A study published in the journal The Lancet HIV reports that there is a significant disparity in HIV prevalence between black and white men who have sex with men. The study was published on Nov. 18 and found a startling 32 percent prevalence rate for black men who have sex with men, compared with only eight percent for white men who have sex with men.
The study also found a significant disparity along the continuum of care for HIV-positive persons. While 51 percent of white MSM are retained in care, the study found only 33 percent of black MSM were retained. Achieving viral suppression saw even greater disparities: just over one third of white MSM had achieved viral suppression compared with just 16 percent of black MSM. Viral suppression, or an undetectable viral load, indicates antiretroviral medication is controlling the activity of HIV and preventing a clinical decline in health. Studies have also indicated that viral suppression is an effective preventative measure in relation to HIV transmission as well.
The Michigan Department of Community Health says it is drilling down on state level data to drive program changes to address such disparities. “We are taking a closer look at the treatment cascade items along race/ethnicity, gender, HIV risk factor and age criteria for Ryan White eligible clients to assess health disparities, and this will be the focus of our upcoming RFP in early summer 2015,” says newly appointed MDCH Public Information Officer Jennifer Smith.
The department is also in the process of finalizing a new round of grants of “care coordination” for state AIDS Service Organizations.
“Ryan White federal funding, including funds utilizing ADAP rebate funding, must be directed toward people living with HIV who are eligible for Ryan White services,” Smith says. “In addition, this funding must demonstrate that clients are indeed becoming healthier and their viral load is suppressed. It is no longer enough for agencies receiving Ryan White or ADAP rebate funding to warmly hand off a client to a provider, or simply make a referral to care. It is the responsibility of any agency receiving Ryan White funding to ensure that clients have improved health outcomes.”
The new study confirms what MDCH has found in its own data analysis of Michigan HIV cases, Smith says.
“First let me say that that I find the information presented in the article distressing but not wholly surprising. We have known about disparate rates of HIV among black MSM for quite some time. Similarly, we have had research for at least the last seven years that indicates that black MSM have similar or less risky behaviors than white MSM, use condoms more consistently and generally have greater knowledge about HIV than white MSM. These things we have known for a while, and in this respect, Michigan and particularly Detroit (the epicenter of the epidemic) are no different,” says Hank Milbourne, chief program officer at AIDS Partnership Michigan.
“What we (the HIV community, HIV researchers, etc.) haven’t done a very good job at is telling these things to the community in ways that they can understand nor have we done a very good job of letting them know that it is because of the higher prevalence of HIV among black MSM that they are more likely to encounter and have sex with someone who is positive and probably doesn’t know their status,” he continued. “We haven’t made it known nearly wide enough that the margin of error for them is much smaller and their chances of acquiring HIV and other STDs is greater.”
Knowing this information, Milbourne says, lead the organization to change many of its policies. The organization has changed its messaging for HIV testing frequency – Milbourne says they now recommend testing every three months – as well as discussions about the prevalence pool of HIV, particularly for black MSM. In addition, for those who do test positive, they are immediately connected to care – even before there is a confirmatory antibody test done.
But getting better at addressing the HIV epidemic in Michigan in general and Detroit specifically is going to require attention to more complicated issues – not just the virus, but structural issues which impede access to testing, prevention options and even care.
“Retaining persons in care is a challenge unless there is also collateral work and resources dedicated that impacts the other contextual factors in a person’s life, i.e. employment, livable wage, stable housing, transportation etc.,” Milbourne says.
For Curtis Lipscomb, the study shows that HIV education programming has to be scaled up “right now,” and LGBT organizations have a significant role to play. “We have seen the dominate issue of marriage equality front and center in our movement. Although marriage is important to the stability of households, it is one of many issues we must organize around — such as poverty, housing and employment,” Lipscombe says. “The LGBT organizations must challenge significant racial disparities in HIV. To read that the prevalence will likely persist for decades due to an alarmingly high concentration of HIV in black gay men frightens me. It suggests a further disappearance of my population and the return of the 80s scare of homosexual men — a time when someone died daily and despair took over emotional wellbeing.”
“If black, gay and bi men continue to die disproportionately, matrimony will mean nothing. This impacts all of us,” Lipscombe continues. “How can we move together if one of our segmented community is disengaged? Marriage will then only become a luxury ‘for those that can afford it.'”
Milbourne agrees there needs to be a shift in focus, particularly from funding entities like MDCH. “Unfortunately, our work with high risk negative MSM (black or white) is not funded and is thus limited,” he says. “Additionally, we are just now beginning to figure how to incorporate the talk about PrEP (a once-a-day pill shown to be at least 92 percent effective in preventing an HIV-negative person from being infected) into our HIV testing encounters, because we realize we must, even though there is no standardized guidance from MDCH to do so. This is one of the prevention efforts mentioned by Greg Millett in his statement about scaling up prevention measures to HIV-negative black MSM. That requires resources to do. But this type of education must not be limited to HIV testing encounters but needs a more widely disseminated education campaign. Currently, the majority of our HIV prevention and care resources, as well as funding, are directed towards HIV positive persons.”