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      Concomitant Socioeconomic, Behavioral, and Biological Factors Associated with the Disproportionate HIV Infection Burden among Black Men Who Have Sex with Men in 6 U.S. Cities

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          Abstract

          Background

          American Black men who have sex with men (MSM) are disproportionately affected by HIV, but the factors associated with this concentrated epidemic are not fully understood.

          Methods

          Black MSM were enrolled in 6 US cities to evaluate a multi-component prevention intervention, with the current analysis focusing on the correlates of being newly diagnosed with HIV compared to being HIV-uninfected or previously diagnosed with HIV.

          Results

          HPTN 061 enrolled 1553 Black MSM whose median age was 40; 30% self-identified exclusively as gay or homosexual, 29% exclusively as bisexual, and 3% as transgender. About 1/6 th (16.2%) were previously diagnosed with HIV (PD); of 1263 participants without a prior HIV diagnosis 7.6% were newly diagnosed (ND). Compared to PD, ND Black MSM were younger (p<0.001); less likely to be living with a primary partner (p<0.001); more likely to be diagnosed with syphilis (p<0.001), rectal gonorrhea (p = 0.011) or chlamydia (p = 0.020). Compared to HIV-uninfected Black MSM, ND were more likely to report unprotected receptive anal intercourse (URAI) with a male partner in the last 6 months (p<0.001); and to be diagnosed with syphilis (p<0.001), rectal gonorrhea (p = 0.004), and urethral (p = 0.025) or rectal chlamydia (p<0.001). They were less likely to report female (p = 0.002) or transgender partners (p = 0.018). Multivariate logistic regression analyses found that ND Black MSM were significantly more likely than HIV-uninfected peers to be unemployed; have STIs, and engage in URAI. Almost half the men in each group were poor, had depressive symptoms, and expressed internalized homophobia.

          Conclusions

          ND HIV-infected Black MSM were more likely to be unemployed, have bacterial STIs and engage in URAI than other Black MSM. Culturally-tailored programs that address economic disenfranchisement, increase engagement in care, screen for STIs, in conjunction with safer sex prevention interventions, may help to decrease further transmission in this heavily affected community.

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          Most cited references8

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          Estimated HIV Incidence in the United States, 2006–2009

          Background The estimated number of new HIV infections in the United States reflects the leading edge of the epidemic. Previously, CDC estimated HIV incidence in the United States in 2006 as 56,300 (95% CI: 48,200–64,500). We updated the 2006 estimate and calculated incidence for 2007–2009 using improved methodology. Methodology We estimated incidence using incidence surveillance data from 16 states and 2 cities and a modification of our previously described stratified extrapolation method based on a sample survey approach with multiple imputation, stratification, and extrapolation to account for missing data and heterogeneity of HIV testing behavior among population groups. Principal Findings Estimated HIV incidence among persons aged 13 years and older was 48,600 (95% CI: 42,400–54,700) in 2006, 56,000 (95% CI: 49,100–62,900) in 2007, 47,800 (95% CI: 41,800–53,800) in 2008 and 48,100 (95% CI: 42,200–54,000) in 2009. From 2006 to 2009 incidence did not change significantly overall or among specific race/ethnicity or risk groups. However, there was a 21% (95% CI:1.9%–39.8%; p = 0.017) increase in incidence for people aged 13–29 years, driven by a 34% (95% CI: 8.4%–60.4%) increase in young men who have sex with men (MSM). There was a 48% increase among young black/African American MSM (12.3%–83.0%; p<0.001). Among people aged 13–29, only MSM experienced significant increases in incidence, and among 13–29 year-old MSM, incidence increased significantly among young, black/African American MSM. In 2009, MSM accounted for 61% of new infections, heterosexual contact 27%, injection drug use (IDU) 9%, and MSM/IDU 3%. Conclusions/Significance Overall, HIV incidence in the United States was relatively stable 2006–2009; however, among young MSM, particularly black/African American MSM, incidence increased. HIV continues to be a major public health burden, disproportionately affecting several populations in the United States, especially MSM and racial and ethnic minorities. Expanded, improved, and targeted prevention is necessary to reduce HIV incidence.
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            Understanding disparities in HIV infection between black and white MSM in the United States.

