HIV prevention among African American MSM: the U.S. Context Darrell P. Wheeler, PHD, MPH Dean & Professor Loyola University Chicago

“Poverty may be the most important risk factor for HIV infection among heterosexuals living in urban areas.” “People of color are disproportionately affected by HIV/AIDS because they are more likely to be poor and not because of their race or ethnicity.” “People living in high-poverty neighborhoods face a number of other challenges as well, including high rates of violence, social isolation, poor infrastructure, high levels of incarceration, and a lack of HIV and sexual health literacy, all of which contribute to the epidemic in distinct and overlapping ways. An inability to meet basic health and nutritional needs worsens HIV, increasing the risk of contracting other infections and hastening the onset of full- blown AIDS. And as viral loads increase from lack of access to care, so does the risk of infection to sexual partners, thereby further fueling the epidemic.” Drivers of HIV epidemics in United States Source: Center for American Progress

HIV epidemic drivers among US Black MSM Younger age at first sexual encounter Sexual abuse during childhood Older sex partners

Drivers – Conceptual Approaches Individual/Behavioral – Internalized homophobia, stigma and “flawed personal character” – AIDS awareness & knowledge – HIV fatigue, fatalism or adaptive responses – Trauma Sexual, physical & emotional – Mental health & illness – Other Sexually Transmitted Infections – Gender identity and identifications – Substance Use and Abuse

Drivers – Conceptual Approaches Interpersonal - – Partner selection (demographic by race, age and/or geography) – Sero-sorting – Inter Partner Violence Physical and virtual Networks Locale (urban, suburban, non-urban, rural) HIV+ Reservoir Internet “House ball” Circuit Parties Transgender Social Exchange – Housing, food and money

Drivers – Conceptual Approaches External, systemic, structural and environmental – Economics – Racism – Criminalization of SGL – Incarceration – Homophobia and Heterosexism – Stigma – Housing and Community Deprivation

Given this context what do we do to improve HIV outcomes for BMSM- the cultural analysis Attending to who is telling the story of the BMSM What questions are being asked; What tools & methods are being used; Positionality of the researcher to the research. Address resilience as well as pathology. Human Rights, Civil Rights and race in the U.S. - the myth of a post racial society! Including a critical analysis of the presumptive neutrality of race categories.

Given this context what do we do to increase activism by BMSM- the cultural analysis Recognition that what it takes to activate a response may not be the same things it takes to sustain the activism. Must address hierarchy of human needs and not just HIV prevention. Must recognize that all barriers are not benevolent or circumstantial. Must address the tendency to of “essentialize” groups to one category can be self defeating

HPTN061: The Brothers Study To determine the feasibility and acceptability of a multi-component intervention for Black MSM, including peer health system navigation Study data collected between 7/2009 and 10/2010. Gave rise to the HPTN Scholars program to increase number of researchers from underrepresented racial and ethnic groups.

HPTN 061 & BMSM Structural, behavioral, and biological factors (e.g. unemployment, unprotected anal sex with multiple partners, and STDs) were associated with new infections among American BMSM Given the rates (2.8% overall; 6% for YMSM; 5% UAI) of HIV infection among BMSM, culturally-tailored programs that encourage repeated HIV/STD testing, engagement in care, and innovative prevention strategies addressing social and environmental factors are urgently needed to decrease further spread.

HPTN O73 Pre Exposure Prophylaxis (PrEP) Uptake and Adherence among Black Men who have Sex with Men (BMSM) in Three US Cities In protocol development –An open label demonstration study to assess the uptake, acceptability, safety, and feasibility of PrEP for Black men who have sex with men (BMSM) in three cities utilizing client-centered care coordination (C4) model.

Acknowledgements FHI360 Sponsored by NIAID, NIDA, NIMH under Cooperative Agreement # UM1 AI For those studies under HPTN I funding such as HPTN 035, HPTN 059, HPTN 027*, HPTN 046*, HPTN 057*, use Cooperative Agreement # U01 AI46749 * Also acknowledge NICHD