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.
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comments 1 - 15 (of 28 total) next
Frederick Wright, Coachella Valley, 2012-09-07 19:52:26
JT, I think you are right for most do not want to give up the little bit of seemly love that they get form sex. I wondering if the new In Home Rapid HIV screening Kits are going to help these men face manhood with more honor and respect for themselves and thier communities? These Kits are proposed to be on sale to all in the public in the next couple of months.It is going to be hard for unkown HIVERs and HIV men to hide from this HIV. Maybe it will help break some of the chains of stigma too.
JT, Washington DC, 2012-09-05 19:42:07
I'm a 50 year old black male - positive for 14 years. I know first hand that many black men are not honest about their status and readily engage in unsafe sex.
Thomas Dossey-McKinnon, Baltimore, 2012-08-27 18:34:46
This study has many holes. I am not quite sure that the participants in this study are being forthright when asked these very sensitive and at times humiliating questions. There is only way to get HIV; exhanging bodily fluids with a partner who is positive. The higher the viral load the greater the chance one can get infected.
Frederick Wright, Coachella Valley, 2012-08-17 08:17:02
JJ and TA I think both of you in your statments show a lack of compassion and judgement for the statements of who cares,or just let them kill them selves and the innocent people in their path. Plus it is clear that you men are afraid of debating the truth within this need to understand or stand tallier and more pure than the DL or MSM or Just People that are in need of help. I question your man hood and courage for you want even use your real name. Whats up Dudes where the hate coming from.
JJ, Manhattan, 2012-08-15 11:57:43
Black men in the surveys obviously lie. That DL shit should really stop. Its totally ignorant mentality. Its also a killer. And enough spending government money studying all this. They lie. And STOP with the postcards about "education" and the "education classes" that teach them how to use a condom and then gives them free movie passes and MTA subway cards, etc etc. The programs are a waste. So are those who "teach" these classes!
T.A., Los Angeles, 2012-08-09 18:32:14
I agree wholeheartedly with David in Philadelphia. The facts are there for all of us. There is no "stigma" or "racism" associated with this. It is plain & simple; black men f*&k and we don't use condoms. It's a choice not a condemnation.
John Wikiera, Central New York, 2012-08-07 12:58:32
Mr. Millet, Well done, I liked what this article said, I've also shared it on twitter. And will post it to our CNY Connections site as well. I was looking at new articles, when I came across your name. Of course I had to read on, I wondered why I hadn't heard back when I emailed you at .who lol. It's great you are out there doing work such as this, there is a long road still to travel on this topic. Be well and it's great I know where to find you now lol.
Thank you, John Wikiera
Mikoleit, San Francisco, 2012-08-06 04:46:15
I am a 55-year-old African-American man. Positive since the beginning of the epidemic.
What I have noticed, chatting with Black men online is that MANY simply do not recognize the term POZ.
I state upfront that I am positive and frankly, I was stunned at the amount of "negative" Black men that hit on me.
I began to understand that the term, "poz" was not clear to many Black folks. I take extra care to say and write, HIV+ to make sure we're all on the same page.
Ronald Dennis, Los Angeles, 2012-08-03 11:45:06
27 years later?
ALL of us know that using condoms prevents HIV infection and have known this fact for years now. The Elisa Test to detect HIV exposure became available in 1985, that is when I found out that I had HIV. Having survived the hell of full blown AIDS that began in my body/life in 1990 when no medicines were available to save me and many others. I am black, almost 68, alive and very well. Lucky for sure, many men were not so lucky. We either have the results or the excuses.
Jeff, New York, 2012-08-02 15:41:09
I regularly call a phone sex line that is made up of about 95% black men. Everyone is looking to hook up, and virtually all of them are willing to nave unprotected anal sex without a condom. Some ask for HIV status, but many do not. The more likely question is, "Where do you want to cum?" or "Where do you want me to cum?" "Inside me" is almost always the preferred answer. If you say you're negative, any need for condoms disappears (but most don't ask about HIV status).
Renee, , 2012-08-02 15:09:25
cont.... Suffice it to say, I totally disagree with this article. While I "knew" the men I chose to have sex with were "safe", I got LUCKY. I got tested for HIV every 3 mo and STILL practiced unsafe sex with BLACK men, staying negative until I had sex with a black man for drugs once. And got HIV. All I am saying is yes, they drink, they do drugs, they DON'T like condoms, and they have sex ALOT. With women and other men.
Renee, Springfield, MO, 2012-08-02 15:05:48
I don't know if I can agree with this. I went wild and crazy in my 30's and had my share of sexual partners. They were ALL black men. Many many many of them LOVED to smoke weed. Many many many of them (like 95% drank alcohol), some of them were unfortunately into another drug----- crack cocaine. I also became addicted to crack cocaine and eventually it took me down a dark road. But I digress. The men I CHOSE to have sex with, the MAJORITY hated to wear condoms. And I happily complied.
sade grown, , 2012-08-02 13:34:59
This is ridiculous!! So you're telling me that black men just "get" it?? They are just trying to blame someone.. racist!!
Zac, New York, 2012-08-01 00:38:02
People did you not see the editor's postscript (it's italicized - you know the slanted letters)? They factored in lying about risk behavior. The evidence clearly point to OTHER FACTORS. Though I guess it is easier to set the blame completely on the individual actor - as if he acts outside of a society and subculture.
frederick wright, Coachella valley, 2012-07-31 17:24:12
comments 1 - 15 (of 28 total) next
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
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