HIV among MSM
A focus on Black MSM and MSMW
Nina T. Harawa, MPH, PhD
Associate Professor
UCLA / Charles Drew University
Brief Overview of HIV/AIDS
Research with U.S. Black MSM
Greg Millett
OAR Workshop on HIV/AIDS in Black MSM
October 20, 2011
Talk Objectives
• Describe the Epidemiology of HIV in MSM
populations
• Discuss factors that heighten MSMs’ HIV risk
above other groups’
• Discuss factors that heighten Black MSM’s HIV
risk and HIV burden above other MSMs’
Who are MSM?
• Diverse group.
– May identify as gay, bisexual, heterosexual or with
no label and be of any racial/ethnic background.
• Estimated to be 4.3-5.4 million in the US (~2%)
• Term is based on history of sexual behavior with
other men – used to separate behavior from identity
from behavior, which is more relevant to risk.
– Sometimes now MSM or MSMO are now used to
refer to those who only have male partners.
– MSMW is used for those with both male &
(recent) female partners.
New HIV Infections among MSM
(2008-2011)
CDC, 2014
• From 2008-2011, HIV among
MSM incidence increased
• Among youth in the United
States
– YMSM aged 13–19 make up
– Among all age groups (except
90% of male HIV cases
35-44)
– 26% among MSM 13-24
• Among young MSM
– 16% among MSM 25-34
– There were more new
– 23% among young black MSM
infections among young black
MSM than among all other
MSM groups combined.
• Among ALL new infections
– Adolescents and young adults
accounted for over a quarter of
new infections in 2010
– In 2011, 62% were attributed to
MSM contact; including 77% of
all male cases
Diagnoses of HIV Infection among Adolescents and Young
Adults Aged 13–24 Years, by Race/Ethnicity, 2008–2011
United States and 6 Dependent Areas
Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been statistically
adjusted to account for reporting delays, but not for incomplete reporting.
a Hispanics/Latinos can be of any race.
HIV among Young Black MSM:
An All Too Familiar Tale
• Young Men’s Survey, 3492 MSM ages 15-22 (7
cities) 1994-1998
Race
HIV prevalence (%)
HIV incidence (%)
Black
14%
4%
Latino
6.9%
1.8%
White
3.3%
2.4%
CDC investigations of HIV outbreaks among young
black MSM
• North Carolina, 2003
• Mississippi, 2006-2008
• Milwaukee, 1999-2008
HIV prevalence by
selected regions and subgroups
35
30
Prevalence (%)
25
20
15
10
5
0
Colfax, 2011 Adapted from: El-Sadr, et al., NEJM, 2010
Individual-level Factors
Heightening Risk for MSM
• More frequent anal sex
• Higher numbers of partners than other men
• Increased prevalence of some STDs –
facilitates HIV acquisition and transmission
• Substance use
Sexual behaviors and HIV Risk






Receptive anal sex (100)
Receptive vaginal sex (20)
Insertive anal sex (13)
Insertive vaginal sex (10)
Giving oral sex (2)
Receiving oral sex (1)
() = relative risk per unprotected
sexual encounter in serodiscordant couples
(MMWR, 2003)
HIV
RISK
Individual-Level Factors
Heightening Risk in Black MSM
•
•
•
•
Undiagnosed infection greater among BMSM
Lower HIV treatment rates for HIV+ BMSM
Higher rates of STIs
Lower rates of participation in clinical trials
The Role of Undiagnosed HIV Infection in
35%
Transmission Risk
30%
25%
20%
HIV Prevalence
Undiagnosed
15%
Diagnosed
10%
5%
0%
Black
Latino
White
Data from NHBS – MSM in 20 US Cities & Puerto Rico
CDC, MMWR, 2010
Sexually Transmitted Infections
• Syphilis rates
– Across 27 states from 2005-2008, increase in syphilis
rate 8x greater among black MSM compared to white
MSM
• Greater overall STIs among black MSM across
studies
–
–
–
–
Current STD
Gonorrhea
Syphilis
Hepatitis B
(OR 2.12 , 95%, 1.68–2.67)
(OR, 1.53; 95% CI, 1.25–1.87)
(OR, 2.14; 95% CI, 1.70–2.69)
(OR, 2.48; 95% CI, 1.27–4.86)
Limitations of Individual-Level Risk
• Research focus for past 30 years
– Plurality of HIV/AIDS studies of MSM report
• Sexual risk behaviors (# male sex partners, UAI, etc)
• Drug use behaviors (IDU, poppers, meth, crack, etc)
• Risk does not explain observed disparities in HIV
infection (Harawa, 2004)
• Can ignore context that influences behavior
• Reinforces blaming the victim
• Groups first affected by the epidemic.
• Homophobia, stigma, and discrimination play an
important but complex role.
