An alarming 60 percent of black men who have sex with men in the United States will become infected with HIV by the age of 40, according to the latest research presented at the XIX International AIDS Conference in Washington, D.C.
The HIV Prevention Trials Network study (HPTN 061) involved 1,553 black men in six cities - Atlanta, Boston, Los Angeles, New York, San Francisco, and Washington - between 2009 and 2011.
It found that 2.8 percent of the study participants became infected with the virus each year, a rate almost half again that of white MSM, said Kenneth Mayer, the study co-chair and medical research director at Fenway Community Health in Boston.
"For younger black MSM, those under the age of 30, there was an HIV incidence rate of about 5.9 per year, or about three times the rate of white MSMs," said Sheldon D. Fields, assistant dean for clinical affairs and health policy at Florida International University. "These rates are comparable to [what is seen in] countries in sub-Saharan Africa that are hardest hit by the epidemic."
Almost all of the participants (97 percent) agreed to take an HIV test. More than half either did not know their HIV status or believed that they were negative when they entered the study, but in fact, 165 of those men (12 percent) were already infected but did not know it.
"Black MSM in America are more affected by HIV than any population in the developed world, it rivals the epidemic that we find in the developing world," said Phill Wilson, president of the Black AIDS Institute.
"Black gay and bisexual men account for only 1 in 500 Americans, but 1 in 4 new HIV infections," he said. "They are significantly less likely to be alive three years after being diagnosed with AIDS than are white or Latino MSMs."
Country's failure
The public face of the AIDS epidemic in the U.S. in the 1980s was of white gay men, "but from 1985 on there was a disproportionate impact in the African American community," said Cornelius Baker, a veteran AIDS advocate based in Washington. "We failed very early on to grapple as a country to wrestle with that disparity."
Baker said it is important to acknowledge the proactive steps that black gay men have taken to educate themselves and create a sense of community and support, often in the face of racism, AIDS phobia, and homophobia within the broader black community.
It has been difficult to financially sustain those efforts because of high rates of poverty within the black community that limit both financial support for organizations and access to health care, according to Baker.
An initial assumption was that black gay men must have been doing something different from other gay men that put them at higher risk for infection. But evidence over the years has shown that is simply not the case, said Gregorio Millett. He is a researcher with the Centers for Disease Control and Prevention and played a leading role in writing the national HIV/AIDS strategy for the United States, released in 2010 ( http://www.whitehouse.gov/sites/default/files/uploads/NHAS.pdf).
"They engage in comparable, if not less risky, behavior than other gay men," Millett said. Young black gay men in particular "are less likely to have amphetamine use, injection drug use, less likely to use drugs during sex, but they are still five times more likely to be HIV-positive and two-and-a-half times more likely to have an STD [sexually transmitted disease]."
"We need to refocus on the context," Millett said.
A leading factor is that the prevalence of HIV is higher among the pool of black gay men with whom they tend to have sex. Higher rates of poverty also mean that black gay men are less likely to be under medical care for their HIV.
"In terms of viral suppression, we are far less likely, at least 50 percent less likely, to be virally suppressed [below the level of detection] compared to white gay men," Millett said.
Each of these factors increases the likelihood of being exposed to the virus. It means that the same level of risky behavior for black gay men carries a greater risk of becoming infected than it would for other gay men.
Speakers also pointed out that it is important to understand the role that homophobia and discrimination play in the lives of black MSM. It often plays out on the "down low," particularly in the South where many black gay men from small towns and cities travel to party in Atlanta.
Atlanta is the epicenter of AIDS for black MSM. While other big city hospitals have closed their AIDS wards, Grady Memorial still fills 30-40 beds with patients suffering from opportunistic infections that are preventable if the patient is receiving medical care, said Carlos del Rio, an AIDS physician at Emory University. Often that care begins much later than it should.
Remedies
There is "an urgent need for bold action and leadership, not business as usual, at every level to reduce the epidemic among black MSM in America," said Wilson. He called for effective targeting of black MSM "with high impact prevention, to build sustainable community infrastructure."
It is important that "in the black gay male community people understand what PrEP is, how it works, and whom it is appropriate for," he said, referring to pre-exposure prophylaxis using the drug Truvada to prevent infection.
Fields added that a prevention study under development that he is co-chairing - HPTN 073 - will look at how to best use PrEP in combination with other prevention tools among black gay men.
Full implementation of the health reform under the Affordable Care Act will be "perhaps the biggest game changer" for black gay men, said Millett.
"It is going to help out enormously," he said.
High portions of black gay men do not have health insurance. The ACA provides coverage for persons making up to 133 percent of the federal poverty level, and has a floating scale of subsidies for persons with somewhat higher income.
Increasing access to health care will result in higher rates of testing for black gay men and linkage to care. That in turn will reduce the level of HIV viral load within the community and the likelihood that the virus will be passed on to another person.
However, those provisions of the ACA are not slated to take effect until January 2014. More importantly, they are dependent up states buying into and helping to pay for an expansion of state Medicaid programs. Many Republican and a few Democratic governors have been reluctant to take on that long-term financial responsibility.
Millett said the formula for distributing AIDS funding under the Ryan White program is shifting from one based upon the cumulative number of cases to one that uses the current HIV caseload. That should benefit the South where the epidemic struck later but continues to grow at a faster pace than in the rest of the country.
The CDC already has begun to shift prevention and testing support to target communities most at risk, particularly black MSM.
Shame, discrimination, homophobia, and poverty are important underlying structural factors that must be addressed, speakers said.
"If we are going to mobilize black gay men, maybe we need to mobilize across broader issues than just HIV, talking about poverty, talking about unemployment, talking about those structural factors," said Wilson.
A report from the Black AIDS Institute issued in July, the 76-page "Back of the Line: The State of AIDS among Black Gay Men in America 2012" ( http://www.blackaids.org/docs/back.pdf) documents the scope of the epidemic. Fields said they will be updating research priorities in light of new data presented at the conference.