The AIDS epidemic in south Florida : black non-Hispanics in our communities remain increasingly vulnerable

We compared demographic variables of individuals in Miami-Dade County, Florida, USA, with Acquired Immune Deficiency Syndrome (AIDS) during two time periods (1993 1995 and 2009 2011). Incidence and mortality-related data were explored in this observational study. Tests of significance were performed to identify differences or associations between selected groups. A correlation analysis was conducted to identify relationships between AIDS diagnosis and socioeconomic indicators. We observed a reduction in the number of new AIDS cases reported and AIDS-related mortality. Nonetheless, AIDS is still disproportionately affecting the black non-Hispanic population. Black non-Hispanic women remain particularly vulnerable to the disease. A positive correlation between AIDS diagnosis and poverty rate and the lack of health insurance, and a negative correlation between AIDS diagnosis and education level were identified. Though the actual number of AIDS cases is declining in this region, it continues to disproportionately affect the poorer, less well educated communities. Despite the availability of improved medication, people in these communities remain particularly vulnerable. 1

The first cases of the disease now known as Acquired Immune Deficiency Syndrome (AIDS) were reported by the Center for Disease Control and Prevention (CDC) over 30 years ago 1 . The effects of Human Immunodeficiency Virus (HIV) infection, the cause of AIDS, were initially diagnosed as Kaposi's Sarcoma and Pneumocystis pneumonia in a population of otherwise healthy men; 94% of whom self-reported their sexual preference as homosexual or bisexual 2 . Nowadays however it is well established that AIDS is not confined to homosexual or bisexual men. In fact, heterosexual contact now plays a significant role in continuing the worldwide AIDS epidemic, and specifically the spread of the disease throughout the United States, including Miami-Dade County and South Florida 3 . In particular, heterosexual contact is the primary mode of HIV/AIDS transmission to women. This is significant since women represented 32% of all reported AIDS cases and 25% of all reported HIV cases in Florida in 2010 4 and almost a quarter of all HIV/AIDS cases in the USA 4 .
Though HIV/AIDS is not confined to homosexual or bisexual men, globally men who have sex with men (MSM) remain most at risk of HIV infection 5 . In the United States, HIV infection in MSM is increasing by 8% annually 6 and this population now accounts for almost 50% of individuals living with HIV/AIDS and for 53% of all new HIV infections 7 . The greatest prevalence and the highest incidence of HIV infection in MSM is found in black MSM 8 . Throughout this article the term black is used to include African Americans, Caribbean Americans, Africans and others who may not self-identify as "African Americans" but who are included in all HIV/AIDS surveillance data as such 9 . This high risk population of young black MSM is difficult to reach, at least in part, due to the stigma associated with HIV/AIDS infection, belief in myths associated with prevention and transmission of HIV/AIDS 3 , and in some parts of the world, the threat of imprisonment.
This study provides a comparison of selected demographic variables and risk factors associated with individuals with AIDS during two three year periods (1993, 1994, 1995 and 2009, 2010, 2011) in Miami-Dade County, Florida. In addition, we provide an interpretation of the most recent AIDS incidence and AIDS-related mortality data. This is significant since according to the

Results
Analysis of the data from the State of Florida Department of Health, Bureau of HIV/AIDS revealed a total of 6,811 new AIDS cases reported during the first triennial period (1993, 1994 and 1995) and 2,193 new AIDS cases reported in the second triennial period (2009, 2010 and 2011) ( Table 1). In addition to this 68% reduction in incidence, there was an 82% reduction in AIDS-related mortality between these two triennial periods.
There has been a steady decline in both incidence and AIDS-related mortality in Miami-Dade County over the past decade ( Figure 1).
Gender and race/ethnicity Further analysis of the incidence of new AIDS cases reported in Miami-Dade County in the two triennial periods by both ethnicity and gender reveals some parallels between the triennial periods. Between 1993 and 1995 black non-Hispanics accounted for 40% of all AIDS cases reported by men, but 75% of all AIDS cases reported by women. In all other racial/ethnic groups, the proportion of new AIDS cases reported was greater in men. The same pattern was observed when the 2009-2011 triennial was considered ( Figure 4); black non-Hispanic men represented 40% of all AIDS cases reported by men yet black non-Hispanic women represented 74% of all AIDS cases reported by women.

Age
The

Socioeconomic indicators
There is a significant positive correlation between AIDS diagnosis and socioeconomic indicators, poverty rate and the lack of health insurance (Table 2). Education, as indicated by graduation from High School, is negatively correlated with AIDS diagnosis (Table 2).

