HIV among MSM

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, 2008–2011United 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

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 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

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 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 withincreased 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. CONSPIRACY Beliefs 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. 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

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

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

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

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

30. 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

31. 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.

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