Men who have sex with men (MSM) continue to bear the greatest burden of the HIV epidemic in the United States.1 According to recent Centers for Disease Control and Prevention (CDC) reports, MSM between 13 and 29 years old account for 38% of new HIV infections. Overall, MSM of all ages are 57% of new infections. Young black and Latino are disproportinately affected.2 MSM are the only group for whom HIV infection continues to increase.
The vast majority of HIV prevention interventions approved by the CDC are developed for heterosexual and injection-drug using (IDU) populations. In fact, only two of the CDC's evidence-based interventions (EBIs) are specific to African-American or Latino MSM. It is not surprising that the rate of new HIV infection is increasing in these risk groups.
Access to appropriate medical care and behavioral interventions to reduce transmission are critical for HIV-positive MSM. The CDC carried out a recent investigation that did not find racial or ethnic differences in access to HIV prevention services among young MSM.3 However, less is known about access to medical care following an HIV diagnosis. Previous CDC research also shows that unknown HIV infection is higher among African-American and Latino MSM compared to their white peers.4 Higher levels of unknown infection may result in fewer chances to access life saving medication. Another result of unknown HIV infection is the greater chance of transmitting HIV to others.5 The data presented below were collected in Los Angeles County in 2008. They highlight differences in HIV risk behaviors, as well as access to HIV prevention and care, among young versus older MSM, and among young African-American and Latino MSM versus young white MSM.
The CDC started the National HIV Behavioral Surveillance (NHBS) system in 2003.6 This system keeps an eye on behaviors known to spread HIV, surveying MSM, IDU, and heterosexuals living in areas with a high rate of AIDS. NHBS data collected during the recent 2008 MSM cycle known locally as the "LA Men's Survey," in Los Angeles County are presented here.7
The LA Men's Survey enrolled 538 MSM residents of Los Angeles County. All participants were offered an HIV test regardless of their current HIV status to obtain an unbiased estimate of HIV prevalence.
Participants ranged in age from 18 to 82 years old (average age 34.9). Participants were 35% Latino, 32% white, 18% African-American, 7% Asian or Pacific Islander, 3% multiple races, and 4% other. The study population reported a high level of education. Almost half were college educated (45%), 30% had attended some college, 20% had completed high school or a GED, and 5% had less than a high school diploma. Most (63%) were employed full time and another 13% were employed part time. Most (64%) earned over $30,000 annually and 66% reported having some form of health insurance. Almost all (91%) of the MSM (487 participants) consented to HIV testing during the interview. Almost one fifth, or 19% (93 participants), tested HIV positive.
Almost two-fifths (37%) of the study population were young MSM between 18 and 29. Social characteristics of young versus older MSM (30+) were similar with the exception of education level and health insurance coverage. Older MSM were more college educated than young MSM (50% versus 35%) and had more health insurance coverage (69% versus 61%). Differences across age groups were observed mainly in risky behaviors.
Young MSM were more likely to engage in binge drinking (5+ drinks in one sitting over the past 30 days) and use non-injection drugs including cocaine and ecstasy than older MSM. Older MSM were more likely to have ever engaged in injection drug use and to have used GHB.
HIV prevalence was calculated for the 91% of MSM who accepted an HIV test. HIV test results showed 10.6% of young MSM were HIV-positive compared to 24.5% of older MSM. Sixty percent of the HIV-positive young MSM (12 of 20) were not aware of their HIV status while 29% of HIV-positive older MSM (21 of 73) did not know their status.
Of the 68 MSM who knew they were HIV-positive before the survey, eight were young MSM. Of these eight young MSM, 88% had seen an HIV doctor in the past 12 months and 38% were currently on HIV medications. Of the 60 older MSM with an HIV diagnosis, 95% had seen an HIV doctor in the past 12 months and 73% were currently on HIV medications.
A number of social characteristics distinguish our sample of 18- to 29-year-old participants. Most were Latino (81 participants), followed by white (50 participants), and then African-American (41 participants). In general, African-American and Latino young MSM experience more money problems compared to white MSM. African-Americans and Latinos report having less education and greater poverty compared to whites, even though full-time employment was similar across all three groups. African-American and white MSM have greater health insurance coverage compared to Latino MSM. Incarceration is much higher among African-American MSM compared to other groups.
White MSM reported higher rates of unprotected anal sex than black and Latino MSM.
