The belief that having sex with someone of your own race lowers your risk of contracting HIV is a misperception that needs to be addressed among black and Latino men who have sex with men (MSM). What’s more, health care workers are missing opportunities to test this population for HIV—even when the men are engaged in care and disclose their sexuality to their doctors.
|Gregorio A. Millett|
To explore these dynamics, researchers led by Gregorio A. Millett, MPH, the CDC/HHS Liaison to the White House Office of National AIDS Policy (ONAP), analyzed data from 1,208 MSM (597 black and 611 Latino) who participated in studies in Los Angeles, New York City and Philadelphia.
Eleven percent of them (18 percent black, 5 percent Latino) turned out to be HIV positive but unaware of their status (referred to as “HIV-positive unaware”). Researchers found that certain variables were more common among the MSM in this group.
Black HIV-positive unaware MSM were associated with:
- Gay identity
- Earning a moderately higher income
- Having health insurance
- Disclosing sexuality to current health care provider
- Fewer than three lifetime HIV tests
- High perceived risk of testing HIV positive
- Belief that sex with other black men reduces HIV risk
- Nongay identity
- High perceived risk of currently being HIV positive
- Belief that sex with other Latino men reduces HIV risk
POZ spoke with Millett, who arrived at ONAP via the CDC, about the implications of these findings, which were printed in the September Journal of Acquired Immune Deficiency Syndromes in an article titled “Mistaken Assumptions and Missed Opportunities: Correlates of Undiagnosed HIV Infection Among Black and Latino Men Who Have Sex With Men.” We also asked Millett how his team in DC might use the data as they implement the National HIV/AIDS Strategy.
Do these findings constitute new information, or is it more like data that bolsters what we’ve already known?
This is new information. Most studies that have looked at sexuality and disclosure and HIV testing among MSM have found that men who disclose their sexuality are more likely to get tested for HIV, and among the studies, we know that black MSM are less likely to disclose their sexuality compared to white MSM in a variety of settings, including with their physicians.
What’s interesting about our study is that we found that even among black MSM who disclose [that they’re gay], they were less likely to be tested and more likely to have unrecognized HIV infection. That’s something that hasn’t been reported before in scientific literature. It’s a new finding, and it has implications for clinicians, particularly in high prevalence areas like Philadelphia. There are limitations to what you can generalize. Other studies—one in Baltimore—found that black MSM who disclosed their sexuality are more likely to get tested than those that didn’t.
What do the findings say about MSM who perceive themselves to be at higher risk but at the same time don’t get tested for HIV? Doesn’t this seem counterintuitive?
It does and it doesn’t. One of the things that’s really salient after the past 30 years of the epidemic is that HIV stigma is still a very huge issue: It’s huge in the African-American community, it’s huge in the MSM community—it’s a huge issue in the United States in general. We know that because of stigma, people are less likely to get tested and to get into care, and less likely to take pills or be adherent. So we’re very clear that unless we address stigma in the United States it’s going to be very difficult to find and test some of the higher risk populations in the United States.
Many of these men in the study who perceive themselves as high risk [didn’t get tested. This is] possibly because of stigma, possibly because they didn’t want to deal with HIV, and a certain sense of denial in terms of being HIV positive. All of those issues are things we really have to think about. And they have huge implications. We know that treatment is prevention and that getting people into care not only has better clinical outcomes for them, but also has better prevention and clinical outcomes for their partners.
One thing about the study that I think is very clear is that these issues are not only about black MSM. This I something you find in the African-American community overall—they’re less likely to get into care; they have higher rates of unrecognized HIV infections. We have to deal with these issues to really build upon these new interventions—or PrEP [pre-exposure prophylaxis, when a negative person takes HIV meds to prevent possible infection], PEP [post-exposure prophylaxis, taking HIV meds within 72 hours of possible exposure to prevent infection], HPTN 052 [a clinical trial showing that treating HIV-positive people with meds prevents transmission, a.k.a. “treatment as prevention”] and others won’t be relevant to these communities.
How prevalent is the misperception that having sex with someone of the same race or ethnicity lowers HIV risk—and why is it important to note?
One of the things we were interested in when we were designing the study was trying to explain why there’s a higher proportion of black or Latino MSM who are HIV positive compared with white MSM. The reason we’re interested in it is because if you look at studies on risk behavior, primarily among black MSM, [you find that they] engage in comparable—if not less—risk behavior but are far more likely to be positive. You find the same dynamic as well among Latino MSM, but to a lesser degree. We were interested in trying to figure out what other explanations might be out there for why [we have] these rates.
One of things we put in our study, which hasn’t been asked before, was the degree to which men believed sex with men of the same race or ethnicity reduces their risk of HIV infection. We thought that was important because we know from anecdotal evidence and other studies that black and Latino MSM might be less likely to get messaging about HIV and risk reduction activities, and they might be more likely to believe—especially at the beginning of the epidemic—that HIV was primarily a disease among white MSM.
How do beliefs regarding HIV prevalence at the beginning of the epidemic affect HIV stats and risks today?
At the very beginning of the epidemic, when it was called gay-related immune deficiency (GRID), a lot of the images in the media were of white gay men, primarily white gay men in New York City and San Francisco. We also know from evidence from epidemiological studies at that time that black gay men were actually engaging in higher risk behavior compared with white gay men, in studies in both San Francisco and New York City. And at that time the messaging in the media and the exclusion of black and Latino faces probably meant that a lot of black and Latino men thought HIV affected white gay men.
The problem with that is that these men were engaging in high risk behavior and HIV was already in these communities—[the virus] probably had an opportunity to build a higher background prevalence in those communities that has continued today due to other factors: higher rates of STIs [sexually transmitted infections], a greater likelihood of black men choosing black partners and Latino men choosing Latino partners, poverty and other issues that really complicate why we see greater HIV rates in these communities. A lot of these beliefs might be a holdover from the beginning of the epidemic.
