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Unrecognized HIV Infection, Risk Behaviors, and Perceptions of Risk Among Young Black Men Who Have Sex with Men --- Six U.S. Cities, 1994--1998
The incidence of human immunodeficiency virus (HIV) infection among young black men who have sex with men (BMSM) is among the highest of all risk groups in the United States (1--3). Two important strategies to reduce HIV transmission among young BMSM are to increase the proportion of men who are aware of their HIV infection and to increase the consistent use of condoms among sexually active men (4,5). However, limited information is available to help develop HIV-testing and condom-promotion programs for young BMSM. To address this need, data from CDC's Young Men's Survey (YMS) were used to evaluate the prevalence of unrecognized HIV infection, barriers to testing, and reasons for nonuse of condoms among BMSM aged 15--22 years. This report summarizes the results of the survey, which indicated that of the 16% of young BMSM participants who were infected with HIV, nearly all were unaware of their infection. Few young BMSM reported testing frequently for HIV, and many reported engaging in behaviors that could transmit HIV because they perceived themselves or their partners to be at low risk for infection. These findings underscore the urgency of expanding and improving prevention efforts for young BMSM by increasing the demand for and availability of HIV-testing services and by providing high-quality prevention counseling that includes assessment and clarification of perceived risks for infection.
YMS was a cross-sectional survey conducted during 1994--1998 of males aged 15--22 years who attended MSM-identified venues (e.g., shopping areas, dance clubs, bars, and organizations) in Baltimore, Maryland; Dallas, Texas; Los Angeles, California; Miami, Florida; New York, New York; the San Francisco Bay Area, California; and Seattle, Washington (1). Extensive formative research was conducted to construct monthly sampling frames of the days, times, and venues attended by young BMSM. Each month, 12--16 venues and their associated day/time periods were selected randomly and scheduled for sampling. During sampling events, men were approached consecutively to assess their survey eligibility. BMSM eligible for the survey were aged 15--22 years and residents in one or more local counties. Participants were interviewed by using a standard questionnaire, had blood drawn for HIV testing, were given appointments to obtain test results, and were provided HIV-prevention counseling and referral for care when needed.
Specimens were tested for HIV at local laboratories with standard assays. Analyses were restricted to men who reported ever having sex with men and who described their racial background as either being only black or having a mixed background that included being black. Analyses excluded records of duplicate participants, who were identified by using the Miragen antibody profile assay (6). Records also were excluded from Seattle because few BMSM had participated in that city.
In the six cities, 920 BMSM participated in YMS (range: 127--202). The participation rate among eligible blacks was 61% (range: 53%--77%). Of the 920 participants, 150 (16%) tested positive for HIV (range: 13%--18%). Of the 150 HIV-infected BMSM, 139 (93%) were unaware of their infection (range: 88%--100%). Of those with unrecognized infection, 99 (71%) reported either that there was no chance, that it was very unlikely, or that it was unlikely that they were infected with HIV; 58 (42%) perceived themselves at low risk for ever becoming infected; and 45 (32%) perceived themselves at low risk both for being and for ever becoming HIV-infected (Table).
During the 6 months preceding the survey, the 920 BMSM reported a median of two male sex partners (interquartile range: one to three), 712 (77%) reported having anal intercourse with another man, and 342 (37%) reported having unprotected anal intercourse (UAI). Of the 79 BMSM with unrecognized HIV infection who had UAI, 41 (52%) reported not using condoms for one or more of the following reasons: they "knew" they were HIV-negative (24%), they "knew" their partners were HIV-negative (20%), or they thought their partners were at low risk for infection (35%); 34 (43%) also reported not using condoms because none were available (Table).
Of the 920 BMSM, 585 (64%) had ever tested previously for HIV, but few had tested frequently (median number of tests: one; interquartile range: zero to two). Of those who had tested previously, 536 (92%) reported last testing HIV-negative, and of these, 87 (16%) were found to be infected with HIV. The 332 (36%) men who had not tested previously gave the following reasons for not testing (more than one reason could be given): low risk for infection (45%), fear of learning their results (41%), and fear of needles (21%). Of those who had not tested previously, 42 (13%) were HIV-infected. Of the 148 men who had not tested previously because of perceived low risk, 122 (82%) ever had anal intercourse with a man, 99 (67%) had at least three lifetime male partners, and 11 (7%) were HIV-infected.
Compared with their noninfected peers, young BMSM with unrecognized infection were more likely to report engaging in UAI and not testing previously because of fear about learning their results (Table). Noninfected young BMSM were more likely to perceive themselves at low risk for infection and not to have tested previously because of this perception.
