1. Black Women and HIV: What you should know David J. Malebranche Assistant Professor Emory University Division of General Medicine

2. Agenda HIV 101 HIV 101 HIV Transmission HIV Transmission Behavioral Risk for HIV Behavioral Risk for HIV Current HIV Treatment Guidelines Current HIV Treatment Guidelines Black Women and HIV Black Women and HIV “Down Low” Men and HIV “Down Low” Men and HIV Conclusion/Questions Conclusion/Questions

3. HIV 101 Immune System Review Immune System Review Bone Marrow: creates immune cells Bone Marrow: creates immune cells Thymus: produces mature T cells Thymus: produces mature T cells Spleen: blood filter for foreign material and stimulator of immune response Spleen: blood filter for foreign material and stimulator of immune response Lymph nodes: filter for lymphatic fluid, which carries foreign material Lymph nodes: filter for lymphatic fluid, which carries foreign material

4. HIV 101 (cont’d) Immune System Cells Immune System Cells T cells T cells CD4 – coordinates immune response ** CD4 – coordinates immune response ** CD8 – kills viruses, tumors and parasites and suppresses immune response CD8 – kills viruses, tumors and parasites and suppresses immune response NK cells – kills foreign invaders and infection NK cells – kills foreign invaders and infection B cells – produces antibodies (proteins) to fight infection B cells – produces antibodies (proteins) to fight infection Polymorphonuclear leukocytes (PMNs) – trap and digest foreign material and infections Polymorphonuclear leukocytes (PMNs) – trap and digest foreign material and infections Antigen presenting cells (APC) Antigen presenting cells (APC) Macrophages Macrophages Dendritic cells Dendritic cells

6. HIV and the Immune System HIV decreases CD4 T-cell count HIV decreases CD4 T-cell count Peripheral destruction Peripheral destruction Decreased production/maturation in thymus Decreased production/maturation in thymus Two in HIV progression: Two in HIV progression: CD4 count (normal count 600-1500) CD4 count (normal count 600-1500) Viral load (amount of virus in bloodstream) Viral load (amount of virus in bloodstream) Train analogy Train analogy

7. HIV Transmission Vaginal/Anal sex Vaginal/Anal sex IV Drug Abuse IV Drug Abuse Vertical Transmission (during birth) Vertical Transmission (during birth) Breast feeding Breast feeding Oral Sex? Oral Sex? Kissing? Kissing? Biting? Biting? Saliva, Tears, Sweat? Saliva, Tears, Sweat?

8. Co-factors in Behavioral Risk Mental Health – Depression, Anxiety, etc. Mental Health – Depression, Anxiety, etc. Sexually Transmitted Infections – Herpes, Syphilis, Gonorrhea, Chlamydia Sexually Transmitted Infections – Herpes, Syphilis, Gonorrhea, Chlamydia Circumcision – increased risk for men Circumcision – increased risk for men Media – blaming the victim Media – blaming the victim Poor risk assessment Poor risk assessment Denial – risk behaviors, drug use, sexuality Denial – risk behaviors, drug use, sexuality

9. Protecting Yourself from HIV Mental Health – you’re not “crazy” Mental Health – you’re not “crazy” Education - Know your risk! Education - Know your risk! Abstinence Abstinence Have your sexual partners tested Have your sexual partners tested Condoms Condoms Microbicides - 2007 Microbicides - 2007 Post-exposure prophylaxis (PEP) Post-exposure prophylaxis (PEP) Sperm Washing – before becoming pregnant Sperm Washing – before becoming pregnant

10. Condoms Latex – best protection Latex – best protection Polyurethane – for those with latex allergy Polyurethane – for those with latex allergy Lambskin – porous; not the best barrier Lambskin – porous; not the best barrier Breakage rate – 2% Breakage rate – 2% >90 - 98% effectiveness preventing: >90 - 98% effectiveness preventing: Pregnancy Pregnancy Gonorrhea/Chlamydia Gonorrhea/Chlamydia HIV HIV Not as effective against Syphilis, HPV (warts) and HSV (herpes) Not as effective against Syphilis, HPV (warts) and HSV (herpes)

