On the compounding manifestations of racism shaping the US HIV/AIDS epidemic: why ending the HIV epidemic must address these factors for success.

Abstract

Objective: Growing racial/ethnic inequities in healthcare access and racially segregated sexual mixing contribute to persistent disparities in HIV incidence in the US. We aim to examine the extent to which eliminating racial/ethnic inequities in healthcare access could reduce disparities in HIV incidence and its interaction with assortative sexual mixing.

Design: A mathematical model.

Methods: We used two independently developed HIV transmission models to estimate HIV incidence among Black, Hispanic/Latino, and White/Other MSM and the corresponding incidence rate ratios (IRRs) comparing Black and Hispanic/Latino to White/Other as a measure of disparity in the four "Ending the HIV Epidemic (EHE)" counties in Georgia. We compared three scenarios: status quo; equal service access across racial/ethnic groups with reported assortative sexual mixing by race/ethnicity; and equal service access with random sexual mixing. We standardized both models to enhance comparability.

Results: Under the status quo, both models projected a reduction in overall HIV incidence but persistent racial/ethnic disparities, with an IRR as large as 8.3 between Black and White/Other MSM. Compared to the status quo, providing equal health service access resulted in a modest reduction in IRRs with reported assortative sexual mixing in 2030, but yielded a much greater reduction when sexual mixing was at random: IRR reduced by up to 38.8% and 58.3% between Black and White/Other MSM in the two models.

Conclusion: This study highlights racially segregated sexual mixing as a barrier to efforts to mitigate racial/ethnic disparities in HIV incidence. Reaching EHE targets will require not only equitable healthcare access but also strategies addressing sexual racism and other structural barriers.