Stuck: Contextualizing the U.S. HIV epidemic among black MSM Greg - PowerPoint PPT Presentation

‘Stuck’: Contextualizing the U.S. HIV epidemic among black MSM Greg Millett amfAR April 2, 2015

New HIV Infections, 2010 2008-2010 Women: 21% decrease MSM: 12% increase Young MSM: 22% increase

Lifetime Risk of HIV Diagnosis by Race • Whites – 1 in 104 for men – 1 in 588 for women • Hispanics – 1 in 35 for men – 1 in 114 for women • Blacks – 1 in 16 for men – 1 in 30 for women Hall et al. JAIDS. 2008; 49: 294-297

Lifetime Risk of HIV Diagnosis by Race • Whites – 1 in 104 for men – 1 in 6 MSM – 1 in 588 for women • Hispanics – 1 in 35 for men – 1 in 5 MSM – 1 in 114 for women • Blacks – 1 in 16 for men – 1 in 3 MSM – 1 in 30 for women Hall et al. JAIDS. 2008; 49: 294-297; MMWR, 2011

HIV Disparities among Black MSM vs. White MSM, Black Community, and U.S. Population 90 80 HIV Prevelance Summary Odds Ratio 70 60 50 40 30 20 3X 10 0 vs. White MSM vs. Black community vs. U.S. population (Millett et. al, The Lancet, 2012; Slide courtesy G Millett)

HIV Disparities among Black MSM vs. White MSM, Black Community, and U.S. Population 90 80 HIV Prevelance Summary Odds Ratio 70 60 50 40 22X 30 20 3X 10 0 vs. White MSM vs. Black community vs. U.S. population (Millett et. al, The Lancet, 2012; Slide courtesy G Millett)

HIV Disparities among Black MSM vs. White MSM, Black Community, and U.S. Population 90 72X 80 HIV Prevelance Summary Odds Ratio 70 60 50 40 22X 30 20 3X 10 0 vs. White MSM vs. Black community vs. U.S. population (Millett et. al, The Lancet, 2012; Slide courtesy G Millett)

Projected HIV Prevalence among MSM Throughout Lifespan Age-Specific HIV Prevalence 100% 90% 80% Black MSM 70% MSM overall HIV Prevalence 60% 50% 40% 30% 20% 10% 0% 20 25 30 35 40 45 50 55 60 Age MSM overall IR 1.9%;AA MSM IR 4.0% Stall, AIDS Behav, 2007 (Stall, 2009)

Estimated probability of being exposed to HIV by at least 1 partner Black MSM 60% (Kelley, 2013; Slide courtesy G Millett)

Estimated probability of being exposed to HIV by at least 1 partner Black MSM 60% 50% (Kelley, 2013; Slide courtesy G Millett)

Estimated probability of being exposed to HIV by at least 1 partner Black MSM 60% 50% White MSM 50% (Kelley, 2013; Slide courtesy G Millett)

Meta-Analysis: Where are HIV-Related Disparities Greatest Between Black vs. Other MSM? (174 US studies) (Millett, The Lancet, 2012)

HIV incidence Incidence/ Rate Ratio Factor 100 PY (95% CI) Black participant 6.6 3.8 (1.7, 9.9) White participant 1.7 ref. Health Insurance 2.6 ref. Social determinants No health Insurance 6.3 2.4 (1.2, 5.0) UAI 5.3 4.8 (1.5, 24) Individual risk behaviors No UAI 1.1 ref. Older partners (≥10 y) 8.6 2.8 (1.2, 6.1) No older partners 3.1 ref. Partner pool / network Black partners 8.6 4.5 (2.1, 10) No black partners 1.9 ref. (Rosenberg et al, 2015)

HIV incidence Age-scaled Cox PH models Black vs. White HR (95% CI): Covariate HR Race = 3.3 (1.4, 7.5) Health (UAI) HR Race = 3.0 (1.3, 6.7) Insurance (Older partners) UAI HR Race = 2.9 (1.3, 6.5) Older partners (no covariate adjustment) (≥10 y) 2.6 HR Race = 2.6 (1.3, 6.5) Black partners (Health Ins.) (Rosenberg et al, 2015)

