July 26, 2012
Behavioral Factors Don't Explain Disproportionate HIV Epidemic Among Black MSM
by Tim Horn
Black men who have sex with men (MSM) are significantly more likely to become infected with HIV compared with non-black MSM, yet they are less likely to engage in many risky behaviors. This is the paradoxical finding of a critical review of nearly 200 studies reported by Gregorio Millet, MPH, of the U.S. Centers for Disease Control and Prevention (CDC) and his colleagues on Tuesday, July 24, at the XIX International AIDS Conference (AIDS 2012) in Washington, DC, and published in a special supplement of The Lancet.
One of the most striking HIV infection imbalances in the United States involves black MSM. Though they represent less than 1 percent of the entire U.S. population, nearly a quarter of all new HIV infection in 2009 were in black MSM. And according to CDC surveillance data, HIV cases increased by an astonishing 48 percent in young black MSM between 2006 and 2009.
To make some sense of the highly disproportionate HIV incidence and prevalence among black MSM, compared with other MSM, Millett’s group analyzed data from 194 studies; seven conducted in Canada, 13 conducted in the United Kingdom and 174 conducted in the U.S. The researchers looked at 69 known risk factors for HIV in the studies, which included a total of 106,000 black MSM and more than a half-million MSM of other races/ethnicities.
Confirming CDC estimates, Millett noted that black MSM were three times as likely to have tested positive compared with their non-black MSM counterparts. They were also six times as likely to have another sexually transmitted infection (STI).
Paradoxically, however, very few of the often-cited behavioral risk factors explained these discrepancies.
Black MSM were somewhat less likely to engage in unprotected anal intercourse with male partners than other MSM, Millett reported. They were also no more likely to engage in unprotected receptive anal intercourse than other MSM. Black MSM were also less likely to have a high number of lifetime male sex partners or a high number of male partners within the year prior to completing surveys or questionnaires in their respective studies.
Black MSM were also more than two times as likely to use condoms and were 50 percent more likely to have been tested for HIV within the previous 12 months. They were also more likely to have been tested for the virus more than once.
Differences in illicit substance use did not explain the higher HIV rate among black MSM. In fact, compared with MSM of other races/ethnicities, black MSM were less likely to have used drugs at any point in their lifetimes or in the months prior to their study participation. Sepcifically, black MSM were less likely to have used alcohol, marijuana, injection drugs or amphetamines, and were less likely to have used any drug before or during sex. Crack cocaine use proved to be the only drug linked more closely to black MSM than other MSM.
So which risk factors did potentially explain the tremendous disconnect? Many, Millett noted, were related to socioeconomic and access-to-care disparities.
Black MSM were significantly more likely to have a current sexually transmitted infection. They were also less likely to have finished high school and more likely to have been incarcerated, to have a low income and to be unemployed.
HIV-positive black MSM in the analysis were more likely to have undiagnosed HIV infection, to have a CD4 cell count below 200, to have no health insurance coverage, to have limited access to ARV therapy, and, in cases where ARVs were prescribed, less adherent to their dosing schedules. Black MSM were also less likely to have undetectable viral loads and were less likely to see their health care providers regularly.
In other words, HIV-negative black MSM may be less likely to engage in risky behaviors, but if they do engage in unprotected anal intercourse, they may be more likely to do so with a highly infectious partner—for example, an HIV-positive black man who does not know he is infected or receiving the care and support he needs to get his viral load undetectable. Another study presented at the conference explored this particular scenario.
With regard to another potentially important disparity—that black MSM are more likely to engage in sexual activity with older MSM—Millett’s group strongly urged increased efforts to diagnose and treat older MSM (those 30 years of age and older) to help stem increasing rates of new infections in young black MSM.
“A clear and paradoxical pattern of similar or less risk behavior and risk of HIV or STIs emerged in [the analysis],” Millett and his colleagues concluded.
“HIV epidemics in black MSM are inextricably linked to social and economic environments that should be considered and addressed to successfully stem disparities in HIV infection,” Millett and his colleagues added. “Interventions that support early initiation of ARV therapy, adherence and clinical visits for HIV-positive black MSM might have a greater effect in the reduction of HIV infection rates than do those that focus on sexual or drug use risks.”
Editor's postscript: A number of comments in response to this article argue that the differences noted in risk behaviors and HIV infection between black MSM and MSM of other races/ethnicities could be due to reporting bias—untruthful responses to questioning—and that black MSM may be under-reporting their risk behavior. Millett and his colleagues noted, however, that other studies have failed to find differences in reporting of risk behavior between black and other MSM. Moreover, Millett and his colleagues noted, the fact that the same pattern (less risk and greater HIV infection) is evident across studies with different mothods, samples of black MSM, and regions of a country (not to mention different countries), along with consistent data collected from 1987 to 2011, arguments pointing to a higher likelihood of bias and under-reporting become less credible.
