What are Black Men’s HIV Prevention Needs?
Who are Black men?
In the U.S., Black men include different ethnic groups from the African Diaspora. They are friends and diverse family members: fathers, grandfathers, husbands, partners, brothers, uncles, sons, nephews, and cousins. They are colleagues working in professional and blue-collar jobs. They also represent different sexual orientations, have diverse spiritual and religious beliefs, and speak different languages, among having other demographic differences.
Why is HIV a concern among Black men?
HIV is a health emergency among Black men of every age and sexual orientation. In 2017, 32% of HIV infections diagnosed in the U.S. were among Black men. They were diagnosed eight times more than white men and two times more than Hispanic men (1). One in every 22 Black men will be diagnosed with HIV in their lifetime. Among the general population of men, Black men have a higher risk of HIV, noted by the differences below that will continue if current trends are not reversed (2-4).
- Men who have sex with men (MSM): black (1 in 2); general MSM population (1 in 6)
- People Who Inject Drugs (PWID): black men (1 in 11); general male PWID population (1 in 42)
- Heterosexual men: black (1 in 97); general heterosexual male population (1 in 524)
Black MSM (BMSM)—including gay and bisexual men (same-gender-loving men )—are more likely than other MSM to be diagnosed with HIV (38% in 2017) (6). Young Black MSM (YBMSM) are most at risk (7). Seventy-five percent of all BMSM diagnosed with HIV in 2015 were ≤ age 34. Many studies have shown that BMSM’s engagement in condomless anal intercourse (CAI) and number of sexual partners are similar to or less than MSM of other race or ethnic groups. However, BMSM are more likely to be diagnosed with HIV. In one study, YBMSM were nine times more likely to be living with HIV than white participants with similar risks (9). The awareness of and demand for Pre-Exposure Prophylaxis (PrEP) – a proven biomedical intervention – is lower for BMSM than white MSM (WMSM) (13). In 2016, 68.7% of the PrEP prescriptions in the U.S. were to Whites, 13.1% to Latinos, and 11.2% to African Americans (14).
What are HIV risk factors for Black men?
Stigma and Discrimination – When Black men experience stigma or discrimination, they are less likely to use PrEP (15), disclose their HIV status (16), and are at higher risk for sexually transmitted infections (STIs, including HIV) (17). Moreover, discrimination-related traumas, based on being gay, black, or living with HIV, are associated with greater CAI (18). High HIV infection rates, racist attitudes of non-Black gay men, and social networks and environments where gay men gather have been found to stigmatize and isolate BMSM from other MSM (19). BMSMW (Black men who have sex with men and women) are even less likely than BMSM (only men) to know their serostatus and less likely to be engaged in care or be virally suppressed (20).
HIV Care Continuum Disparities – Poor retention of Black men in health care is deeply rooted in discriminatory practices of the medical system towards the Black community (21). Consequently, BMSM are less likely than white MSM to know their HIV status, more likely to be diagnosed later, and less likely to stay engaged in care and on treatment (22-23) (and be virally suppressed, with rates lowest for YBMSM ). In order to make effective use of the approach of treatment as prevention (TasP; 25), which means preventing HIV transmission by getting a critical mass of people living with HIV diagnosed and virally suppressed, there must be sufficient numbers of persons living with HIV who get diagnosed and treated (26-28).
Poverty – Discrimination and reduced access to and retention in quality education are reasons that Black men experience more unemployment or are underemployed, compared to white men (29). Consequently, Black men are more likely to be living in poverty, which usually means reduced access to quality health care, compared to white men (30). Rates of HIV increase 3.0 to 5.5 times with increasing neighborhood poverty level from < 10% (low poverty) to more than 30% (very high poverty level) (31-32). For Black individuals living with HIV, poverty is associated with lower levels of engagement in HIV care (33).
Sexual Trauma – Sexual abuse and assault rates are high among MSM and are related to greater risks of HIV infection. In the EXPLORE Study, 39% of MSM reported childhood sexual assault; Black participants were more likely to have a history of assault than no history of assault (34-35).
Sexually Transmitted Infections (STIs) – Having an STI can increase the chances of transmitting or becoming infected with HIV (36). STI disparities in the Black community increase the likelihood of transmission (37-38).
Social networks and sex with men of their race – The high HIV rate among BMSM and their preference for sex with MSM of their same race increase the chances of BMSM having a sexual partner that is living with HIV. A review of studies found that at least 29% of BMSM in networks having sexual contact were living with HIV and 47% of men living with HIV in these networks did not know their status (39).