            We evaluated several hypotheses for disparities in HIV infection between black and white MSM in the United States, including incarceration, partner HIV status, circumcision, sexual networks, and duration of infectiousness. The 2008 National HIV Behavioral Surveillance System (NHBS), a cross-sectional survey conducted in 21 US cities. MSM were interviewed and tested for HIV infection. For MSM not previously diagnosed with HIV infection, we used logistic regression to test associations between newly diagnosed HIV infection and incarceration history, partner HIV status, circumcision status, and sexual networks (older partners, concurrency, and partner risk behaviors). For HIV-infected MSM, we assessed factors related to duration of infectiousness. Among 5183 MSM not previously diagnosed with HIV infection, incarceration history, circumcision status, and sexual networks were not independently associated with HIV infection. Having HIV-infected partners [adjusted odds ratio (AOR) = 1.9, 95% confidence interval (CI) = 1.2–3.0] or partners of unknown status (AOR = 1.4, CI = 1.1–1.7) were associated with HIV infection. Of these two factors, only one was more common among black MSM – having partners of unknown HIV status. Among previously diagnosed HIV-positive MSM, black MSM were less likely to be on antiretroviral therapy (ART). Less knowledge of partner HIV status and lower ART use among black MSM may partially explain differences in HIV infection between black and white MSM. Efforts to encourage discussions about HIV status between MSM and their partners and decrease barriers to ART provision among black MSM may decrease transmission.
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              Health system and personal barriers resulting in decreased utilization of HIV and STD testing services among at-risk black men who have sex with men in Massachusetts.

              Testing for HIV and other sexually transmitted diseases (STD) remains a cornerstone of public health prevention interventions. This analysis was designed to explore the frequency of testing, as well as health system and personal barriers to testing, among a community-recruited sample of Black men who have sex with men (MSM) at risk for HIV and STDs. Black MSM (n = 197) recruited via modified respondent-driven sampling between January and July 2008 completed an interviewer-administered assessment, with optional voluntary HIV counseling and testing. Logistic regression procedures examined factors associated with not having tested in the 2 years prior to study enrollment for: (1) HIV (among HIV-uninfected participants, n = 145) and (2) STDs (among the entire mixed serostatus sample, n = 197). The odds ratios and their 95% confidence intervals obtained from this analysis were converted to relative risks. (1) HIV: Overall, 33% of HIV-uninfected Black MSM had not been tested for HIV in the 2 years prior to study enrollment. Factors uniquely associated with not having a recent HIV test included: being less educated; engaging in serodiscordant unprotected sex; and never having been HIV tested at a community health clinic, STD clinic, or jail. (2) STDs: Sixty percent had not been tested for STDs in the 2 years prior to study enrollment, and 24% of the sample had never been tested for STDs. Factors uniquely associated with not having a recent STD test included: older age; having had a prior STD; and never having been tested at an emergency department or urgent care clinic. Overlapping factors associated with both not having had a recent HIV or STD test included: substance use during sex; feeling that using a condom during sex is "very difficult"; less frequent contact with other MSM; not visiting a health care provider (HCP) in the past 12 months; having a HCP not recommend HIV or STD testing at their last visit; not having a primary care provider (PCP); current PCP never recommending they get tested for HIV or STDs. In multivariable models adjusting for relevant demographic and behavioral factors, Black MSM who reported that a HCP recommended getting an HIV test (adjusted relative risk [ARR] = 0.26; p = 0.01) or STD test (ARR = 0.11; p = 0.0004) at their last visit in the past 12 months were significantly less likely to have not been tested for HIV or STDs in the past 2 years. Many sexually active Black MSM do not regularly test for HIV or STDs. HCPs play a pivotal role in encouraging testing for Black MSM. Additional provider training is warranted to educate HCPs about the specific health care needs of Black MSM, in order to facilitate access to timely, culturally competent HIV and STD testing and treatment services for this population.
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                Author and article information

