1. HIV among MSM A focus on Black MSM and MSMW Nina T. Harawa, MPH, PhD
Associate Professor
UCLA / Charles Drew University

2. Brief Overview of HIV/AIDS Research with U.S. Black MSM
Greg Millett
OAR Workshop on HIV/AIDS in Black MSM
October 20, 2011

3. Talk Objectives Describe the Epidemiology of HIV in MSM populations
Discuss factors that heighten MSMs’ HIV risk above other groups’
Discuss factors that heighten Black MSM’s HIV risk and HIV burden above other MSMs’

4. Who are MSM? Diverse group.
May identify as gay, bisexual, heterosexual or with no label and be of any racial/ethnic background.
Estimated to be million in the US (~2%)
Term is based on history of sexual behavior with other men – used to separate behavior from identity from behavior, which is more relevant to risk.
Sometimes now MSM or MSMO are now used to refer to those who only have male partners.
MSMW is used for those with both male & (recent) female partners.

5. In 2011, among adults and adolescents diagnosed with HIV infection in the United States and 6 dependent areas, an estimated 62% of all diagnosed infections were attributed to male-to-male sexual contact. An estimated 18% of all diagnosed infections were attributed to heterosexual contact for females and 10% for males. An estimated 5% of all diagnosed infections were attributed to injection drug use for males and 3% for females. Approximately 3% of diagnosed infections were attributed to male-to-male sexual contact and injection drug use. Less than 1% of diagnosed infections were attributed to other transmission categories.
Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data are estimates. Estimated numbers resulted from statistical adjustment that accounted for reporting delays and missing transmission category, but not for incomplete reporting.
Heterosexual contact is with a person known to have, or to be at high risk for, HIV infection.
Other transmission categories include hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified.

6. This pie chart shows the percentage distribution of HIV infections diagnosed in 2011 among adult and adolescent men who have sex with men (MSM),* by race/ethnicity, in the United States and 6 dependent areas. Black/African American MSM accounted for approximately 38% of adult and adolescent MSM who were diagnosed with HIV infection. White MSM accounted for an estimated 34% and Hispanic/Latino MSM accounted for 24%. Asians and persons of multiple races each accounted for approximately 2% of diagnoses of HIV infection. American Indians/Alaska Natives and Native Hawaiians/other Pacific Islanders each accounted for less than 1% of diagnoses.
Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data are estimates. Estimated numbers resulted from statistical adjustment that accounted for reporting delays and missing transmission category, but not for incomplete reporting.
Data on men who have sex with men do not include men with HIV infection attributed to male-to-male sexual contact and injection drug use
Hispanics/Latinos can be of any race.

7. From 2008 through 2011, in the United States and 6 dependent areas, the largest estimated numbers of diagnoses of HIV infection were seen among MSM aged years. The number of diagnoses among MSM aged 25–34 increased 16% from 2008 through MSM aged 13–24 had the greatest percentage increase (26%) in diagnoses of HIV infection from 2008 through 2011, and exceeded the decreasing number of diagnoses among those aged 35–44 by 2010.
Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data are estimates. Estimated numbers resulted from statistical adjustment that accounted for reporting delays and missing transmission category, but not for incomplete reporting.
Data on men who have sex with men do not include men with HIV infection attributed to male-to-male sexual contact and injection drug use.

8. New HIV Infections among MSM (2008-2011)
CDC, 2014
Among youth in the United States
From , HIV among MSM incidence increased
YMSM aged 13–19 make up 90% of male HIV cases
Among all age groups (except 35-44)
26% among MSM 13-24
Among young MSM
16% among MSM 25-34
There were more new infections among young black MSM than among all other MSM groups combined.
23% among young black MSM
Among ALL new infections
Adolescents and young adults accounted for over a quarter of new infections in 2010
In 2011, 62% were attributed to MSM contact; including 77% of all male cases

9. Diagnoses of HIV Infection among Adolescents and Young Adults Aged 13–24 Years, by Race/Ethnicity, 2008–2011 United States and 6 Dependent Areas
During 2008 through 2011, blacks/African Americans accounted for more than 55% of diagnoses of HIV infection each year among adolescents and young adults aged 13 to 24 years in the United States and 6 dependent areas. In 2011, of persons aged 13 to 24 years diagnosed with HIV infection, 60% were black/African American, 18% were white, 19% were Hispanic/Latino, 2% were persons of multiple races, 1% each were Asian and American Indian/Alaska Native, and less than 1% were Native Hawaiian/other Pacific Islander.
The racial/ethnic distribution of diagnoses of HIV infection in persons aged 13 to 24 years differs substantially from the distribution of diagnoses among all adults and adolescents (aged 13 and over) in Among all adults and adolescents diagnosed with HIV infection in 2009, 45% were black/African American, 29% were white, 22% were Hispanic/Latino, 2% were Asian, 1% were of multiple races, and less than 1% each were American Indian/Alaska Native and Native Hawaiian/other Pacific Islander.
Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data are estimates. Estimated numbers resulted from statistical adjustment that accounted for reporting delays, but not for incomplete reporting.
Hispanics/Latinos can be of any race.
Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been statistically adjusted to account for reporting delays, but not for incomplete reporting.
a Hispanics/Latinos can be of any race.