11. Acute Retroviral Syndrome Flu-like illness – fever, muscle aches, sore throat, swollen lymph nodes Flu-like illness – fever, muscle aches, sore throat, swollen lymph nodes 2-8 weeks after HIV exposure 2-8 weeks after HIV exposure Rash distinguishes it from the flu Rash distinguishes it from the flu HIV Antibody test often negative HIV Antibody test often negative HIV viral load & glycoprotein testing HIV viral load & glycoprotein testing 30 – 70% of those infected will have this syndrome 30 – 70% of those infected will have this syndrome

12. HIV Testing Methods Elisa Test – sensitive test (low false negative rate) – blood test Elisa Test – sensitive test (low false negative rate) – blood test Western Blot – specific test (low false positive rate) – blood test Western Blot – specific test (low false positive rate) – blood test Orasure – Q-tip swab in mouth Orasure – Q-tip swab in mouth Rapid results Rapid results Routine lab results Routine lab results

13. When to Start Antiretroviral Therapy? CD4 COUNT PLASMA PLASMA HIV RNA HIV RNALEVEL < 5000 5000 – 50,000 > 50,000 < 350 Advise Therapy 350-500 Consider Therapy Advise Therapy > 500 Defer Therapy Consider Therapy Advise Therapy

14. HIV Medications NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NRTIs) These drugs work by blocking Step 4, where the HIV genetic material is converted from RNA into DNA. Approved drugs in this class include: These drugs work by blocking Step 4, where the HIV genetic material is converted from RNA into DNA. Approved drugs in this class include: AZT (Zidovudine, Retrovir®) AZT (Zidovudine, Retrovir®) AZT ddI (Didanosine, Videx®) ** ddI (Didanosine, Videx®) ** ddI ddC (Zalcitabine, Hivid®) ddC (Zalcitabine, Hivid®) ddC d4T (Stavudine, Zerit®) d4T (Stavudine, Zerit®) d4T 3TC (Lamivudine, Epivir®) ** 3TC (Lamivudine, Epivir®) ** 3TC Abacavir (Ziagen®) Abacavir (Ziagen®) Abacavir Tenofovir (Viread) ** Tenofovir (Viread) ** Tenofovir (Viread) Tenofovir (Viread) FTC (Emtriva, Emtricitabine) ** FTC (Emtriva, Emtricitabine) ** Combivir (AZT/3TC combination) Combivir (AZT/3TC combination) Trizivir (AZT/3TC/Abacavir combination) Trizivir (AZT/3TC/Abacavir combination)

15. Side Effects - NRTIs Common Common Headaches Headaches Nausea Nausea Diarrhea Diarrhea Serious Serious Pancreatitis – inflammation of pancreas (All) Pancreatitis – inflammation of pancreas (All) Lactic Acidosis – body burns fat(All) Lactic Acidosis – body burns fat(All) Hypersensitivity – allergic reaction (Ziagen) Hypersensitivity – allergic reaction (Ziagen) Peripheral Neuropathy – nerve burning (Zerit, Videx) Peripheral Neuropathy – nerve burning (Zerit, Videx) Anemia, Neutropenia – low blood counts (AZT) Anemia, Neutropenia – low blood counts (AZT)

16. HIV Meds (cont’d) NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS, (NNRTIs) These drugs blocks the same step of the life cycle (step 4), but in a different way. Three NNRTIs have been approved: 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®) Nevirapine (NVP, Viramune®) Nevirapine Delavirdine (DLV, Rescriptor®) Delavirdine (DLV, Rescriptor®) Delavirdine Efavirenz (EFV, Sustiva®) Efavirenz (EFV, Sustiva®) Efavirenz

17. Side Effects - NNRTIs Common Common Elevated Liver Enzymes Elevated Liver Enzymes Rash Rash Headache Headache Nausea/Vomiting Nausea/Vomiting Serious Serious Dreams, Hallucinations, Mood Swings (Sustiva) Dreams, Hallucinations, Mood Swings (Sustiva) Severe rash with blistering (Viramune, Rescriptor) Severe rash with blistering (Viramune, Rescriptor)

