HIV Disparities and MSM of Color

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1 HIV Disparities and MSM of Color Gregorio A. Millett a Centers for Disease Control and Prevention The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention

2 Outline Epidemiological Overview HIV Risk vs. HIV Burden Behavioral Explanations for Greater Risk Structural Explanations for Greater Risk Biological Explanations for Greater Risk

3

4 Proportion of HIV Diagnoses Among Men Who Have Sex with Men, by Race/Ethnicity, Adults and Adolescents, states N=17,465 Asian/Pacific Islander, 1% Hispanic, 19% American Indian/Alaska Native, 1% White, not Hispanic, 41% Black, not Hispanic, 38%

5 (MMWR, 2008)

6 HIV Prevalence and Incidence Young Black and Latino MSM Initial dx of HIV among MSM ages Black 16% ; Latino 13%; White 9% (MMWR, 1/14/00) Age HIV Prevalence Impact Ages HIV Incidence: Black 4%, Latino 1.8%, White 2.4% (MMWR, 6/1/01) % % Ages HIV Incidence: Black 14.7%, Latino 3.5%, White 2.5%. (MMWR, 6/1/01) Median age 32 46%

7 Risk behavior = HIV infection

8 Non-Injection Drug Use NHBS, Race/ Ethnicity N Drug use (past 12 mos) % White Black Latino API American Indian/ Alaska Native 18 45

9 Sexual Risk Behavior, NHBS, Race/ Ethnicity N >1 male partner (past 12 mos) % Engaged in UAI (past 12 mos) % White Black Latino API American Indian/ Alaska Native

10 Young MSM (ages 15-22): Drug use past 6 months Substance Use Behavior % Black (n=814) % Latino (n=1042) % White (n=1259) Injection drug use * Needle sharing * Uppers/ speed * Powder cocaine * Crack cocaine * Nitrites/ poppers * (Harawa et al., 2004) *P<.05

11 Young MSM (ages 15-22): Sexual Risk Behavior Sexual behavior past 6 months % Black % Latino % White (n=814) (n=1042) (n=1259) Casual male sex partner * IDU male sex partner * HIV+ male sex partner * UAI 48-59* (Harawa et al., 2004) *P<.05

12 HIV Testing NHBS, Race/ Ethnicity No Never Tested % Tested >12 mos ago % Tested <12mos ago % White Black Latino API American Indian/ Alaska Native

13 AIDS Diagnosis 1 & 3 years after HIV diagnosis Race/ Ethnicity HIV Dx (%) No AIDS Dx 1 yr After HIV Dx (%) No AIDS Dx 3yrs After HIV Dx (%) White Black Latino (Hall, 2007)

14 Use of HIV Prevention Services & Programs NHBS, Free Condoms Individual Level Intervention Group Level Interventions Race/ethnicity No. % No. % No. % White, not Hispanic 3, Black, not Hispanic 1, Hispanic 2, Asian/Pacific Islander American Indian/Alaska Native Other/Unknown

15 Use of HIV Prevention Services & Programs NHBS, Free Condoms Individual Level Intervention Group Level Interventions Race/ethnicity No. % No. % No. % White, not Hispanic 3, Black, not Hispanic 1, Hispanic 2, Asian/Pacific Islander American Indian/Alaska Native Other/Unknown

16 Receipt of HIV Prevention Services YMS data (ages 23-29) Compared with White MSM Black and Latino MSM more likely to believe Differential HIV prevention experience services with were HIV prevention important services does not explain the higher HIV Black and Latino MSM more likely to test at prevalence among black and Hispanic MSM HDs and hospitals Black and Latino MSM equally likely to test at private MD Black and Latino MSM equally likely to test 5 or more times in their lifetime (Behel, 2008) N= 2424

17 Race/ Ethnicity STD Testing NHBS, No STD test (past 12 mos) % White Black Latino API American Indian/ Alaska Native

18 MSM Prevalence Monitoring Project Test positivity for gonorrhea, chlamydia, and HIV and seroreactivity to syphilis among men who have sex with men, by race/ethnicity, STD clinics, 2005 Median positivity White Black Hispanic Urethral gonorrhea Rectal gonorrhea Pharyngeal gonorrhea Urethral chlamydia HIV* Syphilis *Excludes persons previously known to be HIV-positive. Seroreactivity.