But I want to caution you that most of the men in the study did not believe that sex with another black or Latino man reduced risk of HIV infection. But those that did subscribe to this belief were more likely to have unrecognized HIV infection.
What’s really important about this, and in terms of steps the CDC is taking, is that the CDC is moving forward for social marketing campaigns for black MSM as well as Latino MSM. And [in August, the CDC launched “Act Against AIDS,”] a campaign for black MSM nationally to increase awareness about HIV infection in black MSM communities and to encourage black MSM to get tested for HIV, which is exactly what the results of this study highlight that needs to be done.
Your study also looked at whether self-identifying as gay or bisexual affects HIV risk. What were the takeaways from these findings?
One of the things we find out often [in studies] is that MSM who identify as gay are more likely to be HIV positive, to have a greater number of sexual partners and to engage in unprotected anal intercourse compared to MSM who don’t identify as gay. What was interesting in our study is that we found that same dynamic for black MSM. But for Latino MSM, we found that bisexually active men or men who identified as heterosexual—more so for bisexual—were more likely to have unrecognized HIV infection.
Why we think we found this result is we think that we had a large component of Latino MSM who were not born in the United States and whose primary language is Spanish rather than English. We think many of these men have perhaps not attended to any of the prevention messages because they are [in English and] for gay-identified men rather than for bisexual or heterosexual MSM. This speaks into a larger narrative where you find that bisexual men overall, irrespective of race or ethnicity, are less likely to be tested for HIV compared to gay men. When you put both those factors together for Latino MSM—those might be some reasons why we find unrecognized HIV infection.
How is the implementation of the National HIV/AIDS Strategy addressing black and Latino MSM?
President Obama launched the National HIV/AIDS Strategy [in July 2010]. What the strategy seeks to do is identify a small number of steps that will make the biggest impact on the HIV epidemic.
There were three goals the president gave us for the National HIV/AIDS Strategy: The first was to reduce number of new infections; the second was to increase access to care and [treatment]; and the third was to reduce HIV/AIDS-related disparities. We added a fourth goal: to increase coordination across federal agencies because we know that coordination is key to addressing the epidemic in the United States.
The strategy identified men who have sex with men, it identified African Americans and Latinos as well as substance users as populations we need to concentrate our efforts on because these are populations [more likely] to become infected with HIV.
A lot of the things we see in terms of combination prevention or in terms of access to care, theoretically, should work for all populations. If you’re able to get people into care in a timely manner once they’re diagnosed, if you’re able to get them virally suppressed, not only do they benefit in terms of clinical outcomes but [so does the entire community], because it means that there’s less virus floating out there and these individuals are less likely to transmit HIV to their partners.
That can happen irrespective of which risk group an individual is in, but why it’s important for black MSM as well as Latino MSM is that in many ways HIV has fallen off the radar in [the lesbian, gay, bisexual and transgender (LGBT)] community. Over the past 30 years, the community that started with a very strong and vigorous response against HIV [has] since become involved in many other issues that are important issues—such as marriage and other civil opportunities.
The problem is that if you look in the [LGBT] medium, you rarely now see studies about HIV/AIDS. And the fact that you rarely see studies about HIV/AIDS is contrary to the fact that when you look at CDC’s HIV/AIDS incidence data you still find that the number of new infections is increasing among young gay and bisexual men—and it’s the only group where the number of new infections is actually [increasing]. So we have a really odd dynamic in the [LGBT] community where the time when we’re really not focusing on HIV/AIDS is the time when we really need to be.
We know from the CDC’s efforts that CBOs [community-based organizations] are perfect places for reaching these communities. Black and Latino MSM are more likely to get tested at CBOs than at a health clinic, and CBOs are uniquely qualified to reach these men. We’re hoping to continue to enlist CBOs in the process of reaching these men and asking these men to bring in their friends to get tested for HIV and to identify individuals with undiagnosed HIV. We’re clear that working with CBOs is essential and integral to making sure we address the epidemic. They can have an impact on our community.
What would you like to see happen in the LGBT community and at the grassroots to address rising HIV rates?
There’s already a lot the federal government is doing. The CDC just released a new cooperative agreement for HIV prevention for young black MSM and transgender individuals. You find HRSA [Health Resources and Services Administration] prioritizing black and Latino MSM and really trying to identify these men and get them linked to care and develop interventions that keep them in care. In terms of the National Institutes of Health, there are a bevy of new studies now trying to take a look at why we’re seeing these disparities among black and Latino MSM and how we can improve clinical outcomes. So there’s a lot taking place on the federal level.
At the community level, there’s a lot that perhaps needs to be done. One of the things is to be sure we educate these men about HIV. We have to be able to tell men in our communities that there’s a greater prevalence of HIV for black and Latino MSM, which means that there’s greater opportunities to come in contact with someone who is HIV positive. That message hasn’t gotten out there as much as it needs to.
There are things that need to be addressed that the CDC or federal government cannot necessarily do on its own. That has to do with HIV/AIDS stigma in black and Latino MSM communities, so that people are able to come out [about their sexuality] without repercussions, as well as disclose their HIV status without repercussions.
We need to be sure that individuals in these communities have access to health care, which is difficult when you have high rates of unemployment in both communities. We need to be sure that people get treatment for STIs [sexually transmitted infections], which we know can facilitate HIV transmission as well as acquisition.
And we need to get social marketing out there [that will lead people to] get tested as often as possible and make sure individuals realize that [HIV] drugs are not as toxic as they used to be and that treatment is incredibly beneficial. That’s a message that really hasn’t permeated in some high-risk communities.