**1. Introduction**

After 40 years of the discovery of the human immunodeficiency virus (HIV) that causes autoimmune deficiency disease syndrome (AIDS), HIV remains a critical public health concern, particularly among racial/ethnic and sexual/gender minority populations. During the intervening years, there have been enormous advances in biomedical prevention strategies (e.g., pre-exposure prophylaxis (PrEP) and treatment therapies antiretroviral therapy (ART) that have transformed HIV from a death sentence to a chronic condition. Yet, despite these lifesaving treatments and therapies, the benefits have not been equally shared. There are still alarming numbers of new infections disproportionately impacting racial/ethnic and sexual/gender minorities, particularly Black gay and bisexual men in the United States. Notably, Blacks represent less than 13% of the population, but Black MSM accounts for 42% of all new HIV infections [1]. There are marked racial/ethnic disparities in health in the US, with Blacks or African-Americans faring substantially

worse compared to their white counterparts, including diabetes prevalence, colorectal cancer incidence and death, and mortality due to coronary heart disease and stroke [2–4]. These disparities are particularly acute in HIV, particularly for Black men who have sex with men (Black MSM). It is estimated half of Black MSM in the U.S. can be expected to become HIV positive in their lifetime [5]. Current surveillance data show that most of the HIV cases are clustered in the Southern U.S., a region marked by racial and structural inequalities as a result of racialized chattel slavery and Jim Crow segregation, where a large majority of the Black population continues to live in neighborhoods, that are divided and unequal reflecting previously codified racial divisions in housing, employment, education, healthcare, public utilities, and infrastructure [6].

While studies have shown African Americans do not have higher rates of sexual risk behaviors than their white counterparts and biomedical advances are effective at prevention and transmission of HIV/AIDS, at issue is accounting for the enormous racial/ethnic disparities in HIV-related outcomes [7]. In this perspective chapter, we explore the evidence underpinning the relationship between structural racism and high rates of HIV among racial and sexual minority populations in the U.S., particularly Black men who have sex with men (MSM). We examine the social, economic, and political policies and practices that engender a social and structural, and built environment that may increase or reduce an individual's HIV vulnerability to exposure to HIV. An examination of structural racism and HIV is timely given the ongoing debates around race and Covid-19, the Black lives matter movement and the ending the HIV epidemic initiative [8–10]. This work builds on previous work on race and HIV by incorporating emerging research employing an intersectional lens to understand the role of multiple identities and interlocking oppressions in explaining differential outcomes around HIV [11–13]. Frist we will review the origins of HIV using a social-ecological lens to better understand the influence of structural factors on increasing barriers to HIV prevention, care, and treatment services among racial/ethnic and sexual/gender minorities. Next, we provide an overview of the types of structural racism followed by a description of the intersectional stigma framework that underpins our conceptualization of how structural racism operates to increase HIV vulnerability. Then we embark on a review of the literature providing evidence linking structural racism and HIV-related disparities. Finally, we end with conclusions, key policy recommendations, and future directions of research to address the unique needs and structural barriers that create the conditions ripe for HIV to flourish among racial and sexual minority populations. While this chapter focuses primarily on the experience of Black sexual minority men in the U.S., it is our hope this information will have broader relevance to other populations and settings to inform the development and implementation of structural level programs and interventions to reduce the number of new infections among racial/ethnic and sexual/gender minority populations, both in the U.S. and beyond.

#### **2. Understanding the structural origins of the HIV epidemic**

Significant success in the prevention of HIV infection in the United States has been achieved. However, those successes were hard-won with significant opposition from hostile government officials, religious groups, and the public at large. In the early days of the AIDS epidemic, there was widespread misinformation about AIDS with many believing it was a disease that affected only homosexuals and was a punishment from God for their turning away from the teachings of the Bible. Alongside these common misinterpretations, longstanding homophobia and antigay stigma and discrimination were the norm. It was within this socio-political

*Perspective Chapter: Centering Race, Stigma and Discrimination - Structural Racism… DOI: http://dx.doi.org/10.5772/intechopen.101528*

context of government inaction and societal scapegoating where HIV went undiagnosed and untreated and allowed to flourish within the Black community, particularly among Black MSMs.

Much of the initial response was largely limited to activities organized by LGBT community-based organizations and the gay community focusing primarily on behavioral change and lifestyle factors including harm reduction (e.g., drug and substance use, sexual risk behavior) or uptake of biomedical therapies (e.g., condoms). The first community-led activities were launched in San Francisco and New York City where the first cases of HIV occurred [14]. These early activities were designed to increase awareness and to educate the gay community about how the virus is transmitted and risk reduction strategies to prevent HIV.