HIV incidence Age-scaled Cox PH models Black vs. White HR (95% CI): Covariate HR Race = 3.3 (1.4, 7.5) Health (UAI) HR Race = 3.0 (1.3, 6.7) Insurance (Older partners) UAI HR Race = 2.9 (1.3, 6.5) Older partners (no covariate adjustment) (≥10 y) 2.6 HR Race = 2.6 (1.3, 6.5) Black partners (Health Ins.) HR Race = 1.6 (0.6, 4.2) (Black partners) HR Race = 1.5 (0.6, 3.9) (Black P, Health Ins.) HR Race = 1 (Rosenberg et al, 2015)

Disparities persist between black and other MSM throughout treatment cascade (24 comparative studies) Undiagnosed HIV 6x HIV Diagnosed HIV+ Detection 3x ART utilization/ access 40% less >200 CD4 cells/mm 3 before ART initiation 60% less Healthcare visits 40% less ART adherence 50% less HIV suppression OR, 0.51 (0.31-0.83) Viral Suppression (Millett, 2012; slide courtesy G Millett)

Disparities persist between black and other MSM throughout treatment cascade (24 comparative studies) Undiagnosed HIV 6x HIV Diagnosed HIV+ Detection 3x ART utilization/ access 40% less >200 CD4 cells/mm 3 before ART initiation 60% less Healthcare visits 40% less ART adherence 50% less HIV suppression OR, 0.51 (0.31-0.83) Viral Suppression (Millett, 2012; slide courtesy G Millett)

Black Clinicians and HIV Testing (Jordan, 2013)

(Rosenberg, 2014)

(Rosenberg, 2014)

(Rosenberg, 2014)

Among HIV-negative Black MSM, experiencing stigma from health care providers was associated with longer gaps in time since last HIV care appointment

Aligning Our Research Investments with the Epidemic • Are research dollars aligned with populations where HIV is most concentrated? • Is participation in research trials reflective of these populations? Figure NIH FY 2010 HIV/AIDS Funding by risk group

96 intervention studies Selection criteria (1) been published between 1991 and 2010 (inclusive) (2) Interventions for HIV- negative youth (13-24 yrs) • MSM overwhelming majority new HIV infections among youth • MSM only group where HIV rates increasing

Making Smarter Investments: CDC Modeling for Philadelphia Untargeted interventions Cost per new infection averted (rank) 51,293 (3) Testing in clinical settings 99,105 (7) Partner services 114,644 (8) Linkage to care Retention in care 75,665 (5) 42,753 (2) Adherence to ART Targeted interventions HRH IDU MSM 866,272 (12) 53,935 (4) 17,965 (1) Testing in non-clinical settings Behavioral intervention for HIV+ 594,796 (10) 700,005 (11) 97,410 (6) people Behavioral intervention for HIV- 15,642,127 (14) 2,931,406 (13) 327,210 (9) people ART, Antiretroviral therapy HRH, High risk heterosexuals IDU, Injection drug users Sansom et al, CDC Grand Rounds August 21, 2012 MSM, Men who have sex with men

Attitudes are changing… a new era?

Structural-Level Experiences &Resiliency, U.S. Black MSM vs. Other MSM 5 4.5 4 HIV Prevalence Summary Odd Ratio 3.5 3 2.5 2 1.5 1 0.5 0 < HS Education Lower Income Ever Incarcerated Unemployed Any Structural Any Resilient Resiliency (young Barrier (Total) Behavior BMSM) (Millett, 2012)

The moment is now… The current administration prioritizes our lives: • Leaders at highest level of government • My Brother’s Keeper initiative • LGBT civil rights prioritized • White House prioritizes HIV • Justice Dept (focused on racial, LGBT equality and reducing discrimination)