Groups at Increased-Risk for HIV
When discussing different populations, people are often described in terms of identity. We create our identities based on how we interact with the world and who we interact with. Some people may create their identity in relation to a social group they belong to. For example, a man who has sex with men may identify as gay. An individual who exchanges sex for money may consider themselves a sex worker.
Some individuals may not consider a particular group, behavior, quality or other feature as part of their identity. Social groups and identifiers are numerous and can be influenced by different aspects of our lives, including our sexual preferences, gender, profession, and culture.
What is a "risk group"?
There are many factors that influence HIV transmission risks, and more specifically, these risks often vary from person to person. Factors that influence HIV transmission risk include participating in behaviors that can lead to HIV transmission, as well as the different rates of HIV cases amongst others around you.
For example, two people participating in similar potentially HIV-transmitting behaviors may not have the same risk depending on who they are engaging in these behaviors with and where they are. Specific social groups or areas of the country may have differences in the prevalence of HIV within them. Based upon the evolution of the HIV epidemic in the United States, as well as social groups that are part of the public health response, it is common to refer to those individuals at increased risk of acquiring HIV as a “risk group.” Several of these groups are outlined below.
Gay and bisexual men
Since the initial reporting of the HIV/AIDS epidemic in the United States, gay and bisexual men were identified as one of the first “risk groups”. Much has been written about the range of specific risk factors that have affected gay and bisexual men, particularly in major urban areas throughout the United States.1
In 2017, it was estimated that there were 39,000 people who were newly diagnosed with HIV in the United States and almost 26,000 of these cases occurred in gay or bisexual men, or 65%.2,3 There are a variety of reasons why this group is at increased risk of acquiring HIV. In the U.S., among those who have acquired HIV through sexual transmission, anal sex has the highest relative risk.4-6 One reason that receptive anal sex is more likely to transmit HIV compared to vaginal sex is that the mucosal tissue in the rectum is thinner and more likely to tear compared to vaginal mucosal tissue.
Additionally, some men may feel uncomfortable seeing a doctor or healthcare professional due to past experiences with stigma or discrimination and fear that this may happen again.7 Also, the fear of receiving a positive HIV test result can cause many people to delay getting tested. As a result, in communities with heightened HIV stigma, there may be more people who are HIV positive but are unaware of their status, and unknowingly transmit the virus to others through unprotected sex.8
People of color
Although African Americans make up around 13% of the U.S. population, they represent about 43% of all HIV diagnoses. Similarly, Hispanic or Latino individuals makeup over 25% of all HIV diagnoses, yet account for 18% of the U.S. population.3 As with other health conditions, the reasons why people of color are disproportionately affected by HIV are complex.
The reasons why many of these differences in health exist can be described as “social determinants of health.” Common “social determinants of health” include access to health care, access to educational opportunities, access to transportation, social support, culture, exposure to violence, and income. Research has shown that these factors create significant challenges both on the individual and community level. For example, people of color are less likely to have adequate health insurance coverage, have less access to healthcare specialists, and are more likely to experience unemployment, and poverty.9 All of these factors can play a role in whether a person has access to HIV testing or treatment, and how often a person is able to see their healthcare provider.
More than 2,350 transgender individuals were diagnosed with HIV between 2009-2014, with 84% of these new diagnoses occurred in transgender women (a woman who was assigned male at birth). In 2017, the percentage of new diagnoses among transgender people was three times higher than the national average.10,11 Roughly half of trans people diagnosed between 2009 and 2014 were living in the southern States. There are several reasons why they may be at an increased risk of having HIV, including a lack of access to healthcare due to fear, stigma, or discrimination as well as sharing needles to inject drugs or hormones, or having unprotected sex.
Many trans people may feel uncomfortable seeing a doctor or healthcare professional for fear of discrimination or because they are uninsured.12 Some survey data has estimated that roughly 30% of transgender individuals avoid seeing a doctor due to discrimination, and roughly one in five have been refused care due to their identity.13 Because of this reduced access to healthcare, transgender people may not be able to have an HIV test as frequently and may be unaware of their HIV status.
In addition to experiencing discrimination in medical settings, discrimination from the general public is also of significant concern for transgender individuals. This can greatly impact their levels of social support, mental health, education, employment, income, housing, substance abuse, and more, all leading to negative health outcomes.12,14 For some, less autonomy over one’s sexual and gender identity during one’s lifetime may result in less confidence in negotiating sexual safety in a relationship with others. More research is needed to further understand the complex nature of HIV risk within the transgender and nonbinary community.
HIV risk during pregnancy, childbirth, and after delivery
HIV can be transmitted to a developing fetus during pregnancy, during childbirth, or after birth (breastfeeding). As a result, pregnant people and babies born to a parent who is HIV-positive are important populations to consider in HIV care and prevention. Mother-to-child transmission is also called perinatal transmission, or vertical transmission. HIV can travel across the placenta (the tissue that provides blood and nutrients) during pregnancy and can be transmitted to the fetus.
A newborn can acquire HIV during childbirth, when it may be exposed to its mother’s blood or other bodily fluids that contain HIV. HIV may also be transmitted through breastfeeding.15,16 With appropriate management with a healthcare team during the course of pregnancy and delivery, the risk of vertical transmission can be less than 1% in the United States.17
Recipients of blood transfusions
When HIV was first identified in the United States, understanding of the virus was limited. There were no tests for HIV, and people did not know how the virus was transmitted. Therefore, it was not known to screen blood and organ donors for the virus. Because of this, units of blood and organs that contained HIV were transfused and unknowingly given to HIV-negative individuals.
However, since the creation of HIV antibody testing, p24 antigen testing, and RNA testing (HIV tests that have been developed since 1985), the likelihood of an HIV-infected blood product being used in a transfusion is negligible in the U.S.18 In the U.S., specific guidelines for blood product screening and donor screening processes have been in effect since the late 20th century. The current risk estimate for transfusion-related HIV infection in the U.S. is 1 in about 2 million, making it incredibly rare.18
Sex workers in the U.S. may be at an increased risk of acquiring HIV. Except for the state of Nevada, sex work is considered illegal, potentially making those who engage in sex work less likely to access healthcare due to stigma or fear. Additionally, since sex work often involves a monetary exchange from the client, clients of sex workers may not wish to use protection and place sex workers in a position where they are less likely to be able to negotiate safer sex practices. As a result, this can put sex workers at an increased risk for HIV.
Data on the prevalence of HIV in this population is not well understood. More research is needed in order to understand the healthcare needs and challenges of this group. There are several reasons why sex workers and their clients may have a greater chance of having HIV, including having unprotected sex with multiple partners, having used drugs with shared needles, having another sexually transmitted infection (STI), as well as not having access to adequate healthcare.19,20
People who inject drugs
Of all newly diagnosed HIV infections in the United States, about 10% are among individuals who inject drugs or individuals who participate in both injection drug use and male-to-male sexual contact.21 While HIV cannot live on surfaces for days and remain infectious as the common cold can, this is not necessarily the case when contained in a syringe. Extensive research shows that HIV dies very quickly when exposed to air and not in a human or animal “host” body.22 In needle sharing (or shared “works”, equipment used to prepare drugs for injection), depending on where infected blood may be within a needle, HIV may be able to live for several weeks if under the right conditions and not exposed to air.21 This is why needle sharing at any time, regardless of time since last injection, may increase the risk of HIV infection.