Dataset Information

Understanding the HIV disparities between black and white men who have sex with men in the USA using the HIV care continuum: a modeling study.

ABSTRACT:

Background

Black/white disparities in HIV incidence and prevalence among men who have sex with men (MSM) in the United States remain largely unexplained. We examined the impact on HIV prevalence and incidence of interventions that decrease disparities in HIV care. Deciding which interventions have most impact on reducing disparities is critical.

Methods

Using available US Centers for Disease Control and Prevention (CDC) estimates, we constructed HIV care continua for black and white MSM for 2009-2010. These estimates were used as parameters in a deterministic model to yield estimated race-specific transmissions, transmission rates, incidence rates, and rate-ratios (RR). We examined the impact of changes in the care continuum for black MSM on transmission and incidence rates.

Findings

Marked disparities were found throughout the care continuum: ultimately, 16% of black and 34% of white MSM achieved viral suppression. Based on these care continua, 9,833 and 9,710 new HIV transmissions were estimated annually respectively from HIV-positive black and white MSM (transmission RR=1·36 and incidence RR=7·92). In a model where black and white MSM have identical care outcomes, transmission RR=1·00 and incidence RR=5·80. Scenarios of 95% diagnosis, 95% retention, and concurrent 95% diagnosis and 95% retention respectively yield transmission RR=1·00, 1·02, 0·56, and incidence RR=5·81, 5·93, 3·28.

Interpretation

Disparities in HIV transmission rates may be reduced by improving the HIV care continuum outcomes, but existing racial disparities in HIV prevalence will likely continue to drive higher incidence among black MSM for decades to come.

SUBMITTER: Rosenberg ES

PROVIDER: S-EPMC4269168 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:BackgroundThe reasons for black/white disparities in HIV epidemics among men who have sex with men have puzzled researchers for decades. Understanding reasons for these disparities requires looking beyond individual-level behavioral risk to a more comprehensive framework.Methods and findingsFrom July 2010-December 2012, 803 men (454 black, 349 white) were recruited through venue-based and online sampling; consenting men were provided HIV and STI testing, completed a behavioral survey and a sex partner inventory, and provided place of residence for geocoding. HIV prevalence was higher among black (43%) versus white (13% MSM (prevalence ratio (PR) 3.3, 95% confidence interval (CI): 2.5-4.4). Among HIV-positive men, the median CD4 count was significantly lower for black (490 cells/µL) than white (577 cells/µL) MSM; there was no difference in the HIV RNA viral load by race. Black men were younger, more likely to be bisexual and unemployed, had less educational attainment, and reported fewer male sex partners, fewer unprotected anal sex partners, and less non-injection drug use. Black MSM were significantly more likely than white MSM to have rectal chlamydia and gonorrhea, were more likely to have racially concordant partnerships, more likely to have casual (one-time) partners, and less likely to discuss serostatus with partners. The census tracts where black MSM lived had higher rates of poverty and unemployment, and lower median income. They also had lower proportions of male-male households, lower male to female sex ratios, and lower HIV diagnosis rates.ConclusionsAmong black and white MSM in Atlanta, disparities in HIV and STI prevalence by race are comparable to those observed nationally. We identified differences between black and white MSM at the individual, dyadic/sexual network, and community levels. The reasons for black/white disparities in HIV prevalence in Atlanta are complex, and will likely require a multilevel framework to understand comprehensively.

Project description:BackgroundThe US HIV epidemic is driven by infections in men who have sex with men and characterized by profound disparities in HIV prevalence and outcomes for Black Americans. Black men who have sex with men living with HIV are reported to have worse care outcomes than other men who have sex with men, but the reasons for these health inequities are not clear. We planned a prospective observational cohort study to help understand the reasons for worse HIV care outcomes for Black versus White men who have sex with men in Atlanta.ObjectiveThe aim of this study is to identify individual, dyadic, network, neighborhood, and structural factors that explain disparities in HIV viral suppression between Black and White men who have sex with men living with HIV in Atlanta.MethodsBlack and White men who have sex with men living with HIV were enrolled in a prospective cohort study with in-person visits and viral suppression assessments at baseline, 12 months, and 24 months; additional surveys of care and risk behaviors at 3, 6, and 18 months; analysis of care received outside the study through public health reporting; and qualitative interviews for participants who experienced sentinel health events (eg, loss of viral suppression) during the study. The study is based on the Bronfenbrenner socioecological theoretical model.ResultsMen who have sex with men (n=400) were enrolled between June 2016 and June 2017 in Atlanta. Follow-up was completed in June 2019; final study retention was 80% at 24 months.ConclusionsHealth disparities for Black men who have sex with men are hypothesized to be driven by structural racism and barriers to care. Observational studies are important to document and quantify the specific factors within the socioecological framework that account for disparities in viral suppression. In the meantime, it is also critical to push for steps to improve access to care, including Medicaid expansion in Southern states, such as Georgia, which have not yet moved to expand Medicaid.International registered report identifier (irrid)DERR1-10.2196/21985.

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