Black MSM

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After years of unfulfilling relationships, Brandon Kennedy was looking for love. In 2008, he thought he found it. He first met his boyfriend at a party and then re-connected with him a year later online.

Though they’d only been seeing each other a few weeks before entering into a committed relationship, Brandon decided to trust his boyfriend when he said he had no sexually transmitted infections (STIs). Brandon had just had his own battery of STI tests performed—including one for HIV—so he was confident he did not pose a risk.

“I was at a point in my life where I had decided that the next time I would even think about having unprotected sex would be in a committed relationship,” Brandon recalls. And so, like countless other couples before them seeking more intimacy, they didn’t use condoms.

Then one day about seven months into what he thought was a monogamous relationship, Brandon experienced an excruciating pain while urinating, prompting him to go to a clinic to get checked out. That’s when he discovered he had syphilis, herpes and HIV.

The pair broke up a short time afterward because of lack of communication—not because of the infections, explains Brandon, who is now 24 years old and currently in school working on a nursing degree.

Brandon’s story is far from unique. Though black men who have sex with men (MSM) comprise less than 1 percent of the U.S. population, black MSM represented almost a quarter of all new HIV cases in 2009. The Centers for Disease Control and Prevention (CDC) reports the number of new cases among black MSM exploded by a whopping 48 percent between 2006 (4,400 cases) and 2009 (6,500 cases)-.

Hoping his story could help others, Brandon was part of the nationwide CDC Let’s Stop HIV Together campaign, which posted billboards all across Washington, DC, this past July during the XIX International AIDS Conference (AIDS 2012).

Researchers discussed the latest findings on black MSM at AIDS 2012. Data from the HIV Prevention Trials Network study 061 (HPTN 061) presented at AIDS 2012 showed that the rate of new HIV cases among black MSM in the United States is two times that among white MSM. Among black MSM younger than 30, the rate is even higher—three times that of white MSM younger than 30.

CDC researcher Gregorio Millett, MPH, presented data at AIDS 2012 culled from nearly 200 studies on black MSM that showed they are significantly more likely to become HIV positive compared with other MSM, yet they are less likely to engage in many risky behaviors for contracting the virus. But that’s old news, says Black AIDS Institute (BAI) CEO and president Phill Wilson, pointing to research that dates back more than a decade.  

In 2001, Linda Valleroy, PhD, of the CDC released initial findings of her Young Men’s Survey (YMS) on the sexual behavior of young gay and bisexual men. Data was collected between 1994 and 1998 from seven U.S. cities and between 1998 and 2000 from six U.S. cities. Although her study was not about men on the “down low” (a.k.a. men who secretly have sex with men while openly dating women, but who do not identify as gay or bisexual), much of the press in the years that followed attributed the myth that black “down low” MSM were mostly responsible for the spread of HIV in the black community, especially among black women.

Final results of her study—which included black men who labeled themselves homosexual or bisexual, but not those on the down low—were released in 2004. Valleroy concluded that the down low was real, but that it was not what was driving the HIV epidemic among blacks. Much of her data revealed that the facts were quite different from the myths.

“[Valleroy] showed that black gay and bisexual men don’t engage in riskier behavior than white or Latino men,” Wilson says. “It also showed that black men actually make their sexual debut later than white gay men, that they have fewer sexual partners in their lifetime than white men, and that they’re reluctant to participate in unprotected male intercourse.”

Such trends should lead to lower, not higher, HIV rates, right? And yet, according to a 2012 BAI report, black gay men have a one in four chance of contracting HIV by age 25 and the odds are 60 percent that they’ll be positive by age 40. Part of the reason, as the report points out, is that black men tend to mostly date other black men—creating a very small dating pool and thus a higher probability of encountering someone with HIV. In addition, younger black guys tend to date older black men, a demographic that happens to be more likely to be HIV positive simply because they’ve been around longer.

Findings at AIDS 2012 from the InvolveMENt study support the BAI report. Eli Rosenberg, PhD, a researcher at the Emory University Rollins School of Public Health in Atlanta, presented the data from an ongoing cohort of black and white MSM in Atlanta. The data showed that HIV-negative black MSM, compared with HIV-negative white MSM, are more than twice as likely to encounter a sex partner who can transmit HIV if safer sex practices are not followed.

According to that study, black MSM faced a 39 percent chance that at least one partner has transmission potential, compared with an 18 percent chance among white MSM at the same risk behavior level. The researchers specifically linked the heightened risk to the fact that 25 percent of black MSM had high viral loads above 400, compared with 8 percent among white MSM (this includes diagnosed and undiagnosed HIV cases). To have a 50 percent chance of getting HIV, black MSM need three partners, compared with seven partners for white MSM. To have a 90 percent chance of contracting the virus, black MSM need 10 partners, compared with 25 partners for white MSM. This is simply a matter of mathematics—not morality.

Linda Beer, PhD, of the CDC showed similar findings at AIDS 2012. She presented the first nationally representative data on disparities in ARV use and viral suppression among sexually active black and white MSM receiving HIV care. The data showed that HIV-positive black MSM were less likely to be receiving antiretroviral (ARV) treatment and to have undetectable viral loads.

While the data showed that almost three out of four white MSM had durably suppressed viral loads—a hallmark sign of being much less likely to transmit HIV, even if sex without condoms occurs—the same was true for only about half of black MSM.