18. HIV Meds (cont’d) PROTEASE INHIBITORS (PIs) These drugs block Step 7, where the raw material for new HIV virus is cut into specific pieces. Six protease inhibitors have been approved: 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®) Saquinavir (SQV, Invirase® and Fortovase®) Saquinavir Indinavir (IDV, Crixivan®) Indinavir (IDV, Crixivan®) Indinavir Ritonavir (RTV, Norvir®) – “boosted” regimens Ritonavir (RTV, Norvir®) – “boosted” regimens Ritonavir Nelfinavir (NFV, Viracept®) Nelfinavir (NFV, Viracept®) Nelfinavir Amprenavir (APV, Agenerase®) Amprenavir (APV, Agenerase®) Amprenavir Kaletra (ritonivir/lopinavir) Kaletra (ritonivir/lopinavir) Atazanavir (Reyataz) Atazanavir (Reyataz)

19. Side Effects - PIs Common Common Diarrhea Diarrhea Nausea Nausea Headaches Headaches Fatigue Fatigue Rash Rash Liver irritation Liver irritation Serious Kidney Stones (Crixivan) Fat deposits/wasting Diabetes (high blood sugar) High Cholesterol Bone damage

20. HIV Meds (cont’d) FUSION INHIBITORS 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: 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: Fuzeon (Enfuvirtide) – administered as a twice daily subcutaneous injection Fuzeon (Enfuvirtide) – administered as a twice daily subcutaneous injection

21. Side Effects – Fusion Inhibitors Injection site reactions Injection site reactions Allergic reactions Allergic reactions Pneumonia Pneumonia Leg and foot nerve pain Leg and foot nerve pain Insomnia Insomnia Depression Depression Constipation Constipation Pancreas problems Pancreas problems

22. Initiation of Antiretroviral Therapy 2 NRTIs and 1 NNRTI 2 NRTIs and 1 NNRTI D4T/3TC and Sustiva D4T/3TC and Sustiva Combivir and Kaletra Combivir and Kaletra 2 NRTIs and 1 PI or “boosted” PI 2 NRTIs and 1 PI or “boosted” PI Combivir and Viracept or Crixivan Combivir and Viracept or Crixivan Combivir and Kaletra Combivir and Kaletra What’s the best regimen to start with???

23. Vertical Transmission HIV transmission from mother to child HIV transmission from mother to child 25 – 30% HIV transmission risk to infant without treatment 25 – 30% HIV transmission risk to infant without treatment Treatment Treatment AZT – reduces transmission from 27% to 10% compared to placebo AZT – reduces transmission from 27% to 10% compared to placebo Viramune – reduces transmission from 21% to 12% compared with AZT Viramune – reduces transmission from 21% to 12% compared with AZT

24. HIV and Black Women Statistical disclaimer – be critical thinkers Statistical disclaimer – be critical thinkers Greatest risk factors Greatest risk factors 38% through heterosexual sex 38% through heterosexual sex 25% through IVDU 25% through IVDU “Significant” number of black women contract HIV through sex with IVDU “Significant” number of black women contract HIV through sex with IVDU 64% of HIV infections among all U.S. women in 2001 64% of HIV infections among all U.S. women in 2001 Why are infections occurring?? Why are infections occurring??

25. The “Down Low” What does Down Low mean? What does Down Low mean? Who is more at risk for HIV – “Down Low” men or “Gay” – identified men? Who is more at risk for HIV – “Down Low” men or “Gay” – identified men?

26. The meaning of “Down Low” Secretive Secretive Undercover Undercover Discreet Discreet An R. Kelly Song An R. Kelly Song A homosexual black man who doesn’t identify as “gay” A homosexual black man who doesn’t identify as “gay” A homo “thug” A homo “thug” A married or coupled heterosexual man who has sex with men on the side A married or coupled heterosexual man who has sex with men on the side

27. Deconstruction

28. Black Masculinity Two main roles during slavery: 1. Physical labor 2. Breeding

29. Theatrical Movie Stereotypes

30. Athletes

31. Hip Hop Artists

32. Criminals

33. Black Masculinities Combined

34. “GAY”

