Sounding the Alarm
Rates of HIV among black men who have sex with men in the US are skyrocketing, but what’s being done?
By Mary Rushton
Thirty-three years ago on June 5, US public health officials issued a brief but haunting report describing an unusual cluster of Pneumocystis carinii pneumonia among five, otherwise healthy men, described as “homosexuals” in Los Angeles, CA.
Since then, much has changed regarding the HIV epidemic in the US, but one thing has remained disturbingly the same—men who have sex with men (MSM) still bear the greatest burden of HIV/AIDS in this country, accounting for nearly two-thirds of all new HIV infections in the US in 2010, and nearly three-quarters of the infections that occurred among men, according to the US Centers for Disease Control and Prevention (CDC; HIV Surveillance Supplement Report 17, 4, 2011).
Moreover, the number of new infections among MSM rose every year from 2007-2010—evidence of a worrisome trend that runs counter to a declining HIV incidence among women and, notably, black women over the same time period.
These statistics are disconcerting enough, but there is another trend among black MSM in particular that has many researchers alarmed. While white MSM continue to represent the largest proportion of new HIV infections among MSM overall, and incidence is rising among MSM of all races (most rapidly among young MSM aged 13-24), the statistics among black MSM are even more dire. In 2012, black gay and bisexual men represented almost as many new HIV infections as white gay and bisexual men, despite significant differences in population size. According to the CDC, young, black MSM accounted for 45% of new HIV infections among black MSM overall, and 55% of new HIV infections among young MSM overall. This raging epidemic among black MSM has been borne out in many studies (see box, below).
But despite mounting evidence, the notion that epidemics might be different in sub-populations of MSM, and require different interventions, is remarkably still an understudied area, says Phill Wilson, president and chief executive officer of the Black AIDS Institute in Los Angeles.
“We have an unprecedented catastrophe among young black MSM,” says Wilson. “We need a massive effort to raise attention to the magnitude of the HIV problem among black men. You can’t put out a fire unless you sound the alarm.”
But precisely what that effort should entail and who should deliver it is unclear. It’s only within the last decade that surveillance experts have managed to deliver data that captures national HIV incidence from year to year, in this case using a serologic testing algorithm for recent HIV seroconversion (see A Static Epidemic, IAVI Report, May-June 2008). Prior to that, HIV surveillance registries were based on diagnoses that included a mixture of newer and older infections, making it difficult to pinpoint where and when new infections were occurring.
And before deciding how to combat the growing problem of HIV among young, black MSM, behavioral scientists and epidemiologists are exploring a litany of potential drivers that might explain the disproportionately high incidence among black MSM. Some of the key factors include higher poverty rates, complacency, higher rates of being uninsured or incarcerated, and less access to clinics and doctors who might provide referrals to care and treatment for other sexually transmitted diseases (STDs) that increase the risk of HIV infection. The high prevalence of HIV/AIDS in poorer urban neighborhoods across the US, where mere geography puts one at risk for acquiring HIV (see Why is HIV Ravaging DC?, IAVI Report, Nov.-Dec. 2010), could also be driving a rising incidence, as well as the sexual networks that tend to flourish in these economically disadvantaged enclaves. However, different studies point to multiple, and different, factors that are the root cause of the surging epidemic among black MSM.
Perhaps most intriguing is what doesn’t seem to be driving higher infection rates among black MSM. A meta-analysis of 600,000 MSM found black MSM are no more likely than other MSM to engage in serodiscordant, unprotected sex, yet are more likely to be HIV-infected (Lancet 380, 9839, 341, 2012).
This paradox, researchers found, could partly be explained by the low rates of ARV use among the HIV-infected partners of black MSM. Greg Millett, the CDC behavioral scientist who led this study, says HIV-infected black MSM in the US were less likely to have health insurance, a high CD4+ T-cell count, adhere to ARV treatment, or have their virus levels fully suppressed by ARV therapy. In other words, even if black MSM were having serodiscordant sex at the same rates as other MSM groups, the risk of acquiring HIV was greater because the viral loads of their infected partners were higher than those in other MSM groups. These low rates of successful treatment among black MSM are driving new HIV infections in black MSM networks and communities, Millett and colleagues concluded in The Lancet article.
Behavioral risk factors also could not explain racial disparities in HIV infection rates found in an earlier meta-analysis, also led by Millett, of 53 studies stretching from 1980-2006 that looked at unprotected anal intercourse. Black MSM reported less overall substance abuse, fewer sex partners, less gay identity, and less disclosure of same-sex behavior, compared to white MSM, and there were no statistically different differences by race in reports of unprotected anal intercourse, commercial sex work, sex with a known HIV-infected partner, or HIV testing history (AIDS 21, 2083, 2007).
