February 6, 2009
In the United States, black men who have sex with men (MSM) account for a disproportionate number of new cases of human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS).1 From 2001 to 2006, the number of HIV/AIDS cases among black MSM aged 13-24 years in 33 states increased 93%.2 In 2006, more new AIDS cases among black MSM were diagnosed in the South* than in all other U.S. census regions combined.3 In November 2007, the Mississippi State Department of Health (MSDH) reported to CDC an increase in the number of young black MSM who received diagnoses of HIV infection at a sexually transmitted disease (STD) clinic in Jackson, Mississippi. MSDH and CDC conducted a survey of 29 young black MSM in the three-county Jackson area who received diagnoses of HIV infection during January 2006-April 2008 to characterize risk behavior and HIV testing behavior. This report summarizes the results of that survey, which found that, during the 12 months before receiving their HIV infection diagnosis, 20 (69%) of the 29 participants had unprotected anal intercourse, but only three (10%) of the 29 thought they were likely or very likely to acquire HIV infection in their lifetimes. Additional investigations are needed to determine whether this sample is illustrative of other groups of black MSM at high risk for HIV infection, especially in the South. Targeted interventions that decrease HIV risk behaviors among black MSM should be developed, implemented, and evaluated to reduce HIV transmission.
Mandatory, confidential, name-based HIV case surveillance has been conducted in Mississippi using the HIV/AIDS Reporting System since 1988; cases of confirmed HIV infection are reported to state surveillance staff members, who then enter information about patient demographics, HIV risk behavior, laboratory results, and clinical status into the reporting system. After an increase in new HIV cases among young black MSM was noted by clinicians at an STD clinic in Jackson in November 2007, a review of HIV surveillance data was conducted. This review indicated that the number of newly diagnosed HIV cases among all black men in the Jackson area (Hinds, Madison, and Rankin counties) increased 20%, from 185 during 2004-2005 to 222 during 2006-2007 (Figure 1). Among black MSM aged 17-25 years in the Jackson area, the number of HIV cases increased from 22 to 32 (45%) during the same period (Figure 2).
To characterize risk behavior and HIV testing behavior among HIV-infected young black MSM, during February-April 2008, MSDH and CDC first identified all black males aged 16-25 years who had received diagnoses of HIV infection during January 2006-April 2008 and who lived in, or received their diagnosis in, the three-county Jackson area. These potential participants were identified by state surveillance staff members using the HIV/AIDS Reporting System and recruited for the survey by telephone, mail, or in person. Participation was voluntary; persons who completed the survey received a $25 gift card. Surveys were completed on a computer questionnaire at the STD clinic or, in some cases, at a location convenient to participants. The survey was self-administered; participants read the questions on the screen of a laptop or handheld computer and marked their answers. The survey included questions on sexual identity and behavior, condom use, HIV testing, drug use, and perceived risk for HIV infection. Analysis was limited to MSM (i.e., persons who self-identified as men who had ever had anal sex with a man).
A total of 86 potential participants were identified initially. Of these, 40 (47%) were located and interviewed. Of the 46 not interviewed, 31 could not be contacted, three had moved from the area, one was deceased, one declined to participate, one did not arrive for the scheduled interview, and nine had no recorded reason for not being interviewed. Of the 40 interviewed, 29 (73%) self-identified as MSM and were included in the analysis. Of the 11 persons not included, seven did not report ever having anal sex with a man, three responded "don't know" or "refuse to answer" to a majority of the questions, and one self-identified as transgender.
Of the 29 black MSM surveyed, the median age at HIV diagnosis was 22 years (range: 17-25 years). A total of 19 men (66%) self-identified as gay/homosexual, seven (24%) as bisexual, two (7%) as straight/heterosexual, and one (3%) as questioning (Table). Twenty (69%) reported having unprotected anal intercourse with a male partner during the 12 months before their first positive HIV test, and 16 (55%) reported having male sex partners aged >26 years during that period. Of the 16 participants aged <22 years, nine (56%) reported having male sex partners aged >26 years. Twenty-six participants (three did not respond) reported a median of 3.5 male sex partners (range: 1-11) during the 12 months before their first positive HIV test. Three (10%) of the 29 surveyed reported having a female sex partner in the 12 months before receiving their HIV diagnoses, and 16 (55%) reported concurrent sexual relationships.§
Six (21%) of those surveyed reported having no HIV test during the 2 years before their first positive HIV test, and five (17%) reported having one test. At the time of their first positive HIV test, three of the 29 thought they were likely or very likely to acquire HIV infection during their lifetime; 15 (52%) thought acquiring HIV infection was unlikely or very unlikely (Table).
None of the 29 reported injection drug use in the 12 months before receiving their HIV diagnosis. Twelve (41%) reported using marijuana; three (10%) reported using ecstasy and/or powdered cocaine (Table).
