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HIV Prevention among Black/African American Gay, Bisexual, and Other Men Who Have Sex with Men: Highlights of Activities of the Centers for Disease Control and Prevention

Guided by the National HIV/AIDS Strategy for the United States, the CDC and its partners are pursuing a high-impact prevention approach to reducing new HIV infections by using combinations of scientifically proven, cost-effective, and scalable interventions directed to the most vulnerable populations in the geographic areas where HIV prevalence is highest.

Factors Contributing to Increase in HIV Infections among Black MSM

Published research does not provide definitive answers about why new HIV infections among young, black/African American gay, bisexual, and other men who have sex with men (MSM) have increased. However, black/African American MSM of all ages experience racial disparities in health and are more likely than other gay and bisexual men of other races/ethnicities to encounter broader social and economic barriers [1]. These and other factors place black/African American MSM at higher risk for HIV.

  • Black/African American MSM and MSM of other races and ethnicities have an increased chance of being exposed to HIV because of the larger number of MSM living with HIV. This higher prevalence of HIV infection among MSM leads to a higher possibility of transmission, even with similar frequency of risk behaviors as other populations.
  • Many black/African American MSM with HIV, particularly young MSM, are unaware of their HIV infection [2]. Low awareness of HIV status among young MSM may reflect several factors: recent infection, underestimation of personal risk, fewer opportunities to get tested, or belief that HIV treatment minimizes their risk of acquiring or transmitting HIV [2 - 3 ]. Persons who do not know they have HIV do not get medical care and can unknowingly infect others.
  • Stigma, homophobia, and discrimination put MSM of all races and ethnicities at risk for multiple physical and mental health problems and affect whether MSM seek and obtain high-quality health services [4]. Negative attitudes about homosexuality (including complacency), discriminatory acts, and bullying and violence can  make it difficult for some MSM to be open about same-sex behaviors with others, which can increase stress, limit social support, and negatively affect health.
  • Sexual risk behaviors account for most HIV infections in MSM [5]. Unprotected receptive anal sex is the sexual behavior that carries the highest risk for HIV acquisition [6]. For sexually active MSM, the most effective ways to prevent HIV and many other sexually transmitted infections (STIs) such as syphilis, gonorrhea, and chlamydia, are to avoid unprotected anal sex and always use condoms [7]. The CDC recommends that all sexually active MSM be tested annually for these STIs [8]. Undiagnosed or untreated STIs may increase the risk of both acquiring and transmitting HIV.
  • Men aged 40 years and older are more likely to have HIV than men aged 18–39 [2]. Young black MSM are more likely to have older sex partners and therefore are more likely to encounter an HIV-positive partner. Thus, sexual relationships with older men may increase risk of exposure to HIV.

Highlights of CDC Program Activities

In fiscal year (FY) 2011, approximately 41percent of the CDC’s budget was targeted to HIV prevention activities for MSM. The CDC's approach to addressing the HIV epidemic among black/African American gay, bisexual, and other MSM involves three areas of commitment:

  • Engaging black/African American gay, bisexual, and other MSM communities and strategic partners;
  • Expanding effective prevention strategies and programs; and
  • Evaluating and disseminating information on strategies and programs.

HIV Prevention Communication

The CDC’s Testing Makes Us Stronger campaignandAct Against AIDS Leadership Initiative (AAALI) are two notable activities to address the epidemic among black/African American MSM. 

  • Testing Makes Us Stronger, focuses on increasing HIV testing among 18-to-44-year-old black/African American gay & bisexual men. The campaign’s messages emphasize that HIV testing is a source of strength, not a reason for fear.

National HIV/AIDS Awareness Days

Working together with state and local public health agencies, community-based organizations (CBOs), and other partners, CDC supports National Black HIV/AIDS Awareness Day and National Gay Men’s HIV/AIDS Awareness Day (NGMHAAD).These Awareness Days urge individuals to have open dialogue about HIV with partners, peers, and families.  

Surveillance and Research

The CDC is actively involved in providing information through surveillance and research to further understanding of HIV risk in affected populations.