Instead, this meta-analysis linked the high HIV infection rates in black MSM with higher rates of gonorrhea, syphilis, and other STDs; less ARV use and undiagnosed HIV infection; and high rates of unprotected anal intercourse (UAI) early in the epidemic. “Since black MSM tend to have sex with other black partners, greater rates of UAI early in the epidemic may have increased the background prevalence of HIV among black MSM, which has continued to rise to the disproportionately high HIV rates observed today in spite of comparable rates of UAI as white MSM since the 1990s,” the study’s authors suggest.
Indeed, the researchers who conducted the InvolveMENt Study (see box, below)—a multivariate analysis of HIV incidence among 562 black and white HIV-uninfected men from Atlanta—associated racial disparities in HIV incidence to a range of socioeconomic factors associated, with poverty and higher HIV prevalence of sexual networks, but found no significant differences in incarceration rates between white and black MSM. Black MSM in the study reported higher rates of homelessness, unemployment, and co-infection with other STDs, and lower rates of having health insurance (PLoS One, doi: 10.1371/journal.pone.0090514 2014).
Eli Rosenberg, an epidemiology professor at Emory University who led this study, says eliminating these structural determinants—particularly sexual networks and unemployment—would significantly reduce if not eliminate the racial disparities in HIV incidence. “Structural and community factors seem to be driving this,” says Rosenberg. “How we deal with it is the challenge.”
In HPTN061 (see box, below), co-infection with other STDs, having multiple sex partners, engaging in unprotected receptive anal intercourse with an HIV-infected partner, or having partners of unknown HIV status were the primary factors associated with a higher HIV risk. Geography also mattered. Living in Los Angeles, where 10 new HIV infections were diagnosed among the cohort, carried a much higher risk than living in Boston, where only one new infection was reported.
| Tracking HIV Among Black Men Who Have Sex With Men |
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The 2007-2010 surveillance report from the US Centers for Disease Control and Prevention (see main story) contains the most recent data on HIV incidence trends in the US among subgroups of men who have sex with men (MSM). But it is hardly the only evidence that HIV infection rates are higher among black MSM, and rising precipitously.
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However, factors that were linked with an increased risk of HIV in other studies were not associated with increased incidence in the HPTN061 cohort. Nor did the HPTN061 study team find an association between incarceration and increased risk of HIV infection. While 24% of the 1,278 black MSM included in the follow-up reported a new incarceration within a year after enrolling in the study, the study found no association between jail time and HIV incidence (J. Acquir. Immune Defic. Syndr. 65, 2, 218, 2014).
What about PrEP?
While there is an unprecedented amount of data emerging from the HPTN061 study team, which published nine studies in the past two years, as well as other studies that offer fresh insights into what is driving the rising incidence among black MSM, none of this research has translated into interventions that seem to be working to halt this alarming spread of HIV. One tool that clearly isn’t being utilized extensively enough by MSM, and black MSM in particular, is pre-exposure prophylaxis (PrEP), the administration of antiretroviral drugs to HIV-uninfected individuals prior to exposure to reduce the risk of infection.
Nearly two years ago, the US Food and Drug Administration granted the California-based pharmaceutical company Gilead Sciences a license to market the once-daily, two-ARV (tenofovir/emtricitabine) combo Truvada to high-risk HIV-uninfected adults after the drug was shown to reduce HIV infection among MSM by 42% (see FDA approves Truvada for use in PrEP, IAVI Report Blog, July 16, 2012). The CDC has been recommending PrEP for MSM since 2011.
Yet PrEP use outside the context of research studies is sparse, according to a survey conducted by Gilead that used nationally representative anonymous patient data from over half the retail pharmacies in the US. The survey found 1,774 men and women had been prescribed PrEP between January 2011 and March 2013. Gilead wasn’t able to break down PrEP use by race or transmission risk, but the drug maker did find that nearly half the PrEP prescriptions were for women, a group that accounts for only 20% of new infections. They also found PrEP use was less common in the young. Only 13% of those taking PrEP were under age 24.
“We think the numbers are artificially low, though,” says Gilead’s director of HIV medical affairs Keith Rawlings. “Don’t forget that thousands of MSM are already receiving PrEP through demonstration projects and as they roll off the studies many may continue [with PrEP],” Rawlings contends. There are over a dozen demonstration projects, pilot studies, and rollout studies looking at ways to make the delivery of PrEP feasible within MSM communities, including several that focus exclusively on black MSM and young MSM (see Preparing for PrEP, IAVI Report, Fall 2013).
But preliminary data from one of the earliest demonstration projects, known as The Demo Project, only managed to enroll a handful of black MSM at its study sites in San Francisco, Miami, and Washington, DC. Most of the 600 HIV-uninfected MSM and transgender women being offered a daily pill to protect them against HIV are white. Enrollment figures reported at the 21st Conference on Retroviruses and Opportunistic Infections, held earlier this year in Boston, showed 48% of enrollees were white, 35% were Latino, and only 8% were black.
