The Unending Paradox: Why Are HIV Rates Higher in Black MSM?
In 2006, Greg Millett and colleagues studied HIV in African American men who have sex with men (MSM) to try to understand why they have the highest rates of infection in the U.S. His study reported that, compared with white MSM, African American MSM had fewer sexual partners, and found no differences in the rates of reported unprotected sex. They found no evidence to support theories ranging from genetic risk factors to increased substance use to higher incarceration rates. The men had similar histories regarding their use of sex workers, and similar HIV testing frequency.
In 2014, Maulsby and Millett published a follow-up review article which included data from new studies done after the initial 2006 study. The report found that African American MSM had higher rates of sexually transmitted diseases (STDs) and higher rates of undiagnosed HIV than their white counterparts. There was also evidence that they were less likely to be connected to care after testing HIV positive, and that they were less adherent to HIV treatment. But the question remained: why?
Here are the primary areas studied as likely contributing to the high rates of HIV infection in this community.
Researchers have concluded that the high prevalence of HIV in Black communities, coupled with high rates of undiagnosed HIV and STDs, might contribute to increased HIV transmission. This is supported by data showing that Black MSM are more likely to have Black partners, resulting in increased HIV risk (Tieu, 2010).
But some studies have found that choosing sexual partners based on race does not increase HIV risk in young Black MSM. This conflict might be explained by the findings of other studies showing that younger Black MSM engaging in unprotected sex with older MSM are at higher risk for HIV (Oster, 2011). The greater risk associated with these age choices has often been reported. But a lack of consistent definitions of "older" and "younger" makes the results inconclusive, and more research is needed.
Stigma and Discrimination
Acceptance of same-sex behavior, by social consensus or by law (marriage, anti-discrimination ordinances, etc.), is correlated with decreases in STD and HIV rates (Francis, 2010). As acceptance increases, more men become part of sexual social networks. This decreases the chance of partnering being limited to small networks, where the risk of HIV is higher. Put simply, the community viral load of a sexual network is decreased as it grows larger, and societal acceptance of homosexuality enables a sexual network's size to increase. But homophobia remains high in many African-American communities, which prevents social networks from increasing in size and thereby reducing their community viral load. Such homophobia also prevents MSM from establishing the long-term relationships that can reduce HIV risk.
African American MSM confront a powerful array of discrimination, including race, gender identity, sexual orientation, and HIV status. An assessment of U.S. attitudes toward homosexuality found that African American MSM were twice as likely to state that homosexuality was wrong as were white MSM. But researchers have not found a direct relationship between risk behavior and discrimination (Rhodes, 2011).
Studies show that Black and white MSM are equally likely to have visited a health care provider in the past year. The CDC reports that MSM were offered HIV tests at the same rate: 61% of Blacks, 60% of Latinos, and 62% of whites.
But Black MSM had lower CD4 counts. Other studies report that African Americans are less likely than whites to adhere to HIV treatment or to stay in care. This is confirmed by CDC data showing that disease progression, infectiousness, and mortality are greater in Black MSM with HIV compared with other MSM. These differences in health outcomes are exacerbated by the fact that Black MSM have a greater chance of living in poverty, are less likely to have health insurance, and make fewer clinic visits when they do have health care. These differences may lessen due to the Affordable Care Act. But many states in the South, where HIV infection rates are high, have not expanded Medicaid as the ACA allows and so many continue to show these inequalities.
Research has consistently found that mental health issues, including depression, affect black MSM more frequently than white MSM. Many studies have focused on determining why these elevated rates occur. A common factor identified in the studies is widespread homophobia. However, research from the 1990s and more recently (deSantis, 2011) found no significant relationship between increased sexual risk behavior among black MSM and rates of mental health disorders. It appears that mental health alone does not explain the HIV infection rate disparities.
Mistrust of medical institutions by African Americans is well established. Many subscribe to HIV conspiracy theories and believe that HIV treatment is more toxic than the virus. But how that mistrust explains differences in HIV care and outcomes is not clear (Clark, 2008). This distrust underlines the need for every person to have access to safe and nonjudgmental HIV services. Unfortunately, research on how Black MSM interact with their medical providers is limited, and more is needed.
Flying in the face of high infection rates, studies such as the 2010 Indiana University National Sex Study reported that African Americans were more likely than other groups to use condoms. In fact, rates of condom use among Black teenagers were the highest of any group. But condom use declines in all groups after age 18, dropping as low as 20.5%, regardless of race.
People who interact with a sexual network that has more people with HIV are at greater risk for infection if condoms are not used. Black MSM with HIV are less likely to disclose their status, and are less likely to be on HIV treatment with an undetectable viral load (which greatly reduces the risk of transmission). Add to this the CDC report that the highest number of undiagnosed HIV infections are in African American communities, and we have some clues to inform prevention efforts.
Millet found that reported drug use during sex did not differ in Black MSM compared with white and Latino MSM. But researchers reported conflicting data, so more research is needed. Current data on substance use do not account for the higher rates of HIV in African American MSM. There are differences in the drugs of choice, with HIV-positive black MSM being more likely to use crack or cocaine and less likely to report meth (Maulsby, 2014).
A CDC presentation at the 2015 CROI meeting reported that 90% of all new HIV infections can be traced to people who are unaware of their HIV status, not connected to care, or not virally suppressed. Most of the studies in this article focus on health disparities. If these disparities were eliminated we would very likely see a drastic reduction in new HIV infections among Black MSM. But other MSM continue to see new HIV infections, even if not at the same rate. Eliminating disparities will not eliminate HIV infections. White MSM are not a model of optimal HIV prevention behavior -- they are just a comparison group.
The HIV-related disparities Black MSM face may be due to barriers to care, low income, unemployment, incarceration, low education, and limited sexual networks. The combination of increased STD incidence, low testing rates, and chronic barriers such as racism, homophobia, and HIV stigma may be the primary culprits. Thus there is a great need for increased HIV testing, linkage to and retention in care, and adherence to treatment for Black MSM.
Attempts to change sexual behavior (our most primal behavior) face a daunting challenge. The history of the AIDS epidemic and the many prevention efforts of the last 30 years illustrate how difficult that challenge can be.
Stephen Karpiak is senior director for research at ACRIA.