POSITIVELY AWARE November/December 2011
To Tell or not? Disclosure should be made to measure. By Enid Vazquez.
Sexual risk or context, which best accounts for HIV infection rates among black MSM?
A basic assumption underlying current approaches to HIV prevention is that the best way to lower HIV infection rates among MSM is to reduce rates of HIV sexual risk-taking. Most studies that have measured rates of HIV prevalence among black MSM find rates of HIV infection that are sometimes several times higher than those found among other MSM populations. Does this mean that black MSM have rates of sexual risk-taking that are several times higher than those found among other MSM populations?
Greg Millett, then with the CDC’s Division of HIV/AIDS Prevention, conducted a set of careful literature reviews to address this question. Millett tested whether African American MSM were more likely to be at sexual risk for HIV; less likely to disclose sexual identity; more likely to use recreational drugs, to have a history of STDs, to get HIV tested, or to have sex with a known HIV-positive partner; and, if positive, less likely to be on antiretroviral treatment. What he found was that African American MSM were not more likely to have higher rates of sexual risk-taking, to use recreational drugs, to have sex with a known HIV-positive person, or to get tested less frequently, but they were more likely to not identify as gay; to have a history of having an STD; and, if positive, less likely to be on antiretroviral medications.
Millett’s findings suggest that being part of a population that engages in medical care less frequently may better explain high rates of HIV infection than just sexual risk-taking. Put another way, lower access to medical care raises the proportion of African American MSM who have high HIV viremia (viral load), which then results in more HIV transmission to uninfected partners. High prevalence rates of men with elevated HIV viral loads within the tightly bound sexual networks often found among African American MSM magnify risk for HIV transmission even among men who rarely take sexual risks. Millett’s analysis thus suggests that it is not simple levels of risk-taking that best explain higher HIV prevalence rates among African American MSM, but rather the context in which these men take occasional sexual risks. This suggests that strategies designed to lower community viral load through combination prevention approaches (i.e., combining behavioral and biomedical interventions with a special focus on men at highest risk) may be particularly effective among African American MSM. This could be accomplished by working with communities of black MSM to share these findings, to dispel the idea that the HIV epidemic is somehow caused by widespread sexual irresponsibility, and to work with African American MSM and service providers to find ways to help black MSM gain access to medical care so that levels of health at the individual and community level are improved.