As time progressed, the government stepped in launching HIV prevention programs to reduce the spread of the disease. These early government initiatives led by the CDC continued the focus on individual-level programming around behavioral change including: (1) the development of the National AIDS Information Line (1983), (2) National AIDS Clearinghouse (1987), (3) America Responds to AIDS, a national public information campaign (1987), and (4) the development and dissemination of Understanding AIDS (1988). Understanding AIDS was groundbreaking, being the first public education campaign utilizing the U.S. postal service to deliver health literacy information to every home in the United States [15]. However, early approaches in delivering basic HIV education and awareness, changing attitudes, and harm reduction among most-at-risk populations often did not address the unique needs and realities of racial/ethnic communities. These programs targeted priority populations deem at elevated risk including high-school and college-aged persons, pregnant women, and healthcare workers [16]. While important advances were made in the gay community benefitting the white gay community, however, they did not substantially reduce HIV risk for African American and LatinX communities. In the late 1980s, we start to see the development of more targeted evidence-based interventions such as the five-city CDC AIDS Community Demonstration Projects (1989), CDC HIV Prevention Research Synthesis Project, and the CDC Diffusion of Effective Behavioral Interventions (DEBI) project [17, 18]. While these studies and interventions were more tailored for marginalized populations such as injection drug uses, sex workers, and racial/ethnic minorities, they were primarily individual-level behavioral change initiatives with only a few structural interventions.

### **3. A conceptual framework for the association between structural racism and HIV**

Researchers in the area of public health, sociology, geography, and urban planning have shown macro-level factors at the structural level can influence health on a number of health-related outcomes including mental health, cardiovascular disease, maternal health, diabetes, and HIV [19–26]. According to Link and Phelan in their theory of fundamental causes they argue that structural factors, that is, socioeconomic status (SES) contribute to inequalities in health [27]. Extrapolating from this premise and building on socio-ecological frameworks, we posit that the broader dynamic and interactive macro-level social, political, and economic processes structure access to societal resources and opportunity structures which are mediated through the built environment has profound consequences influencing sexual risk behavior and access to HIV prevention, care and treatment services. Our model draws inspiration from the following structural frameworks: Structural violence, social determinants of health, neighborhood effects, weathering and intersectionality [13, 28–30]. Each of these theories and frameworks center upstream, macro-level factors as foundational to health disparities and provides a useful conceptual lens to understand the spatial legacies of chattel slavery and contemporary effects of racial capitalism and structural racism. Farmer's theory of structural violence emerged from Paul Farmer's groundbreaking work in HIV in Haiti and argues that structural consequences, for example, slavery, colonialism, Jim Crow, and other forms of oppression have profound material consequences for individuals and populations, particularly racial and ethnic minorities. Next, social determinants of health argues that unequal access to basic needs and resources (i.e., employment, education, housing, and healthcare) disadvantages certain individuals and groups affecting their health outcomes [28]. Diex Roux's neighborhood effects framework highlights the importance of spatial and geographical variations in health arguing the larger structural environment shapes neighborhood/community conditions and features that may influence health outcomes [29]. Finally, we include Geronimus' Theory of weathering which helps us to better understand how effects of structural racism (e.g., residential segregation, poor-quality schools, environmental racism) 'gets under the skin' creating stress in the form of allostatic load which has been shown to affect health outcomes [30]. These active and ongoing adjustments necessary to manage these multiple interacting structural forces and stressors can create wear and tear on the body leading to poor health outcomes, particularly increasing HIV vulnerability for historically marginalized and stigmatized groups such as Black MSM. Moreover, we employ an intersectional approach to emphasize the intersections of multiple and intersecting identities (e.g., race, gender, and sexual orientation) and interlocking systems of oppression (e.g., racism, homophobia, and classism) that may influence an individual's behavior and access to resources and opportunities that impact their health and well-being [11–13]. By utilizing an intersectional perspective, it allows us to center the multiple stigmatized identifies and contend with the insidious and harmful direct effects of intentional and unintentional statesanctioned race-based, structural factors and processes that distribute resources and opportunities that increase HIV vulnerability for Black sexual minority men. Our conceptual model presented in **Figure 1** is informed by the aforementioned socioecological frameworks and divided into three levels: (1) structural level, (2) neighborhood level, and (3) individual level, representing the multilevel and multivalent nature of structural racism. The structural level is defined as macro-level forces (e.g., social, political, economic, and legal policies) developed by governments and powerful institutions that govern the organization and structure of society. The structural racism interpretation of HIV proposes that macro-level structural level forces are paramount in understanding HIV-related health disparities and as such foundational to explaining differential HIV-related outcomes. Neighborhood level refers to the community environment including both social and built environment aspects of neighborhoods. The construct of the neighborhood is derived from the neighborhood effects framework which explicitly acknowledges that relative deprivation in the form of neighborhood structural disadvantage (e.g., access to employment, housing, public transportation, etc.) may influence health-seeking behavior and limit access to HIV prevention, care, and treatment services. Finally, the individual level includes both sociodemographic characteristics (e.g., race, gender, age, and education) and risk factors (e.g., condom use, number of sexual partners) that are derived out of an unequal distribution of resources and exposure that create barriers to healthy behaviors and access to healthcare. Illustrated in **Figure 1** are pathways that are represented by arrows in the diagram modeling key risk factors theorized as having a significant impact on HIV vulnerability and explaining differential HIVrelated outcomes, particularly among Black MSM. The arrows indicate the dynamic and interactive nature of structural racism which has both direct and moderating effects that either reduce or increase an individual's exposure to HIV.

*Perspective Chapter: Centering Race, Stigma and Discrimination - Structural Racism… DOI: http://dx.doi.org/10.5772/intechopen.101528*

**Figure 1.** *Structural racism and HIV vulnerability conceptual framework.*