19 Bartholow, 2005 Bingham, 2003 Bingman, 2001 CDC, 2006 Denning, 2005 Doll, 1990 Harawa, 2004 Heckman, 1999 Linn, 1989 Mansergh, 2002 McKirnan, 1995 McKirnan, 2001 Peterson, 2001 Rhodes, 2006 Ruiz, 1998 Samuel, 1987 Xia, 2006 UAI overall (OR, 1.05, 95% CI, , k =17) Bingham, 2003 Doll, 1990 Easterbrook, 1993 Harawa, 2004 Heckman, 1999 Kramer, 1980 McKirnan, 2001 Samuel, 1987 Stokes, 1996a Xia, 2006 # partners overall Bingham, 2003 Chen, 2002 Easterbrook, 1993 Geisler, 2002 Heckman, 1999 Kim, 2003 MacKellar, 2001 McKirnan, 2001 Ostrow, 1999 Paz-Bailey, 2004 Rhodes, 2006 STD overall (OR, 0.64, 95% CI, , k =10) (OR, 1.64, 95% CI, , k =11) Odds Ratio (95% confidence interva Odds Ratio (95% confidence interval) (Millett, 2007)

20 Aggregated STD Data Across MSM Studies, Sexually transmitted diseases k OR (95% CI) STD ever ( ) STD current dx * ( ) STD, syphilis * ( ) STD, gonorrhea * ( ) STD, Hepatitis B * ( ) *P<.05 (Millett, 2007)

21 General drug use Alcohol Marijuana CDC, 2006 Easterbrook, 1993 Irwin, 2005 Rhodes, 2006 Thiede, 2003 Greenwood, 2001 Irwin, 2005 McNall, 1999 Irwin, 2005 Siegel, 2004 Sullivan, 1998 Injection drugs Amphetamines Cocaine Needle sharing Hallucinogens Bingham, 2003 Chu, 1992 Easterbrook, 1993 Harawa, 2004 Rietmeijer, 1998 Siegel, 2004 Sullivan, 1998 Drugs 1 associated with HIV infection: OR, 0.64 (CI, ); k= 27 ( 1 IDU, amphetamines, crack/cocaine, needle sharing, opiates, nitrites) Halkitis, 2005 Harawa, 2004 Irwin, 2005 Rhodes, 2006 Sullivan, 1998 Harawa, 2004 Irwin, 2005 McKirnan, 2001 Rhodes, 2006 Siegel, 2004 Sullivan, 1998 Easterbrook, 1993 Harawa, 2004 Samuel, 1987 Irwin, 2005 Rhodes, 2006 Sullivan, 1998 Nitrites Opiates Harawa, 2004 McKirnan, 2001 Rhodes, 2006 Sullivan, 1998 Irwin, 2005 Rhodes, 2006 (OR, 0.71, 95% CI, , k =41) (Millett, 2007) Odds Odds Ratio Ratio (95% (95% confidence interva interval)

22 Response bias? NO

23 Behavioral Explanations for Greater HIV Risk

24 HIV Prevalence and Proportion with Undiagnosed HIV Infection in MSM in 5 Cities NHBS, Characteristic Total Tested HIV Prevalence N (%) Undiagnosed HIV Infection N (%) Total (25) 217 (48) Age (14) (17) (29) (37) (31) (79) (70) (49) (30) (34) Race White Black Hispanic API NA/AN Multiracial/Other < <10 25 (21) (46) (17) (7) (29) (20) <10 13 (18) (67) (48) (29) (100) (52) (MMWR, 6/24/05)

25 Unrecognized HIV Infection and Young MSM Undiagnosed HIV infection among younger MSM Ages15-22: Black 91%; Latino 75%; White 75% Ages 23-29: Black 91%; Latino 64%; White 56% (MMWR, 2004; MacKellar et al., 2005) Among men with unrecognized infection, no differences by race in Delayed HIV testing Perceived risk for being HIV+ UAI (MacKellar et al., 2005)

26 Unrecognized HIV Infection Known positives engage in fewer sexual risk behaviors with HIV-negative or unknown status partners (Colfax et al., 2002) Persons with unrecognized infection account for as many as 2/3 of new infections in U.S. (Marks et al, 2006)

27 Greater Sexual Risk Among HIV+ Sexual behavior (past 3 mos) Unaware Black MSM HIV+ aware (N=489) % HIV+ unaware (N=110) % HIV- (N= 541) % Any UAI Any UIAI HIV+ partner Any UIAI HIV- partner Any UIAI Unknown status partner (Marks et al., 2009)

28 Greater Sexual Risk Among HIV+ Sexual behavior (past 3 mos) Unaware Latino MSM HIV+ aware (N=376) % HIV+ unaware (N=32) % HIV- (N=657) % Any UAI Any UIAI HIV+ partner Any UIAI HIV- partner Any UIAI Unknown status partner (Marks et al., 2009)

