Racial Disparities in Antiretroviral Therapy Use and Viral Suppression among Sexually Active HIV-infected Men who have Sex with Men— United States, Medical Monitoring Project, 2009 Linda Beer PhD, Alexandra M. Oster MD, Christine L. Mattson PhD, and Jacek Skarbinski MD for the Medical Monitoring Project July 23, 2012 National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Division of HIV/AIDS Prevention

Background  In the U.S., black MSM (BMSM) are disproportionately likely to become HIV-infected  MSM account for 61% of new infections in the U.S  Blacks comprise 11% of the U.S. male population but 37% of new infections among MSM  Limited work on factors among HIV-infected MSM that may contribute to higher HIV incidence among BMSM  Not been assessed for a large, geographically diverse sample

 High-risk sexual behaviors increase the likelihood of HIV transmission  HIV viral load suppression decreases the likelihood of HIV transmission  BMSM tend to have sex partners of their same race  If HIV-infected BMSM engage in more sexual risk behavior or are less likely to be virally suppressed, this may contribute to higher incidence among BMSM Possible Contributors to Racial Disparities in HIV Infections Among U.S. MSM

Objectives  Are there differences between HIV-infected BMSM and WMSM in factors that increase HIV transmission risk?  Behavioral = sexual behavior  Clinical = ART use and viral suppression  Are there factors that can account for these differences?

Methods  Analysis of Medical Monitoring Project (MMP) data collected June May 2010  National supplemental HIV surveillance system  Monitors behavioral and clinical information on HIV-infected adults receiving care 16 U.S. states (including 6 separately funded cities) and one territory  Three-stage sample design States HIV care-providing facilities HIV-infected adults receiving care

Methods  Compared prevalence among HIV-infected BMSM and WMSM of  Sexual risk behaviors, past 12 months Unprotected anal sex with a negative or unknown HIV status partner Number of sexual partners  Current ART use  Viral suppression Most recent viral load undetectable or < 200 copies/ml Durable viral suppression: all viral loads in past 12 months undetectable or < 400 copies/ml  Persons included: black or white male MMP participants who had oral or anal sex with a man during the past year

Methods  For outcomes that differed between races, used multivariable logistic regression to identify factors that accounted for these differences  Included variables  Were associated with outcome at p <.10  Changed association between race and outcome by > 10%  Compared unadjusted and adjusted predicted prevalence of outcome  Accounted for clustering, unequal selection probabilities, and non-response

Results  Overall response rate = 41%  State/city = 100%  Facility = 76%  Patient = 53%  4217 participants from 461 HIV care facilities  314 BMSM and 696 WMSM met analysis inclusion criteria

Objectives  Are there differences between HIV-infected BMSM and WMSM in factors that increase HIV transmission risk?  Behavioral = sexual behavior  Clinical = ART use and viral suppression  Are there factors that can account for these differences?

Behavioral Factors Associated with HIV Transmission Among Sexually Active HIV-Infected Black and White MSM in Care, Past 12 Months – MMP, 2009 Black MSM (n=314) White MSM (n=696) Bivariate p value % Unprotected anal sex with a negative/unknown status partner Unprotected anal sex with a negative/unknown status partner while not durably virally suppressed Number of sex partners

Objectives  Are there differences between HIV-infected BMSM and WMSM in factors that increase HIV transmission risk?  Behavioral = sexual behavior  Clinical = ART use and viral suppression  Are there factors that can account for these differences?

Objectives  Are there differences between HIV-infected BMSM and WMSM in factors that increase HIV transmission risk?  Behavioral = sexual behavior  Clinical = ART use and viral suppression  Are there factors that can account for these differences?

Factors Associated with ART Use and Viral Suppression Considered for Model Inclusion Age Educational attainment At or below poverty level Homelessness Continuous health care coverage Last HIV care visit > 3 months ago Current depression Disease stage Time since HIV diagnosis

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Summary Are there differences between HIV-infected BMSM and WMSM in factors that increase HIV transmission risk?  Behavioral  No racial disparity in sexual risk behaviors among MSM.  Clinical  BMSM are less likely to be virally suppressed than WMSM, possibly contributing to high HIV incidence among BMSM

Summary What factors account for differences in viral suppression?  ART use  BMSM less likely to use ART  Sociodemographic factors  BMSM younger and more recently diagnosed  Social determinants of health  BMSM lower access to resources that support health (income, education, healthcare)  Other contributing factors  Adherence? ART regimen?

Limitations  Study population is limited to those in care, racial disparities in the entire HIV-infected MSM population are likely higher than those presented  Self-reported information may have led to measurement bias for some measures, although no reason to believe bias would vary by race

Conclusions  Among MSM receiving HIV care in the U.S., most are on ART and the majority are virally suppressed  However, over half of BMSM are not durably virally suppressed, and this may be contributing to disparities in incidence  To decrease racial disparities in incidence and improve the health of BMSM, need to increase proportion virally suppressed  Increase ART use  Address structural inequalities

Acknowledgments  MMP facility staff and patients  MMP Principal Investigators and Project Coordinators  MMP Provider Advisory Board and Community Advisory Board members  CDC Clinical Outcomes Team  Jeanne Bertolli, PhD

Thank you! Linda Beer 001–404– National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Division of HIV/AIDS Prevention