Search: black, men who have sex with men, gay, bisexual, african american, msm, disparities, epidemic, risk factors, anal intercourse, condoms, drugs, education, poverty, care, access, antiretrovirals, aids 2012, millett
Scroll down to comment on this story.
comments 15 - 28 (of 28 total)
frederick wright, Coachella valley, 2012-07-31 17:24:12
I agree the African Americans or the word minority is becoming an excuses to take a microscop to all the infirmities that are equal to all cultures. For instance most cultures have gangs,packs or groups on the bottom that do what it takes to survive. Sex workers in prison,on wall street ,in a gangs create a DL batering system. Having choices of survial or a way out by family,faith
communities,one person at a time is the answer with passion,love and action in the community. Bring back romance
Stevan, Detroit, 2012-07-31 11:22:01
Instead of spew one's subjective anti-black bias, one could take this information and develop effective strategies to counteract the situation. In contrast to others' experiences, I have known the multitude of white AND black men I've known to lie with equal frequency about the exact same things. So, there is no need to think Black men lie more for any reason.
Stevan, Detroit, 2012-07-31 11:18:34
Sounds like some of us are equating our limited, personal experiences with the general population of Black MSM (". . .goes against everything I have ever experienced with black men"). That is a fallacy to think that one's experiences describes the experiences of everyone else in that group. This is the purpose of scientific, multi-discplinary studies, to see BEYOND the narrow views of what individuals experience and get an objective, quantitative view of the target population.
David, Philadelphia, 2012-07-30 21:38:50
Yes after reading all the other posts...when have you ever known people to be completely honest about their sexual behavior? And then to expect black men to be honest about it. LMFAO. There are reasons why we have terms like "DL, Trade and Creepin'" in the black community. They are notorious for lying about their sexual lives. Dogs. Sex is a big part of their lives. That's why black girls have the highest rate of children out of wedlock per capita. Black men,gay or straight...don't care!
David, Philadelphia, 2012-07-30 21:32:13
This report goes against everything I have ever experienced with black men. I am not proud of the number of sex partners I have had over my lifetime but I can honestly say that 99% of them did NOT want to use condoms and I almost most of them used drugs occasionally. These problems are not socioeconomic they are cultural and I believe there is a big difference between the two! Stop making excuses for their bad behavior. We all have equal access to public service messages and clinic help!
Zac, New York, NY, 2012-07-30 17:17:11
It is possible that these MSM, (like many African MSW)may have concurrent sexual partnerships for longer periods of time. If there is a stigma associated with same-sex encounters/relationships, these men may only have sex within the same relatively small sexual network. This could go on for months or years. If even 1 of these partners are also having concurrent sexual partnerships and HIV is introduced in the sexual network it could explain the high incidence and prevalence among Black MSM.
Frederick Wright, Coachella Valley, 2012-07-28 17:00:57
I think this study surly points out a problem in our communities, and the first one I see is the need to demanize the Gay Black Men and Bi Sexual Man to use a term of All these men are considered MSM or Black Men that have lots of sexual partners. Shame,Shame, Shame on this term to disgrace the Gay and Bi sexual black men, and this term is truly keeping these men from adressing the truth. It is fear that is keeping these numbers in Black Gay Men of not being accepted by all of our culture.
Uh Huh, Augusta, 2012-07-27 17:40:55
black people were three times as likely to have lied compared with their non black counter parts about their sexual practices. Hell evryone knows that.
Tim Horn, AIDSmeds, New York, NY, 2012-07-27 16:44:50
See my postscript above in response to some of the points raised thus far.
nvhorseman, Sparks, Nv., 2012-07-27 13:12:31
to continue... Lastly, most black men are not about to put down the truth on a piece of paper that will possibly be used to put them in jail. There is cultural mistrust of the establishment and rightly so. No one is going to give "the man" an opportunity to put you behind bars when it is done so prevalently in black neighborhoods or even in mixed 'hoods of low income. 9 chances out of 10 if 2 people 1 white and 1 black are walking down the street at night, it is the black person who is profiled.
nvhorseman, Sparks, NV., 2012-07-27 13:01:49
During NYC's stop, frisk and search profiling of black citizens, it is common to find drugs on their person. Black people are ghettoized still, thus increasing the density of possible HIV+ people and infection. Black people have not dispersed back across the U.S. or other countries to return home when sick or get a new job because they usually remain in the vicinity of family and they are at the bottom of the economic ladder of this country still. I find nothing paradoxical in your study....
dianeb, Texas, 2012-07-27 12:48:56
These results make NO sense. More likely to use condoms, less likely to have multiple partners and use drugs BUT twice as likely to have an STD. It does not seem that they are getting truthful responses when surveying this population - need to find a better way to get the truth or the epidemic will continue to grow!!
Skeptical, Dallas, TX, 2012-07-27 12:32:32
Test results don't lie, and HIV doesn't discriminate. But people can lie and discriminate. The most likely explanation here is the interview questions about condom use and high risk behavior were not answered truthfully. Previous studies showed that black MSM as a group are more concerned about confidentiality during HIV testing and treatment. A search of online gay dating sites will show that black MSM report their HIV+ status at lower rate than other races, which we know is not accurate.
Dick Power, Washington DC, 2012-07-27 08:50:03
comments 15 - 28 (of 28 total)
I wonder if black MSM are as likely as their couterparts to respond frankly to the questions. That important point is not explored by the research, but certainly is an important consideration before taking this hypothesis that Black MSM are spontaneously becoming infected at so much higher levels w/o engaging in greater risks.
[Go to top]