Reported by: T Bingham, MPH, Los Angeles County Dept of Health Svcs, Los Angeles; W McFarland, MD, San Francisco Dept of Public Health, San Francisco, California. DA Shehan, Univ of Texas Southwestern Medical Center at Dallas, Texas. M LaLota, MPH, Florida Dept of Health. DD Celentano, ScD, Johns Hopkins Univ School of Hygiene and Public Health, Baltimore, Maryland. BA Koblin, PhD, New York Blood Center; LV Torian, PhD, New York City Dept of Health, New York. DA MacKellar, MPH, LA Valleroy, PhD, GS Secura, MPH, RS Janssen, MD, Div of HIV/AIDS Prevention--Surveillance, and Epidemiology; GW Roberts, PhD, Div of HIV/AIDS Prevention--Intervention, Research, and Support, National Center for HIV, STD, and TB Prevention, CDC.
The findings in this report are consistent with previous studies suggesting that in several U.S. cities, the majority of young HIV-infected MSM, particularly BMSM, were unaware of their infection (1,7). In a preliminary analysis of 573 HIV-infected MSM aged 16--29 years sampled in six U.S. cities, proportionally more BMSM were unaware of their infection than were white MSM (91% versus 60%) (7). However, among all young MSM with unrecognized HIV infection, no racial or ethnic differences were observed among those perceiving themselves at low risk for being infected (66%), engaging in UAI (54%), or not using condoms during anal intercourse because of perceived low personal or partner risks for HIV infection (46%) (7). These findings underscore the urgency of improving HIV-prevention efforts for all young MSM by 1) increasing the demand for and availability of HIV-testing services and 2) providing young MSM with high-quality HIV- and STD-prevention services that include assessment and clarification of personal risks for infection.
In accordance with recently revised guidelines, health-care providers should assess the HIV risks of their patients routinely and encourage all MSM at risk for HIV to test at least annually (8,9). Findings from this report indicate that demand for testing by young BMSM might be increased by implementing efforts that increase personal risk perceptions; addressing concerns about testing positive by conveying the benefits of early diagnosis and HIV care; and marketing the availability of oral fluid, urine-based, or finger-stick HIV tests that do not require venipuncture (9). Use of testing services also might be increased by offering testing in nonclinical settings that serve or are attended by young BMSM and by providing high-quality partner referral services for all those who test positive (5,9).
HIV testing should be accompanied by high-quality prevention counseling that includes an in-depth personalized risk assessment, clarification of risk perceptions, and negotiation of steps to reduce risks (9). Because 16% of young BMSM who reported being HIV-negative were found to be HIV-infected, providers should encourage young BMSM to use condoms consistently with all partners, including those who have tested negative previously. In negotiating risk reduction with young BMSM, providers should be prepared to address alcohol, drug, and partner influences on condom use and to help young BMSM cope with emotional responses in high-risk situations. Providers should refer clients who have difficulty in initiating or sustaining safer behavior for more intensive individualized prevention counseling and support services (9,10). Finally, managers of prevention programs should consider increasing the availability of condoms in settings where young BMSM are likely to encounter sex partners.
The findings in this report are subject to at least three limitations. First, findings might not be applicable to young BMSM who do not attend MSM-identified venues or reside in the six participating cities. Second, because approximately 39% of eligible young BMSM chose not to participate, selective nonparticipation could have biased reported findings. Finally, data were collected during face-to-face interviews and are subject to disclosure biases. The finding that nearly all HIV-infected young BMSM in this survey were unaware of their infection might be attributed, in part, to one or more of these biases. However, a high proportion of young BMSM who are unaware of their infection is likely given the high HIV incidence and low frequency of testing among young BMSM (2).
In partnership with state and local health departments, nongovernment organizations, community stakeholders, and other federal agencies, CDC is taking steps to reduce HIV transmission and unrecognized infection among young MSM, particularly BMSM. Since September 2001, five national consultations have helped identify current prevention needs of MSM, including young minority MSM. In 2001, additional resources were made available to expand HIV counseling and testing, outreach services, and behavioral risk-reduction interventions for young minority MSM. Ongoing prevention efforts also are being strengthened through capacity development for minority community-based organizations serving young MSM, and through recently released guidelines calling for expanded risk assessment and HIV testing for homosexual and bisexual men (8,9). Finally, new research efforts, including rapid ethnographic assessments, have been initiated to identify additional factors that influence HIV-acquisition risks among young minority MSM. These and similar efforts signal the increased priority at national, state, and local levels to reduce the considerable racial disparities in HIV morbidity and unrecognized infection among young MSM.
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