US face African style infection rates among young black gay men

Data released this week at the 8th Conference on Retroviruses and Opportunistic Infections have highlighted the disproportionate manner in which HIV is affecting black gay men in the United States.

A study of high-risk behaviour and HIV prevalence carried out in six major metropolitan locations across the US has illustrated the need to develop, evaluate and intensify prevention efforts for young gay men, especially black men.

The 1998-2000 Young Men’s Survey sampled men aged 23-29 at public venues in Baltimore, Dallas, Los Angeles, Miami, New York City and Seattle. In total data from 2401 men were included. The sample size for each city ranged from 313-556. Across the six cities HIV prevalence was high at 12.3% and increased with age, from 10.2% among men aged 23-25 years of age to 14.2% among men aged 26-29.

Age, however is not the biggest predictor of HIV status. In the US, clearly it is an issue of Race.

HIV prevalence among young black gay men was a staggering 30%. This is similar to rates found among pregnant women in Botswana in sub-Saharan Africa, one of the world’s most badly affected regions. HIV prevalence among white gay men was 7%.

In the opening session of the conference Professor Kevin de Cock had posed the question of whether the US would stand by and permit a lack of efforts to identify HIV-positive individuals if it faced 25% infection rates. One could argue that the US is currently facing such rates; it just depends where you are looking and who you are looking at.

A separate study carried out in New York between 1998 and 2000 found similarly high HIV seroprevalence among black gay men aged 23-29. From a total sample size of 542 men, only 2% of white men tested were found to be HIV-positive. Among black men the rate was 33%.

The study also sought to address the question of whether there were discernible differences in risk-taking depending on Race. They found that black men were no more likely to exchange sex for money or drugs, nor were they more likely to have a history of sexually transmitted diseases. Black men were also no more likely to have had anal sex in the last six months or have had unprotected anal intercourse with a serodiscordant partner in the last six months.

Black men also reported significantly fewer partners and significantly less injection drug use.

Although black men were less likely to have had receptive anal intercourse in the previous six months, they were less likely to have used a condom. This is likely to be problematic if black men are having sex with other black men in cities with high background prevalence rates; although the amount of exposure can influence one’s likelihood of becoming positive, so too can one’s choice of sexual partner.

Additionally, black men were more likely to believe that they were HIV-positive or perceived themselves as more likely to become HIV-positive in the future. Fatalism of this kind has been well-documented in the past, but has never been directly linked to such a high background HIV rate.

Data released at the conference yesterday looking at the prevalence of HIV resistance mutations among recently and chronically infected individuals not on treatment found that white gay men were more likely to have mutations conferring resistance to anti-HIV drugs than their black gay counterparts.

The data were compiled between 1997 and 1999 in 10 US cities. Prevalence of resistance mutations was 16% among white gay men and 7% among black gay men. This is hardly surprising since black gay men are much less likely to be in touch with care systems or have a partner taking antiretroviral medication. This was highlighted as the highest predictor of prevalence of resistance mutations; prevalence of resistance mutations among those with a partner taking anti-HIV drugs was 17%.

Such news can hardly be heralded as reassuring for black gay men given the startling rates of HIV prevalence described earlier this week. However it is encouraging to see that if black gay men were encouraged to feel able to access treatment and care, they could do so in the knowledge that rates of resistance may be low enough to allow their first treatment line to have a good chance of being effective.

Exactly how the United States and the black gay community itself will respond to such overwhelming infection rates as documented among black gay men this week remains critical to the control of the epidemic.