  • The National HIV Behavioral Surveillance System (NHBS) has provided important findings on populations at risk of HIV infection. For example, in a recent publication from this system, the authors found that differences in HIV infection between black/African American and white MSM may be partially explained by less knowledge of partner HIV status and lower antiretroviral use among black MSM [9].
  • The Web-Based HIV Behavioral Surveillance System among MSM (WHBS) conducts an annual, national web-based behavioral survey among Internet-using MSM in the United States, including black/African American MSM. The objectives of the project are to describe HIV risk behaviors, HIV testing behaviors, and exposure to and use of HIV prevention services. After three years of data collection, the survey data will be used to conduct a trend analysis to assess changes over time in risk behaviors of Internet-using MSM.
  • In FY 2011, the CDC provided $11.6 million for the first year of the 3-year Enhanced Comprehensive HIV Prevention Planning (ECHPP) demonstration projects for the 12 U.S. cities with the highest number of people living with AIDS for enhanced program planning and coordination. Implementation plans are tailored to match the local epidemic to facilitate local activities that will have a greater chance of reaching MSM, and black/African American MSM in particular, for many services.
  • For the Latino and African American MSM Project (LAAMP), six sites were funded to evaluate the preliminary efficacy of newly developed behavioral interventions designed to reduce HIV acquisition and transmission among high-risk black/African American MSM and Hispanic/Latino MSM.

Expanding Effective HIV Prevention by Health Departments and Community-Based Organizations

Between 2009 and 2012, the CDC awarded over $360 million to state and local health departments across the United States to fund HIV prevention activities. In most places in the United States, this meant directing resources to populations where HIV is most concentrated, including among MSM and communities of color.

  • In 2009, supplemental funds were awarded to 51 health departments to either develop a prevention plan for MSM or enhance existing prevention programs for MSM.
  • In 2010, 51 state and city health departments were funded to 1) assess activities necessary to prevent HIV infection, including reducing STIs and drug use and increasing access to HIV care and prevention services; and 2) identify additional activities or enhancements to the current activities that could be implemented to further prevent HIV infection among MSM.
  • In 2011, 69 CBOs specifically serving black MSM were funded to conduct HIV prevention activities.

Reaching Gay, Bisexual, and Transgender Youth of Color

  • In FY 2011, the CDC awarded $55 million over 5 years to 34 CBOs to expand HIV prevention services for young gay and bisexual men of color, transgender youth of color, and their partners. The awards expand upon a previous program to reach these populations with an increase of $10 million to fund a larger number of CBOs.

Building Capacity to Address the HIV Prevention Needs of Racial/Ethnic Minorities and Other Individuals at High Risk for HIV Infection

  • In 2009, the CDC awarded $110 million over 4.5 years to 31 national and regional organizations that seek to build the capacity of the nation’s HIV prevention workforce, with a focus on capacity building for organizations serving racial and ethnic minorities and other persons at high risk for HIV infection. A significant number of these organizations focus on building the capacity of CBOs that serve black/African American MSM. In 2010, an additional $1.4 million was awarded to nine of these agencies to substantially increase services provided to, and community mobilization among, black/African American MSM.

Expanding Routine HIV Testing
The CDC recommends sexually active MSM be tested for HIV infection at least annually and that gay and bisexual men at high risk (i.e., those who have multiple or anonymous partners, who have sex in conjunction with illicit drug use, or whose partners participate in these activities) be tested more frequently. 

  • The $111 million Expanded Testing Initiative (ETI) was implemented in 2010 to support HIV testing among MSM of all races and ethnicities, Hispanics/Latinos, and injection drug users, and the provision of HIV testing in non-clinical settings, such as pharmacy clinics.
  • The CDC continues to focus on providing HIV testing to MSM. In 2011, the CDC provided $55 million to 34 states and cities with large populations of blacks/African Americans and Hispanics/Latinos to support HIV testing services for these at-risk populations.
  • Through its MSM Testing Initiative, the CDC aims to scale up HIV testing among blacks/African Americans and Hispanics/Latinos. The goal of this project is to establish and evaluate an HIV Testing and Linkage to Care Program to identify HIV-infected MSM previously unaware of their infection and link them to HIV medical care. HIV testing and linkage to care activities will take place in 11 cities from September 2011 to August 2014.

Enhancing HIV Mobilization among Organizations Serving Gay, Bisexual, and Other Men Who Have Sex with Men

Behavioral Interventions

Adapting and Evaluating Effective Behavioral Interventions for MSM

    • Translating the current in-person training of d-up: Defend Yourself!(d-up!), a community-level intervention designed for and developed by black MSM, into an engaging web-based educational tool. d-up! is a cultural adaptation of the Popular Opinion Leader (POL) intervention and is designed to change social norms and perceptions of black MSM regarding condom use [11];
    • An adaptation of Mpowerment for young black/African American MSM, aged 18–29 years, is currently being tested and evaluated.

Evaluating Recruitment Strategies for Improving the Effectiveness of HIV Testing Programs among MSM
The African American MSM Testing Project evaluated the relative effectiveness of three recruitment strategies—alternate venue testing, the social network strategy, and partner counseling and partner services—for identifying  and motivating black/African American MSM, aged 18–64 years, to be tested for HIV and linked to appropriate prevention services. Four sites—one health department and three CBOs located in Atlanta, Baltimore, Washington, DC, and New York City—collected data for this project, and data dissemination activities are ongoing.