Reported by: L Mena, MD, K Johnson, MPH, C Thompson, MBA, Mississippi State Dept of Health. P Thomas, PhD, C Toledo, PhD, J Heffelfinger, MD, M Sutton, MD, R Ellington, MSEd, Div of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention; T Larkins, PhD, ORISE Fellowship; L Rynn, CDC Experience Applied Epidemiology Fellowship; J Doss, MPH, Public Health Prevention Service Fellowship; A Oster, MD, C Dorell, MD, D Dowell, MD, A McIntyre, PhD, EIS officers, CDC.
This investigation identified multiple HIV risk and testing behaviors among a localized group of 29 young black MSM recently confirmed positive for HIV infection. Twenty of the young black MSM (69%) reported unprotected anal intercourse in the 12 months before HIV diagnosis, nearly double the percentage (38%) of black MSM aged 18-24 years who reported unprotected anal intercourse during the preceding 12 months in a large behavioral surveillance system survey conducted during 2004-2005 (National HIV Behavioral Surveillance System, CDC, unpublished data, 2009). In addition, 16 (55%) of the young black MSM reported having male sex partners aged >26 years. Having sex with partners who are older than themselves increases the risk for HIV infection among young black MSM.4
The behaviors presented in this report are derived from a small number of participants in one area and might not represent the behaviors of young black MSM in other areas. However, a 2003 investigation of HIV infection among young black MSM in North Carolina also revealed high prevalence of HIV risk behaviors.5 The findings in this report might be illustrative of behaviors contributing to HIV acquisition, particularly in the South. Further research is needed to understand behaviors and other factors associated with the increasing numbers of HIV infections among black MSM in the South and elsewhere in the United States.
Eleven (38%) of those surveyed reported having no HIV test or only one HIV test during the 2 years before HIV diagnosis. Current CDC guidelines recommend HIV testing at least once each year for sexually active MSM.6 Although young black MSM are more likely to be HIV infected than MSM of other racial/ethnic groups, they are less likely to know that they are infected.7 Among persons who are HIV infected, being aware of one's HIV diagnosis has been associated with a reduction in risk behaviors.8 Increasing the number of young black MSM who are aware of their HIV infection might reduce transmission.
Although many interventions that aim to reduce risk behavior have been developed and studied, few are known to be effective among young black MSM.¶ CDC currently disseminates two HIV prevention interventions specifically developed for black MSM.** Further research must address reducing unprotected anal intercourse, understanding risks related to partner selection and sexual networks, and improving HIV testing rates.
The findings in this report are subject to at least two limitations. First, the survey asked about behaviors in the 12 months before HIV diagnosis, a period more than 2 years before the interview for 11 (38%) of those surveyed, who received their HIV diagnoses in 2006. These persons might have had poorer recall of risk behavior than those who received HIV diagnoses more recently. Second, the findings might not be representative of all HIV-infected young black MSM in the Jackson area because the sample size was small and 53% of the potential participants who were initially identified were not interviewed, primarily because they could not be located.
Reducing HIV transmission among young black MSM is challenging because of many factors, including sexual network patterns, sexual partnering with older men, high prevalence of STDs, lack of awareness of one's HIV status, homophobia, HIV-related stigma and discrimination, and socioeconomic issues. CDC's Heightened National Response to the HIV/AIDS Crisis among African Americans aims to reduce HIV/AIDS in this population by expanding the reach of prevention services, increasing opportunities for diagnosis and treatment, developing new prevention interventions, and mobilizing broader community action.§§ In the United States, reducing the toll of HIV/AIDS on young black MSM will require a combination of strategies, including culturally specific behavioral interventions, expanded testing programs, and comprehensive campaigns to combat stigma.
The findings in this report are based, in part, on contributions by M Colomb, PhD, My Brother's Keeper, Inc; M Robinson, the Nominal Group, Jackson; K Patterson, K Sly, PhD, Jackson State Univ; A Fox, MS, M Monger, Mississippi State Dept of Health; and T Duncan, PhD, K Henny, PhD, T Mastro, MD, and G Millett, MPH, Div of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC.
* Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia.
Participants were asked, "At the time of your first positive HIV test, what did you think were your chances of getting HIV in your lifetime? Very unlikely, unlikely, equally likely and unlikely, likely, or very likely?"
§ Defined as reporting more than one sexual partner during the same week and/or answering "yes" to the question, "Was there ever a time (during the 12 months before your first positive HIV test) when you were sexually involved with one person and also had sex with one or more other partners?"
¶ Additional information available at www.cdc.gov/hiv/topics/research/prs/evidence-based-interventions.htm.
** Additional information available at www.effectiveinterventions.org.
Additional information available at www.cdc.gov/hiv/topics/aa/resources/factsheets/pdf/aa.pdf.
§§ Additional information available at www.cdc.gov/hiv/topics/aa/cdc.htm.