. Twenty-seven percent of HIV diagnoses among black Caribbeans were late.  In 2007 black Caribbeans accounted for over a quarter (26%) of heterosexually acquired gonorrhoea diagnosed in a sample of genitourinary medicine clinics in England and Wales. TYPE III: Post-Colonialization Black Minorities Britain’s Black and Ethnic Minorities Proportions of new HIV, gonorrhoea, syphilis and chlamydia diagnoses among heterosexuals of different ethnic groups, UK*, 2007.

11.  Migrants are defined as ‘any person who lives temporarily or permanently in a country where he or she was not born, and has acquired significant social ties to this country’.  Approx. 3.1% of worlds population – 214 million – were international migrants in 2010 (IOM)  Patterns of migration affected by political tensions, war, economic and environmental crises.  Migration has implications for public health including provision of HIV services, cultural competence of interventions, and understanding epidemic impact and trajectories TYPE IV: Recent Social and Economic Migrants Global impact of migration Source: UN; IOM

12. TYPE IV: Recent Social and Economic Migrants HIV/AIDS in European Region Source: ECDC and WHO Percent of HIV cases originating from countries with generalized epidemics among all heterosexual cases, 2010

13.  An estimated 100,013 black adults and adolescents were diagnosed with HIV infection in 33 states for which country of birth information was available  Of these, 12% were foreign-born  Most were from the Caribbean (54%) and Africa (42%)  A higher percentage of the foreign-born black individuals was female than were the native-born  The foreign-born black individuals were was more likely to have HIV attributable to heterosexual contact than were the native-born individuals  The foreign-born black individuals were more likely than the native-born to be diagnosed with AIDS within 1 year of their HIV diagnosis  The foreign-born, however, were more likely to survive 1 year or 3 or more years after their diagnosis TYPE IV: Recent Social and Economic Migrants Epidemiology of HIV diagnoses among native-born and foreign-born black people, 33 U.S. states, 2001-2007 Source: Satcher Johnson, Public Health Reports, 2010

14. Enhancing HIV prevention across the Diaspora Typology-specific considerations

15.  Gaps in information. Still relatively few studies on the black diaspora and HIV. Surveillance systems are inconsistent. Data reporting not systematic and tied to solutions.  Lack of standardization. A major methodological challenge is terminology used to describe “migrant” in many settings. May include short or long term; transit or settled populations; multi- generational migrants.  Inconsistent policies. Heterogenous national policies and response to HIV prevention treatment and care and support observed across jurisdictions. Especially seen with the way migrant populations are managed.  Obstacles at service delivery level. In many countries administrative barriers to HIV prevention, treatment and care remains a challenge – both for migrant as well as established populations. Enhancing HIV prevention across the Diaspora Address critical needs

16.  Members of the black diaspora have been and remain disproportionately affected by the HIV/AIDS pandemic  A complex array of behavioral, healthcare and social and structural determinants continue to drive HIV within Black communities  Turning the tide within the Black diaspora will require greater awareness, focus, and commitment to engaging and responding to communities needs Summary

17. Thank You Kevin A. Fenton, MD, PhD, FFPH Centers for Disease Control and Prevention 404-639-8000 Email: kif2@cdc.gov Twitter: CDC_DrFenton Web: www.cdc.gov/nchhstp