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HIV Risk in US Black MSM Traced to Age Issues and
Care Barriers--Not to Risk Behavior
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HIV Risk in US Black MSM Traced to Age Issues and Care Barriers--Not to Risk Behavior
19th Conference on Retroviruses and Opportunistic Infections, March 5-8, 2012, Seattle
Mark Mascolini
Younger age at first sex, sexual abuse during childhood, and older sex partners boost HIV infection risk among black men who have sex with men (MSM) in the United States, according to a CDC meta-analysis of research involving US MSM [1]. Black MSM with HIV are more infectious than nonblack MSM because they have lower access to antiretrovirals, lower antiretroviral adherence, lower CD4 counts, and lower clinic attendance. But behavioral risk factors--such as unprotected receptive anal intercourse and number of sex partners--were similar in black and nonblack MSM or less common in blacks.
HIV incidence (the new infection rate) in the United States is highest among MSM, particularly young black MSM [2]. To examine HIV risk factors, structural barriers to care, and risk behaviors among black MSM, CDC investigators conducted this meta-analysis of published and presented quantitative reports comparing black MSM with other MSM from January 1981 through September 2011.
The analysis considered more than 145 studies involving 154,995 black MSM and 523,307 nonblack MSM. Among 13- to 29-year-old MSM, three HIV risk factors were significantly more likely in black MSM than in nonblack MSM: younger age at sexual debut (odds ratio [OR] 1.65, 95% confidence interval [CI] 1.26 to 2.15), any sexual abuse during childhood (OR 1.82, 95% CI 1.49 to 2.22), and having older sex partners (OR 1.47, 95% CI 1.09 to 1.97).
Black MSM did not differ from nonblack MSM in several behaviors that heighten the risk of HIV infection, including unprotected anal intercourse with a partner of a different HIV status, receptive anal intercourse, and number of concurrent partners. And black MSM had lower odds of several HIV risk factors, including number of male partners (OR 0.68, 95% CI 0.55 to 0.84), amphetamine use (OR 0.51, 95% CI 0.29 to 0.89), popper use (OR 0.39, 95% CI 0.23 to 0.67), and substance use with sex (OR 0.54, 95% CI 0.30 to 0.96).
Compared with nonblack MSM, blacks were twice as likely to report use of pre- or postexposure prophylaxis (OR 1.99, 95% CI 1.32 to 3.00), more than twice as likely to have had a viral sexually transmitted infection (STI) (OR 2.17, 95% CI 1.65 to 2.86), and 37% more likely to have had any STI in the past year (OR 1.37, 95% CI 1.07 to 1.76). Black men were much more likely than nonblack MSM to have sex with blacks (OR 11.47, 95% CI 6.02 to 21.88). Blacks did not differ from nonblacks in HIV testing rate over the past year.
The CDC team combined HIV-protective behaviors such as fewer sex partners and no substance use during sex under the term resiliency. Compared with nonblack MSM, resiliency was almost 30% more likely among black MSM (OR 1.29, 95% CI 1.11 to 1.49). But two demographic factors associated with HIV risk and poor care were more than twice as likely among blacks: lower income (OR 2.53, 95% CI 1.55 to 4.15) and any history of incarceration (OR 2.17, 95% CI 1.49 to 3.18).
Among MSM diagnosed with HIV, blacks were significantly less likely to access antiretrovirals (OR 0.51, 95% CI 0.40 to 0.64), to adhere to antiretrovirals if they did start therapy (OR 0.50, 95% CI 0.33 to 0.76), to have a CD4 count above 200 (OR 0.40, 95% CI 0.26 to 0.62), or to visit the clinic (OR 0.63, 95% CI 0.48 to 0.83).
The CDC team proposed that risk-based interventions "will not reduce HIV infection disparities among black MSM" because several risk factors (such as HIV-discordant unprotected anal intercourse, receptive anal intercourse, and number of sex partners) were comparable between races or less common among black MSM.
The investigators suggested that future prevention interventions for black MSM should aim to (1) reduce the proportion of undiagnosed positives and diagnosed men with a detectable viral load, (2) address structural issues that complicate prevention and care, and (3) capitalize on HIV-protective behaviors identified in this study.
The CDC researchers maintained that a test-and-treat approach "will not reduce [HIV] infections among black MSM unless HIV clinical care disparities are addressed."
References
1. Millett G, Peterson J, Flores S, et al. A meta-analysis of HIV infection racial disparities among MSM: US. 19th Conference on Retroviruses and Opportunistic Infections. March 5-8, 2012. Seattle. Abstract 1094.
2. Prejean J, Song R, Hernandez A, et al. Estimated HIV incidence in the United States, 2006-2009. PLoS One. 2011;6(8):e17502. http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0017502.
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