Men Who Have Sex With Men and HIV/AIDS

Since the onset of the HIV/AIDS epidemic in the United States, AIDS incidence has been highest among men who have sex with men (MSM). Despite changes in the demographics of the epidemic, such as a growing number of cases among women, MSM remains the HIV exposure category with by far the highest number of reported new AIDS cases each year. Most of these cases are among MSM of color, who face extraordinary barriers to HIV counseling and testing, and care.¹

Surveillance

In 2003, when 31,614 men were diagnosed with AIDS in the United States, MSM was the HIV exposure category in 56.8 percent of those cases. New AIDS cases related to the exposure category MSM have increased every year since 2000, rising a total of 10.4 percent since then.²

MSM was the HIV exposure category for 45.7 percent of people living with AIDS at the end of 2003.³

Men of color accounted for half of all new AIDS cases related to the MSM exposure category in 2002, the most recent year for which these data are available. Blacks accounted for 36 percent; Hispanics accounted for 19 percent; Asian/Pacific Islanders (A/PIs) accounted for 1.6 percent; and American Indian/Alaska Native (AI/ANs) accounted for 0.6 percent.¹ Men of color also accounted for 59.5 percent of AIDS cases for which the HIV exposure category was MSM/injection drug use.¹

Evidence indicates extraordinarily high seroprevalence rates among some MSM populations. Phase II of the CDC's Young Men's Study examined MSM ages 23 through 29 who frequented certain venues; 13 percent of study participants were HIV positive. Prevalence was 32 percent among Blacks, 17 percent among Whites, and 14 percent among Hispanics.⁴

Critical Issues

Many MSM, especially racial and ethnic minorities, face poor access to health care because of lack of health insurance, poverty, and fear of losing anonymity. In addition to those problems, they must cope with many types of stigma -- for being an MSM, for being HIV positive and, for some, being an ethnic or racial minority. Many MSM face condemnation from their families, communities, and service providers.⁵

Many MSM, especially minority MSM, do not self-identify as gay or bisexual. Thus, prevention and health outreach targeting sexual minorities may not be effective among these individuals -- who may be especially reluctant to seek services at organizations perceived to be gay oriented.⁵

Minority MSM become infected at earlier ages than do Whites and are more likely to learn that they are HIV positive later in the course of infection. Moreover, a higher proportion of minorities than Whites have progressed to AIDS at initial diagnosis.⁷

Some MSM harbor misconceptions about effective HIV treatment: Many are aware of the advancements in medical technology and in the effectiveness of HAART, but they overestimate its power. Others believe that HIV infection is inevitable and may do little to prevent it.⁵

HIV/AIDS prevention among MSM has overwhelmingly focused on sexual risk alone. HIV prevention initiatives may be more effective if they address broad health concerns of MSM. Recent data indicate that among urban MSM, various health problems are highly intercorrelated and that the presence of multiple health problems is significantly associated with high-risk sexual behavior and HIV infection.⁸

MSM and the Ryan White CARE Act

Experiences of providers funded through the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act have revealed program components that are key to reaching MSM. Providers must cultivate trust and then provide high-quality, nonjudgmental services that help MSM acknowledge their risk, get tested, and stay in care over time. The use of peer educators can be critical.⁹

MSM receive services through all CARE Act programs except for the Title IV program, which serves primarily women and children. The HIV/AIDS epidemic in the United States initially emerged among the MSM population; thus, MSM were instrumental in collaborating with Congress to create and pass the CARE Act in 1990.

Today, CARE Act grantees are making concentrated efforts to bring MSM into care in the earliest stages of disease. Additionally, Title I and Title II grantees are striving to achieve greater involvement of MSM of color in the community planning process.

In collaboration with the African American AIDS Policy and Training Institute, the Asian and Pacific Islander Health Forum, Bienstar, and the National Native American AIDS Prevention Center, the Health Resources and Services Administration's HIV/AIDS Bureau conducted a research project -- which involved key informant interviews and structured roundtable discussions -- to identify barriers to care for MSM of color and develop solutions. The results are summarized in the publication Improving Care for HIV-Positive Men of Color Who Have Sex With Men: Barriers and Recommendations and are informing the process through which HRSA and the CDC are collaboratively responding to the epidemic among young MSM of color.

References

1. Centers for Disease Control and Prevention (CDC). HIV/AIDS Surveillance Supplemental Report. 2003;10(1):12-13. Table 4.
2. CDC. HIV/AIDS Surveillance Report. 2003;15:12. Table 3.
3. CDC. HIV/AIDS Surveillance Report. 2003;15:20. Table 10.
4. CDC. HIV incidence among young men who have sex with men -- seven U.S. cities, 1994-2000. MMWR. 2001;50:440-4.
5. HIV/AIDS Bureau. Improving Care for HIV-Positive Men of Color Who Have Sex With Men: Barriers and Recommendations. Rockville, MD: Health Resources and Services Administration; 2002.
6. CDC. HIV/AIDS Surveillance Report. 2003;15:14. Table 5.
7. CDC. HIV/AIDS among racial-ethnic minority men who have sex with men -- United States, 1989-1998. MMWR. 2000;49(1):4-11.
8. Stall R, et al. Association of co-occurring psychosocial health problems and increased vulnerability to HIV/AIDS among urban men who have sex with men. Am J Public Health. 2003;96(3): 939-42.
9. HRSA. Reaching men of color who have sex with men. HRSA CAREAction. June 2003.