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 4.3-5.4 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.

8. New HIV Infections among MSM (2008-2011) CDC, 2014 From 2008-2011, HIV among MSM incidence increased – Among all age groups (except 35-44) – 26% among MSM 13-24 – 16% among MSM 25-34 – 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 Among youth in the United States – YMSM aged 13–19 make up 90% of male HIV cases Among young MSM – There were more new infections among young black MSM than among all other MSM groups combined.

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 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 15-22 (7 cities) 1994-1998 CDC investigations of HIV outbreaks among young black MSM North Carolina, 2003 Mississippi, 2006-2008 Milwaukee, 1999-2008 RaceHIV prevalence (%)HIV incidence (%) Black14%4% Latino6.9%1.8% White3.3%2.4%

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

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) HIV RISK

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

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

16. Sexually Transmitted Infections Syphilis rates – Across 27 states from 2005-2008, 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.

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. *P<.05 versus White MSM High levels of mistrust is associated with medication nonadherence among black men CONSPIRACY Beliefs

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. 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? Psychological Correlates

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 1.Highly assortative sexual mixing among negatives 2.Having a contact in social network approving of unsafe sex associated with UAI 3.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. Viral suppression Adapted from Gardner, CID, 2011 Undiagnosed HIV+ Diagnosed not in care In care and taking ART Diagnosed and in care Structural Barriers Across Treatment Cascade

30. Viral suppression Adapted from Gardner, CID, 2011 Undiagnosed HIV+ Diagnosed not in care In care and taking ART Diagnosed and in care No health insurance Health care providers missing diagnoses Testing/ care not co-located

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

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 2011. PLoS ONE 8(10): e76878. doi:10.1371/journal.pone.0076878 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;29:38-43. 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/hivwww.cdc.gov/hiv Black Gay Research Group (BGRG) www.thebgrg.org www.thebgrg.org National AIDS & Education Services for Minorities (NAESM) www.naesm.orgwww.naesm.org In the Meantime Men’s Group (inthemeantimemen.org) X-Homophobia Campaign.