Report examines rate
of HIV among SF black gay men
by Matthew S. Bajko
San Francisco's black community continues to decline at alarming rates as an increasing amount of African Americans move out of town. According to 2006 census estimates, there were only 51,000 African Americans living in San Francisco, accounting for just 7 percent of the city's population.
Yet African Americans accounted for 14 percent of the city's new HIV diagnoses last year, a rate that has remained stable for close to a decade. Black people living with HIV and AIDS last year totaled 2,146, or 14 percent of the total number of PWAs in San Francisco.
HIV researchers estimate African Americans comprise 8 percent of the city's more than 58,000 gay and bi men, about 4,439 in total. Whites are estimated to make up 65 percent of the total, at about 38,049 men who have sex with men.
Gay white men still account for the bulk of the city's HIV cases; last year 57 percent of new HIV diagnoses were among Caucasians. The number of whites living with HIV and AIDS in the city last year was 9,742, or 64 percent of the total number of PWAs.
Looked at by male AIDS incidence per 100,000 population, however, African American men surpassed whites in 1996 when Caucasian men fell from 600 AIDS cases to below 500 per 100,000 persons. Black men have remained above whites ever since, and in 1992 AIDS researchers noted a significantly higher prevalence of HIV in young African American gay and bi men.
But it was relatively recently that health department epidemiologists realized just how disproportionately AIDS was impacting the city's African American men.
"Much to our shame, we took this by surprise. We should have seen it coming," Dr. Willi McFarland, director of HIV/AIDS Statistics and Epidemiology at the San Francisco Department of Public Health, told the city's HIV Prevention Planning Council at its meeting January 10. "For more than a decade African American men have been disproportionately affected by HIV."
According to McFarland's estimates, 32 percent of African American MSM are HIV-positive in San Francisco, the largest prevalence rate of any ethnic group. It is estimated that 26 percent of white MSM have HIV, while for Latinos it is 23 percent and for Asians and Pacific Islanders it is 10 percent.
"Nearly one third of African American MSM have HIV. That rate of transmission is significantly high," said McFarland. "The question starts to arise why do we see such a discrepancy?"
Until now, the reasons for the discrepancy have puzzled HIV prevention leaders. Studies have failed to show any evidence that gay black men engaged in unprotected anal sex at higher rates than their peers. In fact, data in San Francisco suggests they have less partners and engage in less risky anal sex.
While the general population of African Americans in the city does have higher rates of sexually transmitted diseases, the same does not appear to be true for gay black men, said McFarland. While African American men have higher rates of chlamydia and gonorrhea than their counterparts, until last year they had lower rates of early syphilis, an STD that considerably raises a person's chances of contracting HIV.
Statistically speaking, McFarland said, "There is no outstanding evidence that one group has more STDs than the other."
In an effort to zero in on a reason for the high rates of HIV among black gay men, the council requested that McFarland tailor his annual presentation on the city's HIV endemic to look at the numbers specifically by race. In doing so, McFarland hit upon a possible explanation for why HIV seems so intractable in the black gay male population.
He suggested that the evidence points to black MSM having a closed sexual network that is allowing HIV to devastate the community. According to McFarland's report, African American MSM are 3.2 times more likely to have an African American sexual partner than would be expected if there were no preference.
"We don't know why these networks exist," said McFarland.
Another potential key driver of HIV rates among black men may be data showing African American MSM have partners 10 years older than them at twice the level of white MSM. One recent national study found that older black MSM are less likely to use condoms.
McFarland said based on those data, a picture emerges within the city's black MSM community where HIV infection becomes circular, meaning it is continually being passed down from one generation to the next.
"It is highly likely that HIV infection gets into that network at a very high rate and is sustained at a high rate," he said. "It is similar to Africa, where older men infect younger women. It is a vicious cycle and we may be seeing this in the African American MSM population in San Francisco."
However, at least one HPPC member questioned McFarland's findings. Jonathan Batiste, coordinator of the Black Coalition on AIDS' Black Spectrum program, said the data does not reflect what he sees happening among his clients. And he cautioned that the condom usage among older black MSM was a national study and may not reflect the behaviors of San Francisco's older black male population.
"With the black men I am talking to, it isn't my personal experience that most black men date other black men," said Batiste.
He questioned if the problem may lie with the black community's homophobia keeping African American MSM in the closet.
"Not having a strong gay identity makes you more likely to contract HIV," he said. "You don't have the information you need or a support network."
Another potential reason for the high HIV rates among gay African American men is data showing that the majority of black MSM in San Francisco who are HIV-positive do not know their HIV status. For all other ethnic groups, the reverse is true, the majority of men with HIV know they are HIV-positive.
Why this is remains a mystery, said McFarland, considering black MSM get tested for HIV at similar rates as other MSM. Nonetheless, he said data shows a higher number of black men are unaware they are infected.
"It doesn't make sense why this is happening," he said.
Nor did McFarland have many suggestions for what HIV prevention methods the city should adopt to reduce HIV infections among black MSM.
"I've lost my confidence in knowing what needs to be done," admitted McFarland. "We can't decree things like only have sex with your own race or your own age. So how can you react to this?"
Prior to McFarland's presentation to the council, HIV prevention director Dr. Grant Colfax, who has been on the job four months, laid out what his priorities will be this year. One statistic he zeroed in on is that by the time an African American MSM turns 60 years old in San Francisco, he has an 80 percent chance of being HIV-positive.
"Health disparities are very much there. How do we reach various communities?" asked Colfax.
He said he plans to go out to various sections of town and hold meetings over the next year with different communities impacted by HIV to hear what they would like to see the city do in terms of HIV prevention.
"As the new director the questions for me are do we need to change, and if so, what do we change?"