Racial Disparities in Antiretroviral Therapy Use
and Viral Suppression among Sexually Active
HIV-infected Men who have Sex with Men—
United States, Medical Monitoring Project, 2009
Linda Beer PhD, Alexandra M. Oster MD,
Christine L. Mattson PhD, and Jacek Skarbinski MD
for the Medical Monitoring Project
July 23, 2012
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
Division of HIV/AIDS Prevention
Background

In the U.S., black MSM (BMSM) are disproportionately
likely to become HIV-infected
 MSM account for 61% of new infections in the U.S
 Blacks comprise 11% of the U.S. male population but 37% of new
infections among MSM

Limited work on factors among HIV-infected MSM that
may contribute to higher HIV incidence among BMSM
 Not been assessed for a large, geographically diverse sample
Possible Contributors to Racial Disparities in
HIV Infections Among U.S. MSM

High-risk sexual behaviors increase the likelihood of
HIV transmission

HIV viral load suppression decreases the likelihood of
HIV transmission

BMSM tend to have sex partners of their same race

If HIV-infected BMSM engage in more sexual risk
behavior or are less likely to be virally suppressed, this
may contribute to higher incidence among BMSM
Objectives

Are there differences between HIV-infected BMSM and
WMSM in factors that increase HIV transmission risk?
 Behavioral = sexual behavior
 Clinical = ART use and viral suppression

Are there factors that can account for these
differences?
Methods

Analysis of Medical Monitoring Project (MMP) data
collected June 2009 - May 2010
 National supplemental HIV surveillance system
 Monitors behavioral and clinical information on HIV-infected
adults receiving care
• 16 U.S. states (including 6 separately funded cities) and one territory
 Three-stage sample design
• States
• HIV care-providing facilities
• HIV-infected adults receiving care
Methods

Persons included: black or white male MMP
participants who had oral or anal sex with a man
during the past year

Compared prevalence among HIV-infected BMSM and
WMSM of
 Sexual risk behaviors, past 12 months
• Unprotected anal sex with a negative or unknown HIV status partner
• Number of sexual partners
 Current ART use
 Viral suppression
• Most recent viral load undetectable or < 200 copies/ml
• Durable viral suppression: all viral loads in past 12 months
undetectable or < 400 copies/ml
Methods


For outcomes that differed between races, used
multivariable logistic regression to identify factors that
accounted for these differences
Included variables




Were associated with outcome at p < .10
Changed association between race and outcome by > 10%
Compared unadjusted and adjusted predicted
prevalence of outcome
Accounted for clustering, unequal selection
probabilities, and non-response
Results

Overall response rate = 41%
 State/city = 100%
 Facility = 76%
 Patient = 53%

4217 participants from 461 HIV care facilities

314 BMSM and 696 WMSM met analysis inclusion
criteria
Objectives

Are there differences between HIV-infected BMSM and
WMSM in factors that increase HIV transmission risk?
 Behavioral = sexual behavior
 Clinical = ART use and viral suppression

Are there factors that can account for these
differences?
Behavioral Factors Associated with
HIV Transmission Among Sexually Active
HIV-Infected Black and White MSM in Care,
Past 12 Months – MMP, 2009
Black MSM
(n=314)
White MSM
(n=696)
%
%
Unprotected anal sex with a
negative/unknown status partner
19
20
.69
Unprotected anal sex with a
negative/unknown status partner while
not durably virally suppressed
25
22
.60
Number of sex partners
1
48
45
.01
2-3
31
25
4+
21
30
Bivariate
p value
Objectives

Are there differences between HIV-infected BMSM and
WMSM in factors that increase HIV transmission risk?
 Behavioral = sexual behavior
 Clinical = ART use and viral suppression

Are there factors that can account for these
differences?
Objectives

Are there differences between HIV-infected BMSM and
WMSM in factors that increase HIV transmission risk?
 Behavioral = sexual behavior
 Clinical = ART use and viral suppression

Are there factors that can account for these
differences?
Factors Associated with ART Use and Viral
Suppression Considered for Model Inclusion









Age
Educational attainment
At or below poverty level
Homelessness
Continuous health care coverage
Last HIV care visit > 3 months ago
Current depression
Disease stage
Time since HIV diagnosis
11
7
17
8
Summary
Are there differences between HIV-infected BMSM and
WMSM in factors that increase HIV transmission risk?

Behavioral
 No racial disparity in sexual risk behaviors among MSM.

Clinical
 BMSM are less likely to be virally suppressed than WMSM, possibly
contributing to high HIV incidence among BMSM
Summary
What factors account for differences in viral suppression?

ART use
 BMSM less likely to use ART

Sociodemographic factors
 BMSM younger and more recently diagnosed

Social determinants of health
 BMSM lower access to resources that support health (income,
education, healthcare)

Other contributing factors
 Adherence? ART regimen?
Limitations

Study population is limited to those in care, racial
disparities in the entire HIV-infected MSM population
are likely higher than those presented

Self-reported information may have led to
measurement bias for some measures, although no
reason to believe bias would vary by race
Conclusions

Among MSM receiving HIV care in the U.S., most are on
ART and the majority are virally suppressed

However, over half of BMSM are not durably virally
suppressed, and this may be contributing to disparities
in incidence

To decrease racial disparities in incidence and improve
the health of BMSM, need to increase proportion
virally suppressed
 Increase ART use
 Address structural inequalities
Acknowledgments

MMP facility staff and patients

MMP Principal Investigators and Project Coordinators

MMP Provider Advisory Board and Community Advisory
Board members

CDC Clinical Outcomes Team

Jeanne Bertolli, PhD
Thank you!
Linda Beer
lbeer@cdc.gov
001–404–639-5268
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
Division of HIV/AIDS Prevention