10. HIV among Young Black MSM: An All Too Familiar Tale
Young Men’s Survey, 3492 MSM ages (7 cities)
CDC investigations of HIV outbreaks among young black MSM
North Carolina, 2003
Mississippi,
Milwaukee,
Race
HIV prevalence (%)
HIV incidence (%)
Black
14% 4%
Latino
6.9%
1.8%
White
3.3%
2.4%

11. HIV prevalence by selected regions and subgroups
Colfax, 2011 Adapted from: El-Sadr, et al., NEJM, 2010

12. Individual-level Factors Heightening Risk for MSM
More frequent anal sex
Higher numbers of partners than other men
Increased prevalence of some STDs – facilitates HIV acquisition and transmission
Substance use

13. Sexual behaviors and HIV Risk
Receptive anal sex (100)
Receptive vaginal sex (20)
Insertive anal sex (13)
Insertive vaginal sex (10)
Giving oral sex (2)
Receiving oral sex (1)
() = relative risk per unprotected
sexual encounter in serodiscordant couples
(MMWR, 2003)

14. Individual-Level Factors Heightening Risk in Black MSM
Undiagnosed infection greater among BMSM
Lower HIV treatment rates for HIV+ BMSM
Higher rates of STIs
Lower rates of participation in clinical trials
That said, there are some correlates of HIV risk and HIV related health outcomes that have been found to be particularly relevant for BMSM or YMSM of color and those are highlighted here.

15. The Role of Undiagnosed HIV Infection in Transmission Risk
HIV Prevalence
Data from NHBS – MSM in 20 US Cities & Puerto Rico
CDC, MMWR, 2010

16. Sexually Transmitted Infections
Syphilis rates
Across 27 states from , increase in syphilis rate 8x greater among black MSM compared to white MSM
Greater overall STIs among black MSM across studies
Current STD (OR 2.12 , 95%, 1.68–2.67)
Gonorrhea (OR, 1.53; 95% CI, 1.25–1.87)
Syphilis (OR, 2.14; 95% CI, 1.70–2.69)
Hepatitis B (OR, 2.48; 95% CI, 1.27–4.86)

17. Limitations of Individual-Level Risk
Research focus for past 30 years
Plurality of HIV/AIDS studies of MSM report
Sexual risk behaviors (# male sex partners, UAI, etc)
Drug use behaviors (IDU, poppers, meth, crack, etc)
Risk does not explain observed disparities in HIV infection (Harawa, 2004)
Can ignore context that influences behavior
Reinforces blaming the victim
Groups first affected by the epidemic.
Homophobia, stigma, and discrimination play an important but complex role.
No need to re-litigate

18. Psychological & Social Correlates
Depression associated with serodiscordant UAI
Prevention peer norms
Low peer norms associated with increased likelihood of
unprotected receptive anal intercourse (OR = 2.14; 95% CI = 1.32, 3.47)
unprotected insertive anal intercourse (OR = 1.90; 95% CI = 1.15, 3.14)

19. Discrimination Racial discrimination and homophobia
Black MSM with more integrated racial/ sexual identities report
Higher self-esteem
Greater HIV prevention self-efficacy
Greater social support
Greater life satisfaction
Con of studies examining homophobia and discrimination
Very weak associations (distal, no relationship, poor measures)
Endpoint generally UAI (not serodiscordant UAI, HIV incidence, or HIV testing)
Lack of interventions to address these issues
Timeliness of intervention effects

20. Discrimination
Belief that homosexuality is always wrong
Among blacks, proportion who indicated that homosexuality was "always wrong" was 72.3% in 2008 and largely unchanged since the 1970s
Declined among whites from 70.8% in 1973 to 51.6% in 2008
Racial differences among MSM and belief that homosexuality is always wrong
Twice as many black MSM reported that homosexuality is "always wrong" compared with white MSM (57.1% versus 26.8%, P = 0.003).
Association between belief homosexuality is always wrong and HIV testing
MSM with unfavorable attitudes toward homosexuality were less likely to report ever testing for HIV compared with MSM with more favorable attitudes
Examined link between social support and undiagnosed HIV infection among black and Latino MSM
Black and Latino MSM with less social support were more likely to be diagnosed with HIV infection
Black MSM who were more religious were more likely to have unrecognized infection (ByH, unpublished)
Intervention possibilities
Increase social support for black MSM
Address homophobia among black heterosexuals
Gap: No effective stigma interventions

21. HIV/AIDS Conspiracy Belief
CONSPIRACY Beliefs
HIV/AIDS Conspiracy Belief
Black MSM (n=239) %
Latino MSM (n=152)
White MSM (n=111)
Pharmaceutical companies hiding cure for HIV/AIDS because of profits
58*
50* 42
HIV/AIDS drugs harm you more than help you
56*
48* 41
HIV does not cause AIDS
54* 27
HIV is a man-made virus
41* 35
High levels of mistrust is associated with
medication nonadherence among black men
*P<.05 versus White MSM

22. Physical Abuse Intimate partner violence and black MSM
Association with HIV infection?
Childhood sexual abuse is associated with HIV infection in several studies of MSM
High rates of childhood sexual abuse reported by black MSM

23. Psychological Correlates
Possible intervention implications
Influencing peer norms
Utilizing trusted persons/ CBOs to disseminate information on HIV prevention
Utilizing health navigators for people who test positive
Short-term and effective interventions to address depression/ anxiety?