But other factors are in play. “A significant number of folks are out of care, so undiagnosed HIV is really prevalent in the black gay community,” says Ernest Hopkins, the director of legislative affairs at the San Francisco AIDS Foundation.

Indeed, H. Irene Hall, PhD, of the CDC presented at AIDS 2012 combined data from the National HIV Surveillance System and the Medical Monitoring Project on engagement in HIV care. The data showed that only one in three people with HIV in the United States are being retained in care—in other words, being seen by a health care provider on a regular basis.
She found that black people with HIV were the least likely to be in ongoing care and to have their virus under control. Thirty-four percent of blacks were in ongoing care, compared with 38 percent of whites. Twenty-one percent of blacks had undetectable viral loads, compared with 30 percent of whites.

“Being out of care puts them at a disadvantage to having all their other health care needs addressed as well,” Hopkins added, “and so there are also very high rates of other sexually transmitted infections.”  

In fact, data from the Millet study shows that young black MSM are six times as likely to have another sexually transmitted infection (STI). For these men, it’s even more likely to transmit and contract HIV, and there are several reasons for this heightened risk: possible STI-related lesions; a potential increase in CD4 cells, which are targeted by HIV; and the presence of inflammation triggered by a compromised immune system.

The statistics are sobering, but social issues underscore the science. Kali Lindsey, the director of legislative and public affairs at the National Minority AIDS Council, says HIV is often the furthest thing from a young gay black man’s mind. “When [black men] walk in our neighborhoods we see violence, we see crime, we see substance abuse. We have to manage all of that stuff first before we start appreciating our gay identity and certainly our HIV risk,” he explains. “Unfortunately, many people are unable to understand that HIV is not the worst thing that can happen to a black gay man in America. There are larger things that we deal with on a daily basis.”

Violence was among the social issues covered at AIDS 2012. A study by researchers including Catherine Finneran, MPH, of Emory University showed that gay and bisexual men who experienced domestic violence were twice as likely not to have used condoms during their last sexual encounter. More than half of the survey respondents in the study were non-white.

The Millett study also supports the assertion that both socioeconomic and access-to-care disparities play a significant role. The data showed that black MSM were less likely to have finished high school and more likely to have been incarcerated, to have a low income and to be unemployed.

Further, HIV-positive black MSM 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 ARVs, and, in cases where ARVs were prescribed, to be 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.

The threat of rejection—from family, friends, coworkers and society, as well as potential sex partners—also fuels the hostile environment for black MSM. Add to that a lack of HIV education in general, and you have a recipe for severe stigma and discrimination against black MSM. “Not enough has been done to dispel the myths about how HIV is transmitted,” Lindsey says. “People with HIV are deserving of love. We need to hold the public health community accountable [for the lack of HIV education].”

Lisa Fitzpatrick, MD, MPH, formerly of the CDC and currently the medical director of the infectious diseases department at United Medical Center in Washington, DC, is trying to do her part. Noticing a rise in syphilis among young black MSM—many of them already HIV positive—she’s seeking support for a study on why young black MSM are taking sexual risks. Anecdotal evidence has already provided her with some insights.

“I have a young man who’s 22 who was diagnosed with HIV in 2011,” Fitzpatrick says. “When I asked him when the last time was that he’d been tested for HIV, he said ‘Oh, I get tested every three months.’ And I said, ‘So you’re just waiting for it to be positive, huh?’ and his response was ‘Pretty much.’ It’s like a game of Russian roulette to them. They know it’s lurking, but they don’t talk about it.”

Does that mean “talking about it” is part of the solution? If so, then why don’t more folks speak out? Fitzpatrick says shame fuels the secrecy. “When I ask them what it would take to get MSM to stop taking risks, they say, ‘Well, if other people would talk to us when we’re negative [we’d stand a chance]. We don’t hear from people who are HIV positive.’ But then I ask them if they would be willing to take on that role, and none of them want to,” she says. “They all can offer you some solutions, but none of them want to be visible enough to be a part of the solutions. And that just goes back to a lot of the shame.”

Kenyon Farrow, the communications director of the Praxis Project, a nonprofit focused on creating healthy communities, says part of the solution lies in studying the relationship between young black MSM and medical providers.

“What are the assumptions medical personnel are making? Do physicians just not know how to relate or talk to their patients about sexuality or risk? Are they offering people at the greatest risk for infection HIV tests?” he asks.

Farrow says another part of the solution rests on better sex education in schools. “If we look at the majority of new HIV cases among black MSM over the past 10 years, they’ve mostly been happening in the South,” he explains. “And not just in big cities, but in rural places in states where they are still very heavily promoting abstinence-only education. In Louisiana, teachers can’t even say the word ‘condoms’ in class, and you wonder why you see the rates of HIV in Baton Rouge and New Orleans that you do.”

Brandon, who mistakenly believed his boyfriend to be HIV negative, agrees with Farrow. “I don’t promote 100 percent condom use, and I don’t promote 100 percent safer sex—I promote education,” he says. “If an individual is going to decide to perform in an adult activity, then they need to be able to accept the adult consequences that come along with it. I could blame everything on my ex-boyfriend, but I could’ve practiced safer sex. I take my fair share of the 50 percent of it. Once individuals learn how to take responsibility, that’s where a lot of our progress will come from.”

Undoubtedly the challenges young black MSM face preventing HIV or living with the virus are complex. However, as expert testimonies and the data presented at AIDS 2012 make it clear: The solutions aren’t simple to deploy, but the myths of black MSM are simple to dispel.