Discussion
In this study we report on changes in the maturing AIDS epidemic in Miami Dade County, Florida from our observations of two tri-annual time points, 1993-1995 and 2009-2011. When these two time points are compared, we noted a decrease in the actual number of new AIDS cases reported as well as a reduction in AIDS-related mortality. In fact, there has been a gradual decline in both the incidence of AIDS and in AIDS-related mortality since 2002 (Figure 1). This may be attributed, at least in part, to the implementation of more aggressive treatment strategies (such as antiretroviral therapy (ART)) that delay the progression from HIV infection to AIDS. Despite this reduction in both incidence and AIDS-related mortality, our observations reveal some disturbing trends and emerging issues associated with the increased vulnerability of our minority communities in South Florida and particularly the vulnerability of non-Hispanic black women to AIDS. These observations should impact our intervention strategies moving forward.

R E T R
A C T E D number of AIDS cases diagnosed decreased when comparing the two triennial periods, the proportion of new AIDS cases reported by black non-Hispanics actually increased. Furthermore, the proportion of all AIDS-related deaths due to black non-Hispanic mortality also increased. In comparing these two triennial periods, the incidence of AIDS cases among Hispanics also increased, though less significantly than in black non-Hispanics while the incidence of white non-Hispanic AIDS cases actually decreased.
The disproportionate prevalence of AIDS in the black non-Hispanic community is fuelled, at least in part, by the increase in the incidence of AIDS in young black MSM between 13 and 29 years old 7 who often endure strict criminal justice policies as recently reported 7 . A variety of external factors that disproportionately affect blacks may account for the HIV/AIDS epidemic within our black communities and include, but are not limited to, the increased prevalence of sexually transmitted diseases, high levels of unemployment, dysfunctional social networks leading to low levels of academic achievement, the increased likelihood of imprisonment, increased poverty, reduced access to new retroviral treatment options or simply non-compliance, preventative and health care

Gender
Though men still account for most of the new AIDS cases reported, our observations reveal a significant increase in the proportion of women living with AIDS in Miami-Dade County, and a proportionate increase in AIDS-related mortality in women. HIV/AIDS in women continues to be a major public health concern particularly in our underserved communities where almost 75% of all HIV-infected women are racial and ethnic minorities, particularly black women 10 . According to our observations, 75% of all new AIDS cases reported by women in Miami-Dade County, in both triennial periods were reported by black non-Hispanic women. These women may acquire the virus through high-risk heterosexual contact with men who have multiple sexual partners 10 . These women may lack control over their sexual activities, such as condom use, and may be in abusive relationships 11 making them vulnerable to infection.

Race/Ethnicity
Our observations reveal that the black non-Hispanic population of Miami-Dade County is disproportionally affected by AIDS when compared to other races/ethnicities. We report that though the total According to our observations, the proportion of AIDS cases reported in MSM in Miami-Dade County remained relatively constant between the two tri-annual periods studied. Nationwide, the incidence of HIV/AIDS has also remained relatively stable in MSM with the notable exception of young black MSM. The incidence of HIV/AIDS in this population has increased significantly from 2006-2009 18 .

Socioeconomic indicators
We observed a significant positive correlation between AIDS diagnosis and poverty rate, suggesting that the disease discriminates against poorer populations. This connection is highly significant and not unexpected since good health and longevity is generally associated with high income/less poverty. Given that a lack of health insurance is a proxy for increased poverty, the positive correlation between AIDS diagnosis, poverty and the lack of health insurance is not unexpected. Those with AIDS may find it difficult to obtain employment (increased poverty), and may be discriminated against in the work place making career advancement unlikely, and since the employer is often responsible for health insurance, these uninsured individuals also have limited treatment options including limited access to the most aggressive (and expensive) treatment regimens such as ART. It is generally acknowledged that a lower socioeconomic status is associated with an increase in the behaviors that increase AIDS risk; intravenous drug use, and unprotected sexual activity. However, contrary to this perception is the view that contracting AIDS is actually associated with behaviors more aligned with the lifestyles of the wealthy; increased travel, urbanization, multiple sexual partners. This demographic however is generally better educated than the poorer populations and thus more likely to make lifestyle adjustments when faced with adversity.
In this study we reveal that higher educational attainment, as indicated by graduation from High School, is negatively correlated with disparities. These disparities are potentiated by unequal access by ethnicity to treatment innovations reported almost twenty years ago 12 making these communities most vulnerable to the spread of the epidemic. Culturally appropriate HIV/AIDS intervention programs must reach this target demographic and involve community leaders if they are to reduce the heavy burden of this disease on these communities. Interventions should set short term and long term goals and the most successful will involve evidence-based policy and cultural preventative strategies 13 . Such a program is the Minority AIDS Initiative (MIA) implemented by the Florida Department of Health that focuses on minority communities to address the primary goals of the National HIV/AIDS Strategy (NHAS); raise awareness of HIV status, promote HIV testing and reduce the viral load within the community, encourage preventative care and initiate treatment implementation. In keeping with the goals of the NHAS; to reduce the number of individuals infected with HIV/AIDS, to increase access to care and improve health outcomes, and to reduce health disparities, the recent release of the Healthy People 2020 guidelines is timely. The Healthy People 2020 guidelines set objectives for improved HIV/AIDS diagnosis, testing and prevention.