Psychological & Social Correlates
• Depression associated with serodiscordant
UAI
• Prevention peer norms
– Low peer norms associated with increased
likelihood of
• unprotected receptive anal intercourse (OR = 2.14; 95%
CI = 1.32, 3.47)
• unprotected insertive anal intercourse (OR = 1.90; 95%
CI = 1.15, 3.14)
Discrimination
• Racial discrimination and homophobia
– Black MSM with more integrated racial/ sexual identities
report
•
•
•
•
Higher self-esteem
Greater HIV prevention self-efficacy
Greater social support
Greater life satisfaction
• Con of studies examining homophobia and
discrimination
– Very weak associations (distal, no relationship, poor
measures)
– Endpoint generally UAI (not serodiscordant UAI, HIV
incidence, or HIV testing)
– Lack of interventions to address these issues
– Timeliness of intervention effects
Discrimination
•
Belief that homosexuality is always
wrong
– Among blacks, proportion who
indicated that homosexuality was
"always wrong" was 72.3% in 2008 and
largely unchanged since the 1970s
– Declined among whites from 70.8% in
1973 to 51.6% in 2008
•
Racial differences among MSM and belief
that homosexuality is always wrong
– Twice as many black MSM reported that
homosexuality is "always wrong"
compared with white MSM (57.1%
versus 26.8%, P = 0.003).
•
Association between belief homosexuality is
always wrong and HIV testing
– MSM with unfavorable attitudes toward
homosexuality were less likely to report
ever testing for HIV compared with
MSM with more favorable attitudes
• Examined link between social
support and undiagnosed HIV
infection among black and Latino
MSM
•
•
Black and Latino MSM with less social
support were more likely to be
diagnosed with HIV infection
Black MSM who were more religious
were more likely to have
unrecognized infection (ByH,
unpublished)
• Intervention possibilities
– Increase social support for black
MSM
– Address homophobia among
black heterosexuals
– Gap: No effective stigma
interventions
CONSPIRACY Beliefs
HIV/AIDS Conspiracy
Belief
Black MSM
(n=239)
%
Latino MSM
(n=152)
%
White MSM
(n=111)
%
Pharmaceutical companies
58*
50*
High
levels
of
mistrust
is
hiding cure for HIV/AIDS
associated with
because of profits
42
HIV/AIDS drugs harm medication
you
56*
48*
nonadherence
more than help you
41
HIV does not cause AIDS
54*
48*
27
HIV is a man-made virus
50*
41*
35
among black men
*P<.05 versus White MSM
Physical Abuse
• Intimate partner violence and black MSM
• Association with HIV infection?
• Childhood sexual abuse is associated with HIV
infection in several studies of MSM
• High rates of childhood sexual abuse reported
by black MSM
The Role of Networks
•
•
Characteristics of sex partners coupled with
background prevalence influences transmission risk
–
–
–
Disassortative mixing among positives
–
–
•
•
Older partners
Black partners
Earlier sexual debut
Serodiscordant sex HIV-positive black MSM (Eaton,
2010)
Serostatus nondisclosure with HIV-negative/unknown
status
Serosorting protective for HIV-negative black MSM
•
BUT seroconversion likelihood greater than other MSM
Possible interventions
–
–
–
Increasing HIV status disclosure (given recent HIV
testing)
Improving serosorting efficacy for HIV negative black
MSM
Reducing serodiscordant sex HIV-positive black MSM
Structural Barriers
Definition: Physical, environmental
or social structures, or laws or
policies that affect HIV transmission
risk.
Structural impediments
• Poverty
• Homelessness
• Incarceration
Structural Barriers Across Treatment Cascade
Undiagnosed HIV+
Diagnosed
not in care
Diagnosed and
in care
In care and
taking ART
Viral suppression
Adapted from Gardner, CID, 2011
Structural Barriers Across Treatment Cascade
No health insurance
Health care providers missing diagnoses
Undiagnosed HIV+
Testing/ care not co-located
Diagnosed
not in care
Diagnosed and
in care
In care and
taking ART
Viral suppression
Adapted from Gardner, CID, 2011
Structural Barriers Across Treatment Cascade
No health insurance
Health care providers missing diagnoses
Undiagnosed HIV+
Testing/ care not co-located
Diagnosed
not in care
Not receiving meds b/c of inadequate health insurance
Lack of culturally competent care
Diagnosed and
in care
Stigma assoc w/ taking meds
Suboptimal regimens/ side effects
In care and
taking ART
Stigma
Viral suppression
Adapted from Gardner, CID, 2011
Resilency
• Black MSM just as likely to utilize HIV prevention
programs
• Study show Black MSM engage in less or similar
levels of sexual risk and less drug use
• Most black MSM are not HIV-positive
• Black MSM less likely to report adversity or
homophobia
Additional References
• Wejnert C, Le B, Rose CE, Oster AM, Smith AJ, et al. (2013) HIV
Infection and Awareness among Men Who Have Sex with
Men–20 Cities, United States, 2008 and 2011. PLoS ONE 8(10):
e76878. doi:10.1371/journal.pone.0076878
• David Malebranche, MD, MPH slide set “HIV/AIDS in the
African American Community”
• RR data adapted from Varghese B, Maher JE, Peterman TA, et
al. Reducing the risk of sexual transmission: quantifying the
per-act risk for HIV infection based on choice of partner, sex
act, and condom use. Sex Transm Dis 2002;29:38-43. and CDC,
HRSA, NIH, & HIVMA. Incorporating HIV Prevention into the
Medical Care of Persons Living with HIV. MMWR 2003;52:RR12.
Additional Resources
• CDC: www.cdc.gov/hiv
• Black Gay Research Group (BGRG)
www.thebgrg.org
• National AIDS & Education Services for
Minorities (NAESM) www.naesm.org
• In the Meantime Men’s Group
(inthemeantimemen.org) X-Homophobia
Campaign.