HIV-Related Disparities AmongBlack MSM and Associations with

Structural Factors

Gregorio MillettCenters for Disease Control and Prevention

Washington, DCJuly 24, 2012

Series PapersMeta-Analysis 1

• Purpose:1. Explain HIV-related racial disparities

among US MSM• HIV-positive MSM • young MSM

2. Are there similar racial disparities among MSM in Canada, UK and US?

• Sample: – 106,148 black MSM and 581577 MSM of other

races/ethnicities– 174 US studies, 13 UK studies and 7 US studies

Meta-Analysis 2

• Purpose:1. Estimate HIV prevalence

• black MSM vs. general populations• black populations across the world

2. Assess HIV prevalence among black MSM by African and Caribbean countries that criminalize homosexual behavior

• Sample – 129,976 black MSM in North America,

Caribbean, Europe and Africa

HIV Prevalence Among Black MSM vs. General Black Populations Across Diaspora

HIV prevalence disparities among black MSM vs. general populations

• U.S. 72x more likely to be HIV+

• Canada 73X more likely to be HIV+

• UK111X more likely to be HIV+

HIV Risk Behavior & HIV InfectionBlack vs. Other MSM, U.S. & U.K.

Structural-Level Experiences &Resiliency, U.S. Black MSM vs. Other MSM

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HIV-Related Summary ORs by Rank– Black MSM vs. Other MSM

Partner characteristicsStructural inequalitiesHIV clinical outcomes

Sexual risk behaviorsDrug useNongay identityCircumcision

Diagnosed HIV+OR, 3.00 (2.06-4.40)

Undiagnosed HIVOR, 6.38 (4.33-9.39)

>200 CD4 cells/mm3 before

ART initiation OR, 0.40 (0.26-0.62)

ART adherenceOR, 0.50 (0.33-0.76)

HIV suppressionOR, 0.51 (0.31-0.83)

ART utilization/ accessOR, 0.56 (0.41-0.76)

HIV Detection

Viral Suppression

(Millett, 2012)

Disparities persist between black and other MSM throughout treatment cascade

Diagnosed HIV+OR, 3.00 (2.06-4.40)

Undiagnosed HIVOR, 6.38 (4.33-9.39)

Health insurancecoverage

OR,0.47 (0.29-0.77)

>200 CD4 cells/mm3 before

ART initiation OR, 0.40 (0.26-0.62)

ART adherenceOR, 0.50 (0.33-0.76)

HIV suppressionOR, 0.51 (0.31-0.83)

ART utilization/ accessOR, 0.56 (0.41-0.76)

HIV Detection

Viral Suppression

Healthcare visits

OR, 0.61 (0.42-0.90)

Lower income (<$20k)

OR, 3.42 (1.94-6.01)

(Millett, 2012)

Criminalization of Homosexuality & HIV Prevalence Disparities by Region

Overall sample• No difference in

– Serodiscordant sex– Perceived susceptibility/ tx optimism– Sex network variables (eg, concurrency,

same-race partners)

• Greater risk of serconversion even if engage in serosorting/strategic positioning

• Less– Sex during drug use– Poppers– Amphetamines– Any drugs associated with HIV

infection

Young Black vs. Other Young MSM• Less likely to engage in

– Any substance use– Amphetamine use– Injection drug use – Crack cocaine use– Sex during drug use

• Yet, more likely to have HIV (5x), STI (7x), undiagnosed HIV (45% greater likelihood)

• HIV-related factors for young black MSM– Young sex debut (65% greater)– Childhood sexual abuse (82% greater)– Older sex partners (52% greater)

Other Noteworthy Findings

• Black MSM – 8.5x more likely to be HIV+ vs. black populations

worldwide– 15x more likely to be HIV+ vs. general

populations

• Risk behavior does not explain HIV disparities in UK or US black MSM, and late ART access for black MSM in both countries

• Disparities greatest for structural, clinical, network variables associated with HIV infection

– Future interventions must focus here

• Black MSM 40% more likely to engage in any protective behavior, despite greater exposure to any structural barrier

• Criminalization of homosexual activity is associated with a 2-fold increase in HIV prevalence among black MSM across African and Caribbean countries— Association only statistically significant for

Caribbean countries

• Both reviews establish • Similar patterns in greater risk for HIUV

infection among black MSM across countries

• Addressing structural barriers is essential to eliminating disparities and achieving health equity for black MSM at higher risk for HIV infection worldwide and should be targeted for HIV prevention and care efforts

Summary

• John Peterson, USA• Stephen Flores, USA• William Jeffries, USA• Charles Heilig, USA• Trevor Hart, Canada• Tim Lane, USA• Robert Remis, Canada

• David Malebranche, USA• Sean Rourke, Canada• Patrick Wilson, USA• Jonathan Elford, UK• Kevin Fenton, USA• Riley Steiner, USA

Acknowledgments