These numbers are a stark contrast to the goal laid out in the Black AIDS Institute’s five-year action plan, which calls for a major initiative to deliver PrEP to black MSM and high-risk heterosexual women by 2015. Wilson acknowledges the goal is ambitious, but he also thinks it’s achievable. “This is a matter of investment and resources,” he says. “We have the tools in our hands. I think the problem is money and political will."
A federal response
The passage of the Affordable Care Act (ACA) in March 2010, which extended health coverage to millions of uninsured Americans, may also provide opportunities for expanding prevention and treatment services for people at risk of HIV, policy makers say.
The ACA got off to a rough start last fall when the website created to sign up millions of uninsured Americans kept crashing, turning the program into a punch line rather than a lifeline. But the rollout gradually improved and there are now over eight million people receiving health benefits under the ACA. Groups like the Black AIDS Institute have been promoting the benefits of the new law on their website and urging young men in particular to sign up for coverage.
Unfortunately, the new law continues to face stiff resistance from many lawmakers, which could make it difficult for some low-income individuals to access services under the new legislation. According to the Kaiser Family Foundation, about 45% of HIV-infected individuals live in states unwilling to use the ACA to expand their Medicaid programs for the poor, including many states from the South, a region disproportionately affected by HIV.
Implementation of the US’s first National HIV/AIDS Strategy four months after the ACA was enacted provides another opportunity to reduce the number of new HIV infections, increase access to care, improve health outcomes, and reduce HIV-related health disparities.
The White House recently appointed Douglas Brooks, a gay, black man living with HIV, to lead the Office of National AIDS Policy, the third person to hold this position in the past six years. Brooks, who grew up in Georgia and lives in Boston, has deep roots in AIDS advocacy. “Douglas’s policy expertise combined with his extensive experience working in the community makes him uniquely suited to the task of helping to achieve the goal of an AIDS-free generation, which is within our reach,” remarked US President Barack Obama when he made the appointment on March 25.
Jeff Crowley, who led the development of the National HIV/AIDS Strategy when he was the Obama Administration’s director of the Office of National AIDS Policy from 2009-2011 and is now program director of the National HIV/AIDS Initiative at the O’Neill Institute for National and Global Health Law at Georgetown Law School, says young gay men have distinct needs that have rarely been the focus of attention of health systems.
“We know that young gay men are less likely to be aware of their HIV status and less engaged in care,” says Crowley. “And they have less access to adequate health care services.”
Crowley recently co-authored a 29-page report published by the Trust for America’s Health that offers guidance on how to make the ACA more applicable for young, gay men. Crowley says state and local agencies also need to educate health care providers about the CDC’s testing recommendations for young gay men and to identify clinicians experienced in working with the lesbian, bisexual, gay, transgendered (LBGT) community. “Young people should be able to go to a medical provider where they feel safe and where they receive quality care.”
One program trying to raise awareness and reduce the risk of infection among MSM is Act Against AIDS, a CDC project that uses mass media to deliver HIV prevention messages. A major component of Act Against AIDS includes public-private partnerships with about a dozen organizations such as the Congressional Black Caucus Foundation, the National Association for the Advancement of Colored People, and a leadership initiative that focuses on organizations that exclusively target black and Latino MSM, including 100 Black Men of America and Black Men’s Xchange.
But Wilson is critical of these efforts. “There is not one [HIV] intervention developed by and for black MSM, almost no original work focused on the black MSM community. This is the definition of insanity.”
Testing, testing
More widespread HIV testing is something almost everyone agrees would help deliver prevention messages to black MSM. According to a CDC analysis of 16,069 MSM, HIV testing rates among MSM rose from 2008 to 2011, with an even greater increase among black MSM (see chart, below). The authors of the CDC analysis, who presented their data at CROI in March, say increasing the number of MSM who are tested and linked to care will improve health outcomes and may reduce further HIV transmission.
| Unadjusted HIV testing during the past 12 months among MSM, by race/ethnicity and year of interview—National HIV Behavioral Surveillance System, 2008 and 2011 |
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David Purcell, the deputy director for Behavioral & Social Science in CDC’s Division of HIV/AIDS Prevention, says the CDC is working with state and local health departments to identify and implement the most cost-effective and scalable interventions in the geographic areas hardest hit by HIV and among the most severely affected populations within those areas. The approach is referred to as High-Impact Prevention and he says it is one of the reasons why HIV testing rates are up among MSM, particularly black MSM.
CDC behavioral scientist Patrick Sullivan, in a special report about the HIV epidemic among MSM (Lancet 380, 9839, 388, 2012), says no single HIV prevention approach will be enough to curtail HIV incidence among MSM. But a combination of structural, biomedical, and behavioral interventions that are evidence-based might avert a quarter of new infections in certain countries.
Purcell agrees and says the fight requires action on every level. “Action is needed not only from government agencies, but also from community organizations, and among gay and bisexual men themselves, to ensure all men know their HIV status and take appropriate steps to stop HIV. More prevention strategies are available now than ever before.”
Mary Rushton is a freelance writer based in Cambridge, Massachusetts.