                Contributors
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, USA )
                1932-6203
                2014
                31 January 2014
                : 9
                : 1
                : e87298
                Affiliations
                [1 ]The Fenway Institute of Fenway Health and the Infectious Disease Division of Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, United States of America
                [2 ]Vaccine and infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
                [3 ]Laboratory of Infectious Disease Prevention, New York Blood Center, New York, New York, United States of America
                [4 ]Department of Medicine, Harlem Hospital and Columbia University, New York, New York, United States of America
                [5 ]The Department of Epidemiology and Biostatistics, George Washington University, Washington, DC, United States of America
                [6 ]Department of Global Health and Emory Center for AIDS Research, Emory University Rollins School of Public Health, Atlanta, Georgia, United States of America
                [7 ]HIV Research Section San Francisco Department of Health, San Francisco, California, United States of America
                [8 ]Department of Human Development, Binghamton University, Binghamton, New York, United States of America
                [9 ]Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
                [10 ]Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
                [11 ]FHI 360, Durham, North Carolina, United States of America
                [12 ]School of Social Work, Loyola University Chicago, Chicago, Illinois, United States of America
                Chinese Academy of Sciences, Wuhan Institute of Virology, China
                Author notes

                ¶ Membership of the HPTN 061 Protocol Team is provided in the Acknowledgments.

                Competing Interests: The authors have declared that no competing interests exist.

                Performed the experiments: KHM BK SM MM CDR SB CG SHE WC CCW SG. Analyzed the data: L. Wang TY CM. Contributed reagents/materials/analysis tools: L. Wilton DW CCW EP VC CG SHE. Wrote the paper: KHM BK DW SHE L. Wang. Reviewed manuscript and offered comments and revisions: SM MM CDR SB CG WC EP CCW SG L. Wang L. Wilton.

                Article
                PONE-D-13-26608
                10.1371/journal.pone.0087298
                3909083
                24498067
                ca6d1f2a-5a9d-4140-ae0a-4096e6f122a8
                Copyright @ 2014

                This is an open-access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.

                History
                : 18 June 2013
                : 26 December 2013
                Page count
                Pages: 10
                Funding
                HPTN 061 grant support was provided by the National Institute of Allergy and Infectious Disease (NIAID), National Institute on Drug Abuse (NIDA) and National Institute of Mental Health (NIMH): Cooperative Agreements UM1 AI068619, UM1 AI068617, and UM1 AI068613. Additional site funding was provided by the Fenway Institute CRS: Harvard University CFAR (P30 AI060354) and CTU for HIV Prevention and Microbicide Research (UM1 AI069480). Further support came from the George Washington University CRS: District of Columbia Developmental CFAR (P30 AI087714); Harlem Prevention Center CRS and NY Blood Center/Union Square CRS: Columbia University CTU (5U01 AI069466) and ARRA funding (3U01 AI069466-03S1). This project received support from the Hope Clinic of the Emory Vaccine Center CRS and The Ponce de Leon Center CRS: Emory University HIV/AIDS CTU (5U01 AI069418), CFAR (P30 AI050409) and CTSA (UL1 RR025008). Finally, this paper was also supported by the San Francisco Vaccine and Prevention CRS: ARRA funding (3U01 AI069496-03S1, 3U01 AI069496-03S2) in addition to the UCLA Vine Street CRS: UCLA Department of Medicine, Division of Infectious Diseases CTU (U01 AI069424). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
                Research Article
                Biology
                Population Biology
                Epidemiology
                Infectious Disease Epidemiology
                Medicine
                Epidemiology
                Infectious Disease Epidemiology
                Infectious Diseases
                Sexually Transmitted Diseases
                AIDS
                Viral Diseases
                HIV
                HIV epidemiology
                HIV prevention
                Non-Clinical Medicine
                Health Care Policy
                Health Risk Analysis
                Public Health
                Behavioral and Social Aspects of Health

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