What are not HIV risk factors for black MSM? - A review of the literature (40) has concluded that Black MSM engage in fewer HIV risk behaviors than other MSM. For example, Black MSM reported less UAI with primary male partners, few male sex partners, and less substance use during sex than other MSM. Risk factors such as poverty and STIs are more important drivers of HIV transmission among BMSM than individual risk behaviors.
What is being done?
Research findings for black men of diverse ages, sexual orientations, and HIV serostatus, discussed below, have been shown to reduce sexual risk behaviors and increase engagement in HIV care (41).
Randomized Comparison Group Interventions: Research on one tailored program shows promise for encouraging BMSM to initiate PrEP (42). Six interventions studied in a Randomized-Controlled Trial (RCT) setting, Many Men Many Voices (3MV)(43), Brothers to Brothers (44), Men of African American Legacy Empowerment Self (MAALES)(45), Being Responsible for Ourselves (BRO)(46), Unity in Diversity (UND)(47) and Harnessing Online Peer Education (HOPE)(48) report positive findings about reducing risky behaviors. The intervention nGage, designed to increase retention in care for YBMSM utilizing support confidants, found participants 3 times more likely to have had at least 3 provider visits over 12 months after the intervention (49).
Pre- Post-Test/Repeated Survey Interventions: Black MSM who participated in ‘d-up: Defend Yourself!’ (50), Connect with Pride (51), BRUTHAS (52), Motivational Interviewing (MI) (53), or (SPNS) (54) interventions report improved outcomes, compared to those with limited or no participation. Different studies also reported improvements in social support, self-esteem, and loneliness, as well as improved likelihood of HIV counseling and testing, return for test results, and fewer missed HIV medical visits. For one study, as the number of hours spent attending case management meetings increased, the time in HIV care increased. Finally, a community-level intervention utilizing the Popular Opinion Leader model, based on d-up! and adapted for YBMSM in the House Ball Community, Promoting Ovahness through Safer Sex Education (POSSE), saw declines for multiple sexual partners, TASP with any male partners, and with male partners of unknown HIV status (55).
Blended Pre- Post-Test and Control Group: Young MSM of color who participated in STYLE (Strength Through Youth Livin’ Empowered) reported 83% retention in care, and the chances of attending a clinic visit was greater for the STYLE participants than non-participants (2.58, 95% CI 1.34-4.98) (56).
What still needs to be done?
Prevention prioritizing Black men should not simply address high-risk sexual behaviors but also societal and structural issues. We need policies that will prevent new infections and add to our understanding of disparities, including structural interventions (57-58). We need to combine behavioral and biomedical interventions; abandon a “one size fits all” approach; address high STI rates, traumatic events and structural and access barriers; and, consider the intersection of health and social conditions. The need to address stigma must not be lost. Data must be presented with background, community perspective, and accurate explanation. HIV disclosure must include strategies to help partners and family members receive information that their loved one is gay or living with HIV. Broad implementation of successful interventions in areas where HIV is highest for Black men is necessary.
- CDC. HIV among Afr. Americans. September 2019 (https://www.cdc.gov/hiv/group/racialethnic/africanamericans/index.html).
- Gavett G. Timeline: 30 Yrs. of AIDS in Blk. Americans. KQED Frontline. Jul 10, 2012.
- Hess K, et al. Est. lifetime risk of dx of HIV infect in the U.S. CROI 2016. Boston, abstract 52.
- Hess, KL et al. Lifetime risk of a diagnosis of HIV infection in the United States. Ann Epidemiol. 2017 April; 27(4): 238–243.
- Truong N, et al. What is in a label? Multiple meanings of 'MSM' among same-gender-loving Black men in Mississippi. Glob Public Health. 2016 Aug-Sep;11(7-8):937-52.
- CDC. HIV and Gay and Bisexual Men. September 2019. https://www.cdc.gov/hiv/group/msm/index.html
- Mitsch A, et al. Age-associated trends in diagnosis and prevalence of infection with HIV among men who have sex with men – United States, 2008-2016. MMWR Mob Mortal Wkly Rep. Sep 2018; 67(37):1025-1031.
- CDC. HIV and African American Gay and Bisexual Men. September 2019. https://www.cdc.gov/hiv/group/msm/bmsm.html
- Millett GA, et al. Greater Risk for HIV Infect of Blk MSM: Lit Rev. AJPH. Jun 2006;96(6):1007-19.
- Millet GA, et al. Disparities in HIV Infect among Blk and Wht MSM: Meta-Analysis. AIDS. Oct 1 2007;21(15):2083-91.