Age
Most people living with AIDS in Miami-Dade County are between the ages of 40 and 49 years old. Analysis of our data reveals two interesting observations 1) the proportion of AIDS cases reported among adolescents (10 to 19 years old) increased from 0.7% in the three year period from 1993 to 1995, to 1.6% in the three year period 2009 to 2011, driven by the increased incidence of AIDS in young black MSM described previously; 2) over the same time period, the proportion of AIDS cases reported in the 65 years and older age group increased from 2.1% to 3.9% with the average age of persons now living with AIDS in Miami-Dade County increasing from 39 years to 44 years. This may be due, at least in part, to ART that improves life expectancy and the quality of life in those living with HIV 14 as well as newly diagnosed cases in the older age groups. In fact, according to the Florida Department of Health, newly reported HIV/AIDS cases among persons aged 50 and over increased by 28% from 2001 (17% of total) to 2010 (28% of total) 15 . The increased incidence of AIDS among the older population can be attributed to what has been referred to as the "Viagra Effect" 16 ; increased sexual activity combined with infrequent condom use in this population, leading to enhanced susceptibility to sexually transmitted diseases including HIV/AIDS. In fact, many older adults remain sexually active and one in seven men report taking medication to improve sexual activity 17 .

R E T R A C T E D
specifically black non-Hispanic women, young black MSM, and older adults engaged in medication-supported sexual activity will be effective. Interventions must leverage the popularity of community leadership, include those currently living with HIV/AIDS and integrate age-appropriate educational initiatives. This is a communicable chronic disease that is 100% preventable with increased education, self-awareness and responsibility.

Limitations of this study
The HIV/AIDS data collection process in the United States has not been consistent during the period analyzed; changes in the diagnostic criteria have created inconsistencies in the number of cases reported in virtually all counties and in all racial/ethnic, gender, age and HIV/AIDS risk factor categories. The inconsistency of the data results in fluctuating data trends and complicates interpretation. The selection of two three-year periods for analysis and comparison as in this study reduces data inconsistencies and increases reliability. an AIDS diagnosis, indicating that those individuals most vulnerable to the disease are the least educated. Individuals who attend High School are more likely to experience HIV/AIDS education, be more cognizant of the myths surrounding HIV/AIDS transmission, and be more responsive to educational campaigns regarding condom use and the importance of ART regimen compliance for example. These results strongly suggest that an education initiative targeted to poorer communities may be used as a "tool" to slow the spread of the AIDS epidemic in South Florida.

Conclusion
In recent years, the CDC's efforts to combat AIDS in Miami-Dade County have been somewhat successful, as the number of new cases of AIDS diagnosed is dropping and there has been a significant reduction in AIDS-related mortality over the past decade. However the AIDS epidemic is changing as it matures, now targeting our vulnerable poorer communities. The AIDS epidemic sweeping through South Florida and the United States is now a significant cause of mortality in women, particularly black non-Hispanic women, infected by heterosexual contact, and disproportionately affects our ethnic/racial minority communities. The disease is changing and so must our intervention efforts. Injection drug use and high-risk alcohol-related sexual behavior are no longer the most likely means of infection and more focused interventions based on epidemiological studies and behavioral analyses of social and sexual networks should become more significant.
MSM remain the group most significantly affected by AIDS, particularly young black MSM who engage in unprotected sexual activity. Only sustained community-based, culturally sensitive interventions that are appropriately disseminated to at risk minority groups,

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