behavioural, economic and biological factors are all associated with increased
HIV risk for black men who have sex with men (MSM) in the United States,
according to the results of a study published in PLOS ONE. The research involved 1553 black men recruited in six US
cities. Men recently diagnosed with HIV were more likely than their
HIV-negative peers to be unemployed, to have sexually transmitted infections
(STIs) and to report unprotected receptive anal sex. Although not associated with
increased HIV risk, the results also showed that many men had symptoms of
depression and feelings of internalised homophobia.
enhances Black MSM’s disproportionate risk of HIV, by finding that those who
were unemployed and those with untreated STIs were more likely to have
undiagnosed HIV infection, raising the possibility that economically-related
non-engagement with the health care system may enhance the impact of biological
amplifiers of HIV transmission,” comment the authors.
Black MSM have a
higher HIV prevalence and incidence than any other sub-population in the US. Previous
research has shown that factors including drug use during sex, partner mixing,
STIs, poverty and homelessness each contribute to the high rates of HIV seen in
A team of
investigators wanted to see how these different factors interacted, and
designed a study comparing their prevalence among men newly diagnosed with HIV,
to the prevalence seen in men with existing HIV infection and in HIV-negative
Recruitment to the
study (HPTN 061, the "Brothers" study) took place between July 2009 and October
2010. Self-identifying adult black men who had had unprotected anal sex with at
least one man in the previous six months were eligible for participation. Recruitment
was directly from the community or via sexual networks.
screened for HIV and STIs on entry to the study. Data were gathered on age,
employment status and income. Participants were also interviewed about their sexual
behaviour and drug use. Validated scales were used to assess symptoms of
depression and internalised feelings of homophobia.
The men had a
median age of 40 years; 30% identified as exclusively gay or homosexual, 29% as
bisexual and 3% as transgender.
A total of 262 men
(16%) had a previous HIV diagnosis and 96 men (8%) were newly diagnosed with
Over half the men
(55%) had not had a college education, 69% were unemployed and 38% had an
income of less than $10,000 a year. Only 11% reported a regular partner.
Compared to men
who were HIV negative, men who were newly diagnosed with HIV were less likely
to be in employment (21 vs 35%, p = 0.01) and less likely to have a college
education (35 vs 46%, p = 0.04).
reported a median of five sexual partners in the past six months, and 82%
reported two or more male partners. Approximately half (51%) reported
unprotected receptive anal intercourse and 75% said they had had unprotected
insertive anal sex with a man. Overall, 44% of participants reported sex with a
female partner and 25% with a transgender partner. Approximately a third
reported transactional sex.
Men who were newly
diagnosed with HIV were more likely to report sex with partners of unknown HIV
status than men who were previously diagnosed (p = 0.0004) or HIV negative (p
diagnosed men were more likely than their HIV-negative peers to identify as gay
or homosexual (42 vs 26%, p =0.004), more likely to report unprotected
receptive anal intercourse (69 vs 47%, p < 0.001) and less likely to
report sex with a female partner (32 vs 49%, p = 0.002).
HIV-negative men also showed that individuals newly diagnosed with HIV were
more likely to have rectal gonorrhoea (5 vs 3%, p < 0.001), rectal
chlamydia (15 vs 6%, p < 0.001) and at least one STI (31 vs 14%, p <
0.001). Prevalence of STIs was also higher among newly diagnosed men compared
to men with previous HIV infection.
third (36%) of participants reported using stimulant drugs and 56% reported the
use of cannabis. Almost half (47%) said they had used drugs during their last
anal sex encounter. Depressive symptoms were present in 45% of men and 43% had
medium to high levels of internalised homophobia. Levels of substance use,
depression and internalised homophobia did not differ according to HIV
After taking into
account potential confounders, the investigators identified several factors
associated with recent HIV infection.
Compared to men
existing HIV infection, the newly diagnosed patients were younger (AOR = 2.9;
95% CI, 1.5-5.6). Comparison with HIV-negative men showed that recently
diagnosed individuals were more likely to be unemployed (AOR = 2.6; 95% CI, 1.4-4.6);
to have an STI (2.3; 95% CI: 1.4-4.0); to report unprotected receptive anal sex
(AOR = 2.3; 95% CI: 1.4-3.8); and to have at least one HIV-positive partner (AOR
= 3.8; 95% CI, 2.3-6.3).
receptive anal intercourse was the major mode of HIV transmission among the
men, studies on how best to promote sexual health among Black MSM are needed,”
conclude the authors. “Further research designed to develop prevention
interventions for Black MSM should also assess whether addressing socioeconomic,
behavioral and broader health concerns may lead to decreases in HIV incidence
in this heavily impacted population.”