- Magnus M, et al. Elevated HIV Prev. Despite Lower Rates of Sexual Risk Behav among Blk MSM in DC. AIDS Patient Care STDS. Oct 2010;24(10): 615–22.
- Maulsby C, et al. HIV among Blk MSM in the U.S.: Lit. Rev. AIDS and Behav Jan 2014;18(1):10-25.
- Cohen SE, et al. Response to race and PH impact potential of PrEP in the U.S. J Acquir Immune Defic Syndr. Sep 1 2015;70(1):e33-e35.
- Highleyman L. PrEP use rising in U.S. but large racial disparities remain. Jun 24, 2016. https://www.cdc.gov/mmwr/volumes/67/wr/mm6741a3.htm
- Chaill S, et al. Stigma, med mistrust, and racism affect PrEP awareness and uptake in Blk compared to Wht MSM in Jackson, MS and Boston, MA. AIDS Care, 2017.
- Overstreet NM, et al. Internalized stigma and HIV status disclosure among HIV-pos MSM. AIDS Care 2013;25 4, 466-471.
- Watson, RJ, et al. Risk and protective factors for sexual health outcomes among Black bisexual men in the US: Internalized hetersexism, sexual orientation disclosure, and religiosity. Archives of Sexual Behavior. Jan 2019; 48(1): 243-253.
- Fields EL, et al. Assoc. of Discrimination-Related Trauma with Sexual Risk among HIV-Pos Afr. Am. MSM. AJPH. May 2013;103(5):875-80.
- Raymond HF, et al. Racial Mixing and HIV Risk among MSM. AIDS Behav Aug 2009;13(4):630-37.
- Friedman, MR et al. HIV Care Continuum disparities among Black bisexual men and the mediating effect of psychosocial comorbidities. J Acquir Immune Defic Syndr. Apr 2018; 77(5):451-458.
- Eaton, L et al. Role of Stigma and Med Mistrust in Routine Hlth Care Engagement of MSM. AJPH. Feb 2015;105(2): e75–e82.
- Levy ME, et al. Understand Structural Barriers to Accessing HIV Test & Prev Servs among Blk MSM in the U.S. AIDS Behav. 2014 May; 18(5): 972–996.
- Christopoulos KA, et al. Linkage and Retention in HIV Care among MSM in the U.S. Clin Infect Dis. 2011 Jan 15; 52(Suppl 2): S214–S222.
- Singh S, et al. HIV Care Outcomes Among Men Who Have Sex With Men With Diagnosed HIV Infection - United States, 2015. MMWR Mob Mortal Wkly Rep. Sep 2017; 66(37):969-974.
- Centers for Disease Control and Prevention. HIV Treatment as Prevention. 2018; https://www.cdc.gov/hiv/risk/art/index.html. Accessed May 31, 2019.
- Cortopassi AC, Driver R, Eaton LA, Kalichman SC. A new era of HIV risk: it's not what you know, it's who you know (and how infectious). Annu Rev Psychol. 2019;70:673-701.
- Eaton LA, Matthews DD, Bukowski LA, et al. Elevated HIV prevalence and correlates of PrEP use among a community sample of Black men who have sex with men. J Acquir Immune Defic Syndr. 2018;79(3):339-346.
- Kalichman SC, Price D, Eaton LA, et al. Diminishing perceived threat of AIDS and increasing sexual risks of HIV among men who have sex with men, 1997-2015. Arch Sex Behav. 2017;46(4):895-902.
- Ethnic and Racial Minorities and SES. Factsheet. APA. http://www.apa.org/pi/ses/resources/publications/factsheet-erm.pdf
- Alameda Co. CA eHARS data (2008-2012). Verbal communication with Nina Murgai, Dir, HIV/AIDS Surv Unit.
- 29. Wiewel EW, et al. Assoc bwt Neighborhood Poverty and HIV Dx among Males and Females in NYC, 2010-2011. PH Rep. Mar-Apr 2016;131(2):290-302.
- Lechtenberg RJ, et al. Poverty, Race, Engagement: Diff Assoc with Retention in Care among PLWH in Alameda Co. UCSF CFAR HIV Hlth Disparities Symposium, Mar 24, 2017.
- Mimiaga MM, et al. Child Sexual Abuse Assoc with HIV Risk–Taking Behav and Infect among MSM in the EXPLORE Study. J Acquir Immune Defic Syndr. 2009 Jul 1:51(3):340-348.
- Millett GA, et al. Common roots: A contextual review of HIV epidemics in Black men who have sex with men across the African diaspora. Lancet. Jul 2012;380(9839):411-23.
- CDC. STDs and HIV – CDC Factsheet. Nov 17, 2015.
