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Black Men Who Have Sex with Men Have Higher HIV Rate despite Less Sexual Risk Behavior

Black men who have sex with men have a far higher rate of HIV infection than other racial/ethnic groups in Washington, DC, even though they have fewer male sex partners, have less unprotected anal sex, and use condoms more often, according to an analysis described in the October 2010 issue of AIDS Patient Care and STDs. The reasons for this disparity not fully understood, but another recent study suggests that negative community attitudes toward and secrecy about homosexuality may be a contributing factor.

Washington, DC, has among the highest levels of HIV prevalence (total infections) and incidence (new infections) in the U.S. But rates vary considerably across racial/ethnic groups. While an estimated 3.2% of the city's population as a whole is estimated to be living with HIV, this rises to 7.1% among black men. Nationwide, a2008 Centers for Disease Control and Prevention (CDC) analysis found that HIV prevalence among black men was about 6 times higher than that of white men.

Manya Magnus from George Washington University School of Public Health and Health Servicesand colleagues performed a study to assess HIV risk behaviors in a community-based sample of men who have sex with men (MSM) in DC.

Data were compiled from the National HIV Behavioral Surveillance system. MSM age 18 and older were recruited using venue-based sampling between July 2008 and December 2008. A total of 500 men were included, approximately one-third (35.6%) of whom were black. Participants completed behavioral surveys and received rapid oral HIV screening using the OraQuick test, confirmed by Western blot if positive.

Results

• Out of all men tested, 14.1% were confirmed as being HIV positive.
• 41.8% of these men were previously unaware of their HIV status.
• Black men were significantly more likely than those of other racial/ethnic groups to be HIV positive:
  • Black men: 26.0%;
  • White men: 7.9%;
  • Latino/Hispanic, Asian, or other: 6.5%.
• Black men reported having fewer male sex partners than men of other groups.
• Fewer black men reported ever engaging in intentional unprotected anal sex.
• Black men more often reported using condoms when they last had anal sex.
• Black men were less likely than those of other groups to have been previously tested for HIV, to have health insurance, and to disclose having sex with men to healthcare providers.

"Despite significantly higher HIV/AIDS rates, black MSM in DC reported fewer sexual risks than non-black," the investigators concluded.

"These findings suggest that among black MSM, the primary risk of HIV infection results from non-traditional sexual risk factors, and may include barriers to disclosing MSM status and HIV testing," they continued. "There remains a critical need for more information regarding reasons for elevated HIV among black MSM in order to inform prevention programming."

Attitudes about Homosexuality

A study described in the December 1, 2010 Journal of Acquired Immune Deficiency Syndromes looked at attitudes toward sex between men, since stigma and reluctance to discussing homosexual behavior can contribute to increased likelihood of unsafe activities.

Sara Nelson Glick and Matthew Golden from the University of Washington and the public health department in Seattle-King County in Washington state analyzed race-specific trends in U.S. population attitudes toward homosexuality, reporting of male same-sex sexual behavior, and behaviors that might influence the relationship between stigma and HIV transmission among MSM.

The researchers used data from the General Social Survey, an annual cross-sectional survey of national attitudes about social issues that has included questions bout homosexuality since the early 1970s. This analysis included data from more than 30,800 white and black respondents through 2008.

The researchers found that nearly three-quarters (72.3%) of black respondents in 2008 said that homosexuality was "always wrong" -- a proportion largely unchanged since the 1970s. Among white respondents, in contrast, this figure fell from 70.8% in 1973 to 51.6% in 2008, with most of the change occurring since the early 1990s. As seen in a number of other studies, survey participants who personally knew someone who was gay were significantly less likely to have negative attitudes about homosexuality.

Even among men who reported same-sex sexual behavior, 57.1% of black respondents in 2008 said homosexuality was "always wrong," compared with 26.8% of whites. MSM who held unfavorable attitudes toward homosexuality were about half as likely as those with more favorable attitudes to report ever having been tested for HIV.

Based on these findings, the study authors wrote, "U.S. attitudes toward homosexuality are characterized by persistent racial differences, which may help explain disparities in HIV infection rates between black and white MSM."

The fact that MSM, like heterosexuals, preferentially choose sex partners from the same racial/ethnic group "further magnifies the population-level impact of what might otherwise be relatively small differences in behavior," they elaborated in their discussion.

Other research has shown that black people with HIV tend to learn their serostatus at a later stage of disease, meaning they start antiretroviral therapy with more advanced illness and may maintain a high viral load -- which increases the risk of HIV transmission -- for a longer period. The National Institutes of Health is starting a pilot program in Washington, DC, and the Bronx, New York, to study whether expanded testing and early treatment can help reduce the rate of new infections.

Investigator affiliations:

Magnus study: George Washington University School of Public Health and Health Services, Washington, DC; District of Columbia Department of Health, HIV/AIDS, Hepatitis, STD and Tuberculosis Administration, Washington, DC.

Glick and Golden study: Departments of Epidemiology and Medicine, University of Washington, Seattle, WA; HIV/STD Program, Public Health-Seattle and King County, Seattle, WA.

11/12/10

References

M Magnus, I Kuo, G Phillips, and others. Elevated HIV Prevalence Despite Lower Rates of Sexual Risk Behaviors Among Black Men in the District of Columbia Who Have Sex with Men. AIDS Patient Care and STDs 24(10): 615-622. October 2010.

SN Glick and MR Golden. Persistence of Racial Differences in Attitudes Toward Homosexuality in the United States. Journal of Acquired Immune Deficiency Syndromes 55(4): 516-523. December 1, 2010.