The study looked at some sexual risk behaviors reported in the past 12 months by race/ethnicity for young MSM. Young African-American MSM report more sex with females compared to the other groups. Compared to African-Americans and Latinos, white MSM reported greater rates of unprotected anal sex with male partners, but a lower rate of being high on drugs or alcohol during sex with their last male partner. African-American and Latino MSM reported having more anal sex with older partners compared to whites.
Only 6% of young MSM decided not to participate in the HIV-testing component of NHBS compared with the 12% of older MSM who refused. HIV prevalence was highest among African-Americans (21.1%), followed by Latinos (11.5%) and whites (4.2%). Unknown HIV infection was more common among African-Americans (6 of 8 were unaware) and Latinos (5 of 9 were unaware) compared to whites (2 of 2 knew they were HIV infected).
Other differences across race/ethnicity were observed in the young MSM's degree of gay identity and openness to others about their relationships with other men. In the sample young white MSM were most likely to identify as gay, be out to their families and health care providers, and feel more connected to the gay community followed by Latino and then African-American MSM. Young African-American MSM were more likely to identify as bisexual, followed by Latino and white MSM respectively.
Self-reported drug and alcohol use during the past 12 months was similar across race/ethnicity for young MSM. We did, however, see some drug preferences by racial/ ethnic groups. For example, crystal methamphetamine was used more frequently by Latinos, cocaine was more common among whites, and ecstasy was more common among African-Americans and whites.
There were some differences in young MSM's access to group-level interventions in LA County. One third of young African-American MSM (32%) had taken part in a group session to discuss HIV prevention, compared to 15% of Latinos and 4% of whites. Similar percentages of young MSM received free condoms in the past 12 months across race/ethnicity: 68% of African-Americans, 67% of Latinos, and 82% of whites. Exposure to one-on-one conversations with outreach workers -- not HIV counselors -- was reported by 20% of African-Americans, 10% of Latinos, and 16% of whites.
Twenty young MSM in our sample (ages 18-29 years) tested HIV positive. African-Americans are excessively represented among those with HIV. African-Americans make up only 18% of the study population of young MSM to the 35% Latino and 32% white. However, they represent 40% of HIV-positive young MSM, compared to whites (10%), Latinos (45%), and multi-racial men (5%). The following risk factors are indicative of HIV transmission among MSM in this sample: African-American race/ethnicity, earning less than $20,000/year, reporting a weak connection to the gay community, reporting anal sex with mostly African-American partners, ecstasy use in the past 12 months, and being arrested in the past 12 months.
HIV prevalence data presented here, especially among young African-American and Latino MSM, continues at levels seen in LA County since the mid 1990s. While African-American and Latino MSM do not report riskier sexual or drug-use behaviors than whites or other racial/ethnic groups, higher rates of HIV remain.
Within the population of 18- to 29-year-old MSM in LA, risk factors for HIV infection reflect characteristics of social and sexual networks rather than individual risk behaviors that are traditionally addressed in HIV prevention interventions. While anal sex without condoms and the use of drugs that correlate with unsafe decisions directly influence HIV risk, it is likely that other environmental and structural factors -- such as poverty, homophobia, and HIV stigma -- are the real drivers of the HIV epidemic among MSM in the United States.
Trista Bingham, M.P.H., Ph.D., is an epidemiologist with the Los Angeles County Department of Public Health who studies disparities in HIV prevention and care. To view references, go to www.gmhc.org/ti.html.
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Behel, S.K., et al. "HIV prevention services received at health care and HIV test providers by young men who have sex with men: an examination of racial disparities." Journal of Urban Health, 85(5), 727-743. (2008.)
MacKellar, D.A., et al. "Unrecognized HIV infection, risk behaviors, and perceptions of risk among young men who have sex with men: opportunities for advancing HIV prevention in the third decade of HIV/AIDS." Journal of Acquired Immune Deficiency Syndrome, 38(5), 603-614. (2005.)
Marks, G., et al. "Meta-analysis of high-risk sexual behavior in persons aware and unaware they are infected with HIV in the United States: implications for HIV prevention programs." Journal of Acquired Immune Deficiency Syndrome. 39(4), 446-453. (2005.)
Gallagher, K.M., et al. "Behavioral surveillance among people at risk for HIV infection in the U.S.: the National HIV Behavioral Surveillance System." Public Health Reports, 122 (1), 32-38. (2007.)
MacKellar, D.A., et al. "Surveillance of HIV risk and prevention behaviors of men who have sex with men -- a national application of venue-based, time-space sampling." Public Health Reports, 122 (1) 39-47. (2007.)
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