24. The Role of Networks
Characteristics of sex partners coupled with background prevalence influences transmission risk
Older partners
Black partners
Earlier sexual debut
Concurrency not associated with HIV infection
Concurrency does not explain greater risk
Black partners not a sufficient explanation for disparities
Black MSM couples engage in less risk than
other same race couples
interracial couples with one black partner

25. The Role of Networks Black MSM prefer black partners (Clerkin, 2011)
Other MSM prefer non-black partners (Raymond, 2009)

26. The Role of Networks
Drilling down on the influence of sexual and social networks among black MSM
Peterson, 2008: First descriptive study of HIV risk behaviors in network of black MSM
Oster, 2011: First phylogenetic analysis of HIV+ MSM to examine associations with demographics and transmission dynamics
Fuqua, 2011: Utilized networks to recruit black MSM for HIV testing
Latkin, 2011: Examined differences in networks of MSM and MSM/W, and examined serostatus disclosure
Schneider, 2011: Multiple findings
Highly assortative sexual mixing among negatives
Having a contact in social network approving of unsafe sex associated with UAI
Disassortative mixing among positives

27. The Role of Networks
Characteristics of sex partners coupled with background prevalence influences transmission risk
Older partners
Black partners
Earlier sexual debut
Disassortative mixing among positives
Serodiscordant sex HIV-positive black MSM (Eaton, 2010)
Serostatus nondisclosure with HIV-negative/unknown status
Serosorting protective for HIV-negative black MSM
BUT seroconversion likelihood greater than other MSM
Possible interventions
Increasing HIV status disclosure (given recent HIV testing)
Improving serosorting efficacy for HIV negative black MSM
Reducing serodiscordant sex HIV-positive black MSM

28. Structural Barriers
Definition: Physical, environmental or social structures, or laws or policies that affect HIV transmission risk.
Structural impediments
Poverty
Homelessness
Incarceration

29. Structural Barriers Across Treatment Cascade
Undiagnosed HIV+
Diagnosed
not in care
In care and
taking ART
Diagnosed and
in care
Viral suppression
Far way from HPTN 052
Adapted from Gardner, CID, 2011

30. Structural Barriers Across Treatment Cascade
No health insurance
Health care providers missing diagnoses
Undiagnosed HIV+
Diagnosed
not in care
In care and
taking ART
Testing/ care not co-located
Diagnosed and
in care
Viral suppression
Far way from HPTN 052
Adapted from Gardner, CID, 2011

31. Structural Barriers Across Treatment Cascade
No health insurance
Health care providers missing diagnoses
Undiagnosed HIV+
Diagnosed
not in care
In care and
taking ART
Testing/ care not co-located
Not receiving meds b/c of inadequate health insurance
Lack of culturally competent care
Diagnosed and
in care
Stigma assoc w/ taking meds
Suboptimal regimens/ side effects
Stigma
Viral suppression
Far way from HPTN 052
Adapted from Gardner, CID, 2011

34. Immunogenetics Increased HIV Susceptibility
CCR5 allele: acquisition and disease progression
HLA allele: racial differences in protective effect by HIV subtype
Duffy antigen: Protective effect for malaria among blacks, but increases risk for HIV infection
Barriers to Effective HIV Treatment
Antiretroviral treatment possibly less effective in black populations
Poorer response to HCV antiviral therapies with peginteferon and ribavirin due to Vitamin D deficiencies among blacks compared to non-blacks
Greater multidrug resistant HIV among
Black MSM
Black MSM sexual networks

35. Resilency Black MSM just as likely to utilize HIV prevention programs
Study show Black MSM engage in less or similar levels of sexual risk and less drug use
Most black MSM are not HIV-positive
Black MSM less likely to report adversity or homophobia

36. Additional References
Wejnert C, Le B, Rose CE, Oster AM, Smith AJ, et al. (2013) HIV Infection and Awareness among Men Who Have Sex with Men–20 Cities, United States, 2008 and PLoS ONE 8(10): e doi: /journal.pone
David Malebranche, MD, MPH slide set “HIV/AIDS in the African American Community”
RR data adapted from Varghese B, Maher JE, Peterman TA, et al. Reducing the risk of sexual transmission: quantifying the per-act risk for HIV infection based on choice of partner, sex act, and condom use. Sex Transm Dis 2002;29: and CDC, HRSA, NIH, & HIVMA. Incorporating HIV Prevention into the Medical Care of Persons Living with HIV. MMWR 2003;52:RR-12.

37. Additional Resources CDC: www.cdc.gov/hiv
Black Gay Research Group (BGRG)
National AIDS & Education Services for Minorities (NAESM)
In the Meantime Men’s Group (inthemeantimemen.org) X-Homophobia Campaign.