- CDC. 2015 STDs Surveillance – STDs in Racial and Ethnic Minorities. Jan 23, 2017.
- Scott HM, et al. Racial/ethnic and sexual behav disparities in rates of STIs, SF (1999-2008). BMC Pub Hlth. Jun 6, 2010;10:315.
- Pathela P, et al. MSM have higher risk for newly dx HIV and syphilis compared with heterosexual men in NYC. J Acquir Immune Defic Syndr. Dec 1, 2011;58(4):408-16.
- Hurt CB, et al. Invest Sexual Network of Blk MSM: Implications for Transmission and Prev of HIV Infect in U.S. J Acquir Immune Defic Syndr. Dec 2012;61(4):515-21.
- Maulsby C, et al. Rev of HIV Interv for Blk MSM. BMC Pub Hlth. 2013;13:625.
- Millett GA, Peterson JL, Flores SA, et al. Comparisons of disparities and risks of HIV infection in black and other men who have sex with men in Canada, UK, and USA: A meta-analysis. Lancet. 2012;380:341-348.
- Wheeler, DP, et al. Pre-exposure prophylaxis initiation and adherence among Black men who have sex with men (MSM) in three US cities: results from the HPTN 073 study. Journal of the International AIDS Society. 2019; 22: e25223.
- Stein R. Reduced sexual risk behaviors among young Men of color Who have Sex with Men: findings from the community-based organization behavioral outcomes of many Men, many voices (CBOP-3MV) project. Prev Sci. 2015;16(8):1147–58.
- Peterson JL, et al. Evaluation of an HIV risk reduction intervention among African-American homosexual and bisexual men. AIDS 1996, 10: 319 – 325.
- Harawa NT, et al. Efficacy of a culturally congruent HIV risk-reduction intervention for behaviorally bisexual black men: Results of a randomized trial. AIDS. 2013;27(12):1979–88.
- Jemmott III, JB, et al. On the efficacy and mediation of a One-on-One HIV risk-reduction intervention for African American Men Who have Sex with Men: a randomized controlled trial. AIDS Behav. 2015;9(7):1247–62.
- Tobin K, et al. Unity in diversity: results of a randomized clinical culturally tailored pilot HIV prevention intervention trial in Baltimore, Maryland, for African American Men Who have Sex with Men. Health Educ Behav. 2013;40(3):286–95.
- Young SD, et al. Social networking technologies as an emerging tool for HIV prevention: a cluster randomized trial. Ann Intern Med. 2013;159(5):318–24.
- Bouris A, et al. Project nGage: Results of a Randomized Controlled Trial of a dyadic network support intervention to retain Young Black Men who have Sex with Men in care. AIDS Behav. Dec 2017; 21(12): 3618-3629.
- Jones KT, et al. Evaluation of an HIV prevention intervention adapted for Black men who have sex with men. Am J Public Health. 2008, 98:1043–1050.
- Wu E, et al. Adaptation of a Couple-Based HIV Intervention for Methamphetamine-Involved African American Men who have Sex with Men. Open AIDS J. 2010, 4:123–131.
- Operario D, et: al. The Bruthas Project: evaluation of a community-based HIV prevention intervention for African American men who have sex with men and women. AIDS Educ Prev 2010, 22: 37–48.
- Parsons JT et al. A randomized controlled trial utilizing motivational interviewing to reduce HIV risk and drug use in young gay and bisexual men. J Consult Clin Psychol. Feb 2014; 82(1):9-18.
- Magnus M, et al. Characteristics associated with retention among African American and Latino adolescent HIV-positive men: results from the outreach, care, and prevention to engage HIV-seropositive young MSM of color special project of national significance initiative. J Acquir Immune Defic Syndr. 2010, 53:529–536.
- Hosek SG, Lemos D, Hotton AL, Isabel Fernandez M, Telander K, Footer D, Bell M. An HIV intervention tailored for black young men who have sex with men in the House Ball Community. AIDS Care. 2015;27(3):355–62.
- Hightow-Wiedman LB, et al. Keeping them in “STYLE”: finding, linking, and retaining young HIV-positive black and Latino men who have sex with men in care. AIDS Patient CARE STDS. Jan 2011: 25(1): 37-45.
- Peterson, JL, et al. Soc. discrimination and resiliency not assoc with differ in HIV infect in blk and wht MSM. JAIDS. 2014:66;538-543.
- Sullivan PS, et al. Understand racial HIV/STI disparities in blk and wht MSM. PLoS One. 2014;9: e90514.
