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.
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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.