by Bob Roehr
One of the great mysteries of HIV/AIDS is why black men who have sex with men (MSM) have a rate of HIV infection that is at least twice that of white men in the same population. Gregorio Millett conducted a meta-analysis of behavioral data looking for answers. The researcher at the Centers for Disease Control and Prevention (CDC) presented the data at the 2007 National HIV Prevention Conference in Atlanta in early December.
Millet found no significant differences in the individual sexual behavior of black and white MSM in studies conducted after 1990 that could explain the higher rate. “Among young MSM, those ages 15 to 29, African Americans were one-third less likely than whites to report engaging in unprotected anal intercourse.”
“In additional black MSM were 36 percent less likely to report as many sex partners as white MSM…and were significantly less likely to use drugs commonly associated with HIV infection, such as cocaine, injection drugs, and amphetamines.”
Blacks were 71 percent less likely to identify as gay and 58 percent less likely to disclose same-sex activity to others. “Each are associated with lower sexual risk behavior with male partners and a lower likelihood of being HIV-positive.”
However, black MSM were 60 percent more likely than whites to report unprotected anal intercourse in the 1980s. “The high prevalence of unprotected sex in the epidemic’s early years may have shaped the current epidemic by creating a high HIV background prevalence among black MSM,” said Millett. This likely has been maintained and reinforced by the tendency of persons to have sex within their own racial and geographic communities.
Black MSM were more than twice as likely to test positive for another sexually transmitted disease (STD), “which increases the likelihood of transmitting or acquiring HIV by as much as five times.” They also were half as likely to be on antiviral therapy, so their viral load was likely to be higher. The risk of transmission increases as viral load goes up.
In a separate study, Millett found that circumcision appears to offer no protective benefit to black or Latino MSM in the United States. That is contrary to what has been found in three studies of heterosexual men in Africa where circumcision was found to be protective. He said, “It is possible that the disproportionately higher prevalence of HIV in black and Latino MSM communities may offset any moderate protective effect that circumcision might afford.”
Serosorting and STDs
There is increasing evidence that HIV-positive men are practicing serosorting,– only having sex with others who are positive–and using that as the reasons for not practicing safer sex. While that may reduce the spread of new HIV infections, it also appears to be resulting in greater numbers of other STDs among those who bareback.
Kenneth Mayer reported on a group of 398 HIV-positive patients at Fenway Community Health in Boston. Their ages ranged from 21 to 70, with an average of 42; about two-thirds were on therapy and 58% had undetectable viral load. “Some 37% reported engaging in unprotected anal intercourse in the previous three months;” that rose to 41% with other persons known to be positive.
“About 8 percent of the men had a bacterial STD diagnosed within the previous 12 months; most of those cases were syphilis. Unprotected anal intercourse was associated with a four-fold increased risk for STD infections,” Mayer said. More than half of the men had used recreational drugs within the last three months. “Those who used methamphetamine were three times as likely to have a new STD, and be engaging in unprotected anal intercourse.”
Mark Stenger said Washington State has merged case report numbers for HIV and STDs. “From 1996 to 2005, among men who were known to be HIV-positive at the time they were diagnosed with gonorrhea, that case rate tripled from 921 to 2946 per 100,000. In contrast, in men presumed to be HIV-negative, we calculated a case rate of 76, which doubled to 130 per 100,000.” The rate is almost ten times higher among HIV-positive men.
Patient and doctor
A survey of 641 MSM taken at seven Black Pride events across the country found that 85 percent self-identified as gay or bisexual, said CDC researcher Andrew Voetsch. Only 55 percent of them were out to their healthcare provider; those under 25 and bisexual were significantly less likely to be out to their provider.
That is important because being out to your provider “is the strongest predictor of being offered an HIV test.” The survey showed that 65 percent of the men who were out were offered the test, but only 45 percent of those who were not out to their provider were offered it.
Wayne Steward, a researcher at the University of California San Francisco, found that a sense of fatalism on the part of healthcare providers affected how likely they were to offer prevention counseling to their HIV-positive patients. Fatalism “seems to modify the expression of a lot of other beliefs, making them more pronounced.”
“If the patient was MSM, they were encountering providers with significantly higher fatalism than patients who were not MSM.” When it came to race, he said, “Unlike almost everything else that I’ve ever seen, being African American actually protects when it comes to prevention counseling…There is more fatalism among providers seeing gay, white men.”
“If you are a white gay man, you have a lot of fatalism coming towards you and not a lot of counseling. If you are a black gay men, you don’t get as much counseling as say a black heterosexual women, but you get more counseling than if you were a white gay man.”
Steward does not believe it is the result of homophobia, “it’s more complicated than that.” He speculated that it might be tied up with the rhetoric, “gay men should know better,” though he said more study is needed.