Prepared by Bob Haas & Barbara Green-Ajufo, DrPH, MPH . Updated April 2020 by Beth Bourdeau, PhD, Wilson Vincent, PhD, MPH, Rob Newells, George Jackson, and Andrew Wilson, MPH.
Special thanks to the following reviewers of this Fact Sheet: Emily Arnold, Jesse Brooks, Lorenzo Hinojosa, Loren Jones, Micah Lubensky, Daryl Mangosing, Janet Myers, Nasheedah Bynes-Muhammad, Rob Newells, John Peterson, Greg Rebchook, Andrew Reynolds, and Wilson Vincent Reproduction of this text is encouraged; however, copies may not be sold, and the University of California San Francisco should be cited as the source. Fact Sheets are also available in Spanish. ©2020, University of CA. Comments and questions about this Fact Sheet may be e-mailed to [email protected]. This publication is a product of a Prevention Research Center and was supported by Cooperative Agreement Number 6U48DP006374-01-03 from the Centers for Disease Control and Prevention.
Tel-Me-Box: Validating and testing a novel, low cost, real-time monitoring device with hair level analysis among adherence-challenged patients
“Tel-Me-Box” is a small, low-cost, adherence monitoring device, developed by our team that transmits a wireless signal to a server when opened. Since it cannot assess actual drug ingestion, validation against a biological measure of adherence is crucial. The overarching hypothesis of this application is that adherence data captured by Tel-Me-Box will demonstrate strong relationships with an objective biomarker of adherence (i.e. hair concentrations of ARVs) and predict virologic suppression in treated HIV-infected individuals. We additionally hypothesize that tailored real-time adherence feedback via this device will improve adherence rates to HIV therapy for adherence-challenged patients in a pilot randomized clinical trial. This five-year study is being conducted in collaboration with our colleagues at St. John’s National Academy of Health Sciences in Bangalore and the Karnataka State government.
PIs: Maria L. Ekstrand PhD, Monica Gandhi MD, MPH
Co-Is: Sara Chandy MD, Rajani Shamsundar, MD
UCSF-based Project Staff: Elsa Heylen MA, Amanda Mazur MS
September 23, 2016 - July 31, 2021
Improving Mental Health through Integration with Primary Care in Rural Karnataka
The overall goal of this study is to improve screening, diagnoses and treatment of Common Mental Disorders among individuals with dual mental illness and cardiovascular disease diagnoses in rural South India. The multi-level intervention uses a collaborative care model that will be tested in a cluster RCT and includes low-cost, evidence-based sustainable strategies targeting multiple chronic diseases. This five-year study is being conducted in collaboration with our colleagues at St. John’s National Academy of Health Sciences in Bangalore and the Karnataka State government.
PIs: Maria L. Ekstrand PhD, Krishnamachari Srinivasan MD
Co-Is: Prem Mony MD, Denis Xavier MD, Mary Whooley MD
Project Staff: Elsa Heylen, Yasmin Williams, additional staff TBN
July 6, 2014 - April 30, 2019
Stigma as a barrier to cancer palliative care outcomes among people with HIV in India
Cancer incidence is rising among people living with HIV, as improved access to antiretroviral treatment has led to an increased life expectancy worldwide, including in India, thereby also increasing the need for palliative care services. While it is well known that HIV stigma acts as a barrier to engagement and retention in HIV care, we do not yet know how the additional stigma of cancer may compound this problem. The proposed study would meet this need by adapting our current India HIV stigma measures and African palliative outcome measures for use among people living with co-morbid HIV and cancer in India, and to adapt a novel evidence-based African intervention to improve access to effective palliation and end-of-life decisions throughout the care continuum in India. This is a two year study conducted in collaboration with our colleagues at Kasturba Medical College, Manipal.
PIs: Maria L. Ekstrand PhD, Naveen Salins MD
Consultant: Richard Harding PhD
UCSF-based Project Staff: Elsa Heylen MA, Amanda Mazur MS
Sep 13, 2018 - Aug 31, 2020
National Gay Men's HIV/AIDS Awareness Day – September 27, 2018 [booklet]
This brochure lists research focusing on HIV testing and helpful resources produced by CAPS/PRC. You might use it to:
- Stay up-to-date on research and learn what we found out from research
- Use the materials in trainings/presentations
- Advocate for services/funding
- Write grants
- Develop new or modify existing HIV prevention programs
- Evaluate current programs
- Connect with CAPS/PRC to develop new projects.
Lead researchers (PIs) are listed for each study. This brochure was prepared by the Community Engagement (CE) Core, previously known as the Technology and Information Exchange (TIE) Core: “Tying research and community together.”