29 Serosorting Serosorting: Practice of having unprotected sex with partners of same (real or perceived) HIV status Possible that serosorting may have more serious consequences among different groups of MSM of color depending upon 1. Community HIV prevalence 2. Intraracial sexual mixing patterns 3. Rates of serodiscordant UAI

30 Comparison of Serosorting Between HIV- Negative Black MSM and Latino MSM Sexual behavior (past 3 mos) HIV- Latino MSM (N= 657) % UIAI with HIV- partner 24 HIV- Black MSM (N= 541) % URAI with HIV- partner 20 UIAI with Unknown Status partner URAI with Unknown Status partner 12 7 (Marks et al., 2009)

31 Comparison of Serosorting Between HIV- Negative Black MSM and Latino MSM Sexual behavior (past 3 mos) HIV- Latino MSM (N= 657) % HIV- Black MSM (N= 541) % UIAI with HIV- partner URAI with HIV- partner UIAI with Unknown Status partner URAI with Unknown Status partner (Marks et al., 2009)

32 Structural Explanations for Greater HIV Risk

33 The Influence of Sexual Networks Sexual mixing and HIV infection risk (Service, 1995) MSM of color Sex with older male partners (Bingham, 2003; Berry, 2007; Choi, 2003) Intraracial sexual mixing Black MSM (Bingham, 2003; CDC, 2003; Berry, 2007 ) API MSM (Choi, 2003) Concurrency- Black MSM fewer sex partners, but 3x > odds to have had concurrent partnerships (Bohl, 2009)

34 Partner Selection and HIV Risk (Raymond, 2009) Percent who agreed with I prefer to have sexual partners who are (Asian, Black, White, Latino)

35 Partner Selection and HIV Risk (Raymond, 2009) Percent who agreed with Having sex with a(n) (Asian, Black, White, Latino) partner has more risk of HIV infection

36 Gay Community Racism and API and Latino MSM API MSM and discrimination from White MSM (Paul, 2008) Differences in phenotype among Latino MSM and discrimination from gay community (Ibanez, 2009) Darker skin associated with higher scores on scale measuring perceived racism within gay community Indigenous Indian or African features each associated with higher scores on scale measuring perceived racism within gay community HIV rates greater among darker Latino MSM?

37 Discrimination and Sexual Risk Latino MSM Experience with discrimination associated with greater rates of sexual risk (Jarama, 2005) Homophobia, racism, poverty, psychological distress explained 19% of sexual risk (Diaz, 2004) API MSM Anti-immigrant discrimination experiences associated with UAI Conversations with friends or family about discrimination associated with lower rates of UAI (Yoshikawa, 2004) Black MSM No perceived discrimination low condom peer norms greater sexual risk (Jones, 2007) History of discrimination associated with greater sexual risk (Zamboni, 2006)

38 Biological Explanations for Greater HIV Risk

39 Immunogenetics and HIV Risk CCR5 base 32 allele Protective against HIV infection (Marmor, 2001; Stephenson, 2001) Slower disease progression (Huang, 1996; Michael, 1997) <.1% of non-whites (Martinson, 2000) Duffy Antigen Genetic mutation protects against malaria 40% greater risk of acquiring HIV Prevalence: 90% of Africans; 60% of African-Americans

40 Circumcision Rates in the United States Prevalence in general population White (81-88%) Black (65-73%) Latino (42-54%) (Xu, 2007; Laumann, 1997) Rates declining

41 Circumcision and HIV risk among MSM of color Published Studies Black MSM (U.S. & South Africa) Latino MSM (2 U.S., Peru/Ecuador) API MSM (Taiwan) SE Asian (UK) Issues: Cross-sectional, non-random samples, MC status self-report, HIV status self-report, perceived HIV status of sex partner(s)

42

43 Summary Greater disease burden among MSM of color (Black & Latino) despite comparable or less risk Possible contributors: Unrecognized HIV infection Partner concurrency Serosorting Partner characteristics Partner preferences/ Racism Immunogenetics Intervention implications?

44 Next Generation of HIV Prevention Interventions Cohort studies that capture contextual factors for greater risk Intervention studies that combine behavioral and biomedical intervention approaches HPTN 061 (Brothers study) Using social networks to recruit Black MSM ID men with undiagnosed HIV infection ID known positives who are not in care Use peer health navigators for HIV+ MSM Counseling and testing high risk negatives

45 Thank You Greg Millett (202)

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