The proportion of newly diagnosed HIV-positive men who have sex with men (MSM) in the United States who were promptly linked to care and started antiretroviral therapy (ART) increased substantially between 2008 and 2014, investigators report in the online edition of the Journal of Infectious Diseases. But the research also revealed racial disparities in ART initiation rates, which in 2014 were 9% lower among black compared to white MSM.
“Blacks continue to be less likely to be prescribed ARV [antiretroviral] treatment,” comment the authors. An editorial notes that the differences in ART use “persisted even after controlling for other predictors of lower access, namely, less education, lower income and lack of health insurance.” Its author calls for further research to identify the reasons for this persisting difference.
MSM remain the group most affected by HIV in the United States. The National HIV/AIDS Strategy (NHAS), which was originally published in 2010 and updated in 2015, prioritised prevention and care for MSM, especially those in the Southern states.
The national strategy set two important targets: that 85% of people should be linked to HIV care within three months of diagnosis (one month in the 2015 update) and that the proportion of people starting ART should also increase.
Investigators wanted to see if NHAS targets were being achieved among MSM. They therefore monitored changes in rates of three-month linkage to care and ART initiation between 2008 and 2014.
The study population consisted of 1144 adult MSM in 2008, increasing to 1228 in 2011 and 1716 in 2014. Participants were recruited at treatment centres in 20 cities across the United States. Data were obtained on predictors of engagement with care, including age, level of education, health insurance, region and race.
The proportion of white MSM decreased by 14% between 2008 and 2014 whereas the proportion of black MSM increased by 13%. The proportion of people with health insurance increased from 75% to 86%.
Overall, the proportion of people linked to care within three months of diagnosis increased from 79% in 2008 to 87% in 2014 (prevalence ratio [PR] = 1.05; 95% CI, 1.03-1.07). The proportion of people linked to care increased by approximately 5% each three-year period, and the rate of increase was similar across subgroups. However, linkage to care was more likely among people with higher levels of education and health insurance.
The proportion of people linked to care within one month of diagnosis also increased, from 75% in 2008 to 78% in 2014 (PR = 1.04; 95% CI, 1.02-1.07).
Overall prevalence of ART increased from 69% in 2008 to 88% in 2014 (PR = 1.15; 95% CI, 1.12-1.18), a percentage change of 15% per three years.
In all years, higher rates of ART use were observed among white people, older age groups, better educated MSM and those with insurance. There were also regional disparities, with people in Southern states having the lowest level of ART use. But the association with region and poor ART uptake disappeared when the investigators took into account race. In 2014, black MSM were 9% less likely to be on ART compared to white MSM (83% vs 92%).
Although the proportion of uninsured men on ART has increased from 50% in 2008 to 70% in 2014, men with current health insurance remain more likely to be on ART. In 2014 90% of the currently insured were on ART. The authors note that men who live in the South are less likely to be insured because fewer Southern states have expanded Medicaid coverage under the Affordable Care Act.
“Our analysis demonstrated increases in linkage to care and ARV treatment among HIV-positive MSM,” conclude the authors. “Despite these increases, a large disparity in ARV provision between white and black MSM remains, particularly in the South, where the population density of black MSM is greater.”
The editorial offers several possible reasons for this enduring racial disparity, including substance and alcohol use, education, lower income, mental health, clandestine sexual orientation, stigma and community attitudes and lack of social support and networks.
Understanding the racial differences in ART use should be a research priority, says the author. Experience thus far suggests that the gap can be bridged using innovate programmes such as community outreach, peer educators and use of incentives.
“The issues involved are often as much societal as medical, as with access to housing and education, employment and adequate income, substance use and mental health services, and other social determinants of health,” concludes the author. “How health systems can be improved and linked to communities of need without addressing these overarching issues remains a massive challenge for investigators and implementers alike.”
Hoots BE et al. Updated data on linkage to human immunodeficiency virus care and antiretroviral treatment among men who have sex with men – 20 cities in the United States. J Infect Dis, online edition. DOI: 10.1093/infdis/jix007, 2017.
Vermund SH. The continuum of HIV care in the urban United States: black men who have sex with men (MSM) are less likely than white MSM to receive antiretroviral therapy. J Infect Dis, online edition. DOI: 10.1093/infdis/jix009, 2017.