The largest-ever cohort of black men who have sex with men
(MSM) recruited in the United States has found that, among those who were
initially HIV negative, 3 in every 100 acquired a new HIV infection within a
year. This incidence rate is comparable to those observed in the general
populations of sub-Saharan Africa countries that are hardest hit by the HIV
And in black gay men under the age of 30, the rate was even
– 6 in every 100 became HIV positive within a year.
These data, presented to the 19th International AIDS
Conference (AIDS 2012) in Washington DC on Monday, have come from HPTN 061, a
longitudinal study whose ultimate aim is to establish the feasibility and
acceptability of providing a ‘combination prevention’ package of interventions
for black gay men in the US.
It is well known that the American HIV epidemic is
concentrated in a series of geographic hotspots and population hotpots. Whereas
black men who have sex with men probably comprise less than 1% of the
population, they make up nearly a quarter of the new infections.
The researchers, led by Beryl Koblin, Darrell Wheeler and
Ken Mayer, recruited black gay men in six of the geographical hotspots – Atlanta, Boston, Los Angeles, New
York City, San Francisco and Washington DC. It’s important to note that the
recruitment criteria would have excluded some men with a lower risk of HIV
infection – those who did not report unprotected anal sex in the previous six
months could not take part.
A total of
1553 men were enrolled. Of these:
(11.2%) already knew that they were living with HIV.
(12.4% of those without a diagnosis already) received a new HIV diagnosis when they were tested upon entry to the
- 1168 (75.2%) were HIV negative at the beginning
of the study.
All men identified as Black, African American, Caribbean Black or multi-ethnic Black. All were
over 18, but 38% were under the age of 30. Just under half were college
educated, but only 35% had any sort of employment. In terms of sexual behaviour, 45% had female as well as male
incidence of new HIV infections was 2.8% (95% confidence interval 1.8-4.1%).
In other words, 2.8% of men acquired HIV during a year of follow-up.
aged 18 to 30, incidence was much higher at 5.9% (95% confidence interval 3.6-9.1%). This is a very different pattern to that found with white men who have
sex with men, who are more likely to be infected in their thirties.
was also particularly high in some other sub-groups:
- 6.0% in those who had a sexually transmitted
infection at baseline.
- 4.9% in those reporting unprotected receptive
- 4.3% in those identifying as gay or homosexual
(lower in those describing their sexuality in another way).
- 3.8% in those who only had male partners at
Commenting on his findings, Darrell Wheeler said, “We have
known that black MSM are affected by HIV at disproportionately higher rates
when compared to other MSM in the US, but the HPTN 061 HIV incidence rates
were extremely high. They make it very clear that we must urgently find and
implement ways to stem the spread of HIV among black gay men in this country,
and critically among young black gay men.”
At the same conference session, Ken Mayer presented data on
the factors associated with already having HIV on entry to HPTN 061, whether
previously diagnosed or not. Due to there being more men in these
circumstances, some statistically significant associations emerged here that
were not observed in relation to the new infections. The following figures come
from multivariate analyses.
Of note, there was a greater likelihood of a man already
knowing he had HIV if he was was unemployed (odds ratio 2.5).
In terms of men having undiagnosed HIV on entry to the
study, this was also more likely for unemployed men (odds ratio 2.4). In
comparison with men with an annual household income of over US$50,000, those with
less than $10,000 were more likely to have HIV (odds ratio 3.6), as were those with
an income between $10,000 and $50,000 (odds ratio 3.3).
“You might think the United States has it easy,” Phill
Wilson of the Black AIDS Institute had said earlier in a plenary speech.
Despite the country’s wealth and can-do spirit, too many Americans were
struggling with poverty, homelessness, addictions, marginalisation and stigma.
“We not only have the largest epidemic in the developed world, we have one of
the most complicated epidemics in the entire world,” he said.
And at the abstract session where the HPTN 061 data were
presented (alongside several other studies on related themes), some audience
members questioned researchers’ focus on the behavioural and the biological
when it appears that structural and socioeconomic factors may be behind black
MSM’s elevated risk. For example, Vickie Mays of the University of California
suggested that interventions that focus on job training skills should be
(For more on this topic, read The paradox of HIV in black MSM in the US – very high infection rates despite no more risky sex and more precautions.)