Evaluating Locally Developed Behavioral Interventions Focused on MSM
The CDC supports the rigorous evaluation of locally developed behavioral interventions as a way to identify innovative strategies developed by the community, and for the community, that are effective in reducing HIV risk among black/African American MSM.

  • The CDC is supporting the evaluation of two locally developed interventions for black/African American MSM: the Critical Thinking and Cultural Affirmation intervention, developed by Black Men’s Exchange Program in New York City; and My Life. My Style., developed by In the Meantime Men’s Group, Inc., in Los Angeles.

Organizational Initiatives to Support Focus on Populations Most Affected by HIV

The CDC has created structures within its organization that aid in addressing the HIV epidemic among MSM, including black/African American MSM.

  • The goals of the agency-wide CDC/ATSDR Sexual and Gender Minorities (SGM) Workgroup are to improve understanding of SGM health disparities and needs, increase two-way communication with key SGM external partners, and promote SGM program services, education and communication products, data collection, and research within CDC.
  • The primary purpose of the CDC MSM Executive Committee is to provide a forum to discuss and coordinate activities related to preventing HIV and AIDS, viral hepatitis, and other STIs among gay, bisexual, and other MSM. The Executive Committee is responsible for providing input on emerging issues that affect risk for STIs among MSM to address the inclusion of these issues in surveillance, research, prevention programs, capacity building, policy, monitoring and evaluation, and communications to appropriate staff, external partners, and consumers.
  • The Office of Health Equity within the Division of HIV/AIDS Prevention (DHAP OHE) was established in 2010 to provide leadership on understanding the determinants of HIV and AIDS inequities and developing strategies for increasing health equity, and to coordinate and monitor the Division’s activities related to reducing health inequities among populations most disproportionately affected by the epidemic. The OHEMSM Coordinator manages activities directed to gay, bisexual, and other MSM, including black/African American MSM, and provides assistance to Division leadership on a wide array of HIV-related research, surveillance, and programmatic activities that guide the national HIV prevention mission.

CDC’s Commitment

CDC is committed to the continued prioritizing of proven strategies for those at highest risk of HIV infection.  Additionally, the CDC’s Strategic Plan, the National HIV/AIDS Strategy for the United States , and High-Impact HIV Prevention provide direction to prioritize prevention activities for gay and bisexual men—particularly young black/African American and Hispanic/Latino gay and bisexual men—and engage in strategies to reduce HIV incidence, increase access to care and optimize health outcomes, and reduce HIV-related health disparities among these populations.

References

  1. 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;388:341-8.
  2. CDC. Prevalence and awareness of HIV infection among men who have sex with men—21 cities, United States, 2008. MMWR 2010;59:1201-7.
  3. Crepaz N, Hart TA, Marks G. Highly active antiretroviral therapy and sexual risk behavior: a meta-analytic review. JAMA 2004;292:224-36.
  4. Wolitski RJ, Fenton KA. Sexual health, HIV, and sexually transmitted infections among gay, bisexual, and other men who have sex with men in the United States. AIDS Behav 2011;Suppl 15:S9-17.
  5. Fenton KA. Changing epidemiology of HIV/AIDS in the United States: implications for enhancing and promoting HIV testing strategies. Clin Infect Dis 2007;45(Suppl 4):S213-20.
  6. Crepaz N, Marks G, Liau A, et al. Prevalence of unprotected anal intercourse among HIV-diagnosed MSM in the United States: a meta-analysis. AIDS 2009;23:1617-29.
  7. CDC. Statement on serosorting among gay, bisexual and other men who have sex with men. http://www.cdc.gov/msmhealth/Serosorting.htm. Accessed August 15, 2012.
  8. CDC. Sexually Transmitted Diseases Treatment Guidelines, 2010. MMWR 2010;59(RR-12). [Special Populations: MSM, p. 12].
  9. Oster AM, Wiegand RE, Sionean C, et al. Understanding disparities in HIV infection between black and white MSM in the United States. AIDS 2011;25:1103-12.
  10. Wilton L, Herbst JH, Coury-Doniger P, et al. Efficacy of an HIV/STI prevention intervention for black men who have sex with men: findings from the Many Men, Many Voices (3MV) project. AIDS Behav 2009;13:532-44.
  11. Jones KT, Gray P, Whiteside YO, et al. Evaluation of an HIV prevention intervention adapted for Black men who have sex with men. Am J Public Health 2008;98:1043-50.

 

 

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