35. The social construction of “gay” Rainbow flags Rainbow flags Pink triangles Pink triangles Pride Marches Pride Marches “Will and Grace” “Will and Grace” “Queer as Folk” “Queer as Folk” “Queer Eye for the Straight Guy” “Queer Eye for the Straight Guy” Homophobia vs. “Gay-o-phobia” Homophobia vs. “Gay-o-phobia” Religion Religion Culture Culture

36. Gender Role Conflict “Occurs when rigid, sexist, or restrictive gender roles result in personal restriction, devaluation, or violation of others or self.” “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 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)

37. So What is “Down Low” in the context of HIV prevention? Battle of the brainwashing and discrimination Black Masculine Stereotypes Vs. “Gay” Stereotypes

38. “Down Low” relation to HIV Myths: Myths: More promiscuous than heterosexual or “gay” men alone More promiscuous than heterosexual or “gay” men alone More likely to have unprotected sex More likely to have unprotected sex More likely to have HIV More likely to have HIV Reality: Reality: Potential mode of HIV transmission to black women (and other black men) 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 Thirty-three percent of black men with HIV contract it from IV drug use

39. Qualitative Research 8 Focus Groups 8 Focus Groups 81 self-identified BMSM 81 self-identified BMSM Atlanta, NYC and Upstate NY Atlanta, NYC and Upstate NY NYC Dept. of Health, Columbia University and New York State Black Gay Network NYC Dept. of Health, Columbia University and New York State Black Gay Network $25 participant compensation $25 participant compensation Support from AIDS Education Training Center (AETC) Support from AIDS Education Training Center (AETC)

40. 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)

41. 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)

42. 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)

43. 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)

44. 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)

45. Why is all this important? 30% HIV prevalence for 23-29 year old BMSM in large metropolitan areas (YMS, 2001) 30% HIV prevalence for 23-29 year old BMSM in large metropolitan areas (YMS, 2001) 14.7% HIV incidence rate (YMS, 2001) 14.7% HIV incidence rate (YMS, 2001) 93% of HIV-infected BMSM not aware of their status (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 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) 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) 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)

46. HIV, Statistics and Media Hype No scientific studies on HIV and “down low” black men – NONE! 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) Few scientific studies on the social context of sexuality among black men (or women) NY Times, Village Voice, Washington Post – “Down Low” experts NY Times, Village Voice, Washington Post – “Down Low” experts “Down Low” has become a catch phrase for self- marketing and promotion “Down Low” has become a catch phrase for self- marketing and promotion The Culture of Fear – “Bowling for Columbine” The Culture of Fear – “Bowling for Columbine”

47. Real Topics on the “Down Low” Child sexual abuse (male and female) Child sexual abuse (male and female) “Situational sex” “Situational sex” Gender and power dynamics in sex Gender and power dynamics in sex Lack of condoms in prisons Lack of condoms in prisons Sexual prejudice in the Church Sexual prejudice in the Church The mental health of black people in the United States The mental health of black people in the United States

48. Conclusions No Justification for “Down Low” No Justification for “Down Low” Sexuality is not as static as we think Sexuality is not as static as we think Know your partner’s status Know your partner’s status Treat everyone like they’re HIV positive until you know for sure Treat everyone like they’re HIV positive until you know for sure Assess your own risk based on your behavior, not who you are Assess your own risk based on your behavior, not who you are

49. Reconstructing HIV Prevention HIV prevention for the entire black community HIV prevention for the entire black community Start addressing our mental health Start addressing our mental health Scrap the overemphasis on “Down Low” Scrap the overemphasis on “Down Low” Focus on HIV risk behavior Focus on HIV risk behavior More qualitative research to compliment the statistics More qualitative research to compliment the statistics Realistic assessment of role of churches Realistic assessment of role of churches Emphasize women’s resiliency factors Emphasize women’s resiliency factors Redefining gender roles Redefining gender roles

50. Contact Information David Malebranche, MD, MPH David Malebranche, MD, MPH dmalebr@emory.edu dmalebr@emory.edu dmalebr@emory.edu (404) 616-0347 wk (404) 616-0347 wk 69 Jesse Hill Jr. Drive 69 Jesse Hill Jr. Drive Atlanta, GA 30324 Atlanta, GA 30324