African-American men who have sex with men (MSM) are significantly less likely to be taking antiretroviral medications than are their white counterparts, an analysis of multi-year data found. The study was published in The Journal of Infectious Diseases.
The National HIV Behavioral Surveillance (NHBS) project has surveyed groups at risk for seroconverting (such as MSM or intravenous drug users) in three-year cycles since 2003. Interviewees are asked about their HIV testing and treatment history, behaviors linked to a risk of seroconverting and demographic information. The survey for MSM who live with HIV includes questions about their antiretroviral therapy (ART) and how soon after their HIV diagnosis they visited an HIV clinic for the first time (linkage to care).
Interviews with MSM were conducted in 2008, 2011 and 2014 at various locations in 20 urban areas across the United States. Only those who had learned between three months and three years before the survey that they were living with HIV were included in the analysis. This means that a different set of people was recruited and interviewed during each of the cycles.
The racial mix of study participants contributing data changed over time, with the number of whites decreasing by 14 percentage points and the number of African-Americans increasing by 13 percentage points between 2008 and 2014. Health insurance coverage increased during that period. In 2008, three-quarters of interviewees had such insurance and, in 2014, 86% did. NHBS interviewed more MSM during each cycle. Accordingly, the number of people whose responses were used for this analysis rose from 236 in 2008 to 358 in 2014.
The proportion of MSM who were linked to care increased from 79% of those surveyed in 2008 to 87% in 2014 (PR, 1.05; 95% CI, 1.031.07). During each of the three survey years, more education, a higher income and having medical insurance increased the likelihood that a participant had attended a clinic appointment within three months of HIV diagnosis. The same variables applied to the probability of taking ART, but the data revealed another variable here: race. Nine percentage points more whites than African Americans were prescribed ART in 2014. Data over the entire study period "suggest a widening of the disparity between 2011 and 2014," study authors wrote.
Regional differences in the number of study participants who had been linked to care or were on ART disappeared when the data were adjusted for the higher proportion of African Americans in the U.S. South compared with other regions. However, the study was conducted only in urban settings, and in the South more people live with HIV in rural areas than do in other parts of the country, researchers cautioned. That fact may skew the regional data, they added.
In an accompanying editorial Sten H. Vermund, M.D., Ph.D., of Yale University discussed a variety of interventions to address this racial disparity. Community outreach, health workers, internet-based engagement and "bridging from significant transitions into care" are promising approaches in his view. However, "[s]tructural barriers loom large as a new administration takes over under our 45th president," he added. Potential government actions include elimination of the Affordable Care Act, less money for Medicare and Medicaid and cuts to funding under the Ryan White CARE Act. Such measures "would all be expected to exacerbate racial/ethnic health disparities," Vermund said.
Addressing ethnic differences in the risk of seroconversion and access to HIV care requires dealing with social determinants of health, not just medical issues. These societal problems include inadequate housing and mental health or substance use services, lack of access to education and employment -- and the need for "an adequate income," Vermund concluded.
Barbara Jungwirth is a freelance writer and translator based in New York.
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