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Purpose: Experienced homophobia—negative treatment and perceptions that gay, bisexual, and other men who have sex with men (MSM) encounter because of their sexual orientations—may promote HIV infec...

Summary San Francisco was the first city in the USA to develop a Getting to Zero HIV elimination strategy. The cause of decreased HIV incidence has been attributed to the use of biomedical prevention methods, such as pre-exposure prophylaxis (PrEP) and treatment as prevention (TasP). These strategies have benefitted White men who have sex with men (MSM), whose population has increased over the past decade. However, Black MSM in San Francisco continue to have higher HIV incidence and outmigration rates. We posit that the declining overall HIV incidence, including among White MSM, is not only explained by the use of TaSP and PrEP, but is also due to the declining Black population and rising HIV incidence among Black MSM, who have historically been more likely to acquire HIV due to structural, racial, and criminal justice-related factors than have White MSM.

Emerging epidemiological data suggest that white Americans have a lower risk of acquiring COVID-19. Although many studies have pointed to the role of systemic racism in COVID-19 racial/ethnic disparities, few studies have examined the contribution of racial segregation. Residential segregation is associated with differing health outcomes by race/ethnicity for various diseases, including HIV. This commentary documents differing HIV and COVID-19 outcomes and service delivery by race/ethnicity and the crucial role of racial segregation. Using publicly available Census data, we divide US counties into quintiles by percentage of non-Hispanic white residents and examine HIV diagnoses and COVID-19 per 100,000 population. HIV diagnoses decrease as the proportion of white residents increase across US counties. COVID-19 diagnoses follow a similar pattern: Counties with the highest proportion of white residents have the fewest cases of COVID-19 irrespective of geographic region or state political party inclination (i.e., red or blue states). Moreover, comparatively fewer COVID-19 diagnoses have occurred in primarily white counties throughout the duration of the US COVID-19 pandemic. Systemic drivers place racial minorities at greater risk for COVID-19 and HIV. Individual-level characteristics (e.g., underlying health conditions for COVID-19 or risk behavior for HIV) do not fully explain excess disease burden in racial minority communities. Corresponding interventions must use structural- and policy-level solutions to address racial and ethnic health disparities.

Background HIV services, like many medical services, have been disrupted by the COVID-19 pandemic. However, there are limited data on the impacts of the COVID-19 pandemic on HIV treatment engagement outcomes among transgender (trans) and nonbinary people. This study addresses a pressing knowledge gap and is important in its global scope, its use of technology for recruitment, and focus on transgender people living with HIV. The objective of this study is to examine correlates of HIV infection and HIV treatment engagement outcomes (i.e., currently on ART, having an HIV provider, having access to HIV treatment without burden, and remote refills) since the COVID-19 pandemic began. Methods We utilized observational data from the Global COVID-19 Disparities Survey 2020, an online study that globally sampled trans and nonbinary people (n = 902) between April and August 2020. We conducted a series of multivariable logistic regressions with lasso selection to explore correlates of HIV treatment engagement outcomes in the context of COVID-19. Results Of the 120 (13.3%) trans and nonbinary people living with HIV in this survey, the majority (85.8%) were currently on HIV treatment. A smaller proportion (69.2%) reported having access to an HIV provider since COVID-19 control measures were implemented. Less than half reported being able to access treatment without burdens related to COVID-19 (48.3%) and having the ability to remotely refill HIV prescription (44.2%). After adjusting for gender in the multivariable models, younger age and anticipated job loss were significantly associated with not having access to HIV treatment without burden. Outcomes also significantly varied by geographic region, with respondents reporting less access to an HIV provider in nearly every region outside of South-East Asia. Conclusion Our results suggest that currently taking ART, having access to an HIV provider, and being able to access HIV treatment without burden and remotely refill HIV medication are suboptimal among trans and nonbinary people living with HIV across the world. Strengthening support for HIV programs that are well-connected to trans and nonbinary communities, increasing remote access to HIV providers and prescription refills, and providing socioeconomic support could significantly improve HIV engagement in trans and nonbinary communities.

Background COVID-19 has rapidly emerged as a global public health threat with infections recorded in nearly every country. Responses to COVID-19 have varied in intensity and breadth, but generally have included domestic and international travel limitations, closure of non-essential businesses, and repurposing of health services. While these interventions have focused on testing, treatment, and mitigation of COVID-19, there have been reports of interruptions to diagnostic, prevention, and treatment services for other public health threats. Objectives We conducted a scoping review to characterize the early impact of COVID-19 on HIV, tuberculosis, malaria, sexual and reproductive health, and malnutrition. Methods A scoping literature review was completed using searches of PubMed and preprint servers (medRxiv/bioRxiv) from November 1st, 2019 to October 31st, 2020, using Medical Subject Headings (MeSH) terms related to SARS-CoV-2 or COVID-19 and HIV, tuberculosis, malaria, sexual and reproductive health, and malnutrition. Empiric studies reporting original data collection or mathematical models were included, and available data synthesized by region. Studies were excluded if they were not written in English. Results A total of 1604 published papers and 205 preprints were retrieved in the search. Overall, 8.0% (129/1604) of published studies and 10.2% (21/205) of preprints met the inclusion criteria and were included in this review: 7.3% (68/931) on HIV, 7.1% (24/339) on tuberculosis, 11.6% (26/224) on malaria, 7.8% (19/183) on sexual and reproductive health, and 9.8% (13/132) on malnutrition. Thematic results were similar across competing health risks, with substantial indirect effects of the COVID-19 pandemic and response on diagnostic, prevention, and treatment services for HIV, tuberculosis, malaria, sexual and reproductive health, and malnutrition. Discussion COVID-19 emerged in the context of existing public health threats that result in millions of deaths every year. Thus, effectively responding to COVID-19 while minimizing the negative impacts of COVID-19 necessitates innovation and integration of existing programs that are often siloed across health systems. Inequities have been a consistent driver of existing health threats; COVID-19 has worsened disparities, reinforcing the need for programs that address structural risks. The data reviewed here suggest that effective strengthening of health systems should include investment and planning focused on ensuring the continuity of care for both rapidly emergent and existing public health threats.

Background The COVID-19 pandemic caused by SARS-CoV-2 has highlighted consistent inequities in incidence, disease severity, and mortality across racial and ethnic minority populations in the United States (US) and beyond. While similar patterns have been observed with previous viral respiratory pathogens, to date, no systematic review has comprehensively documented these disparities or potential contributing factors. In response, this review aims to synthesize data on racial and ethnic disparities in morbidity and mortality due to viral acute respiratory infections (ARI) other than SARS-CoV-2. This review will focus on understanding structural health and social factors to contextualize race and ethnicity driving these disparities in the US. Methods We will conduct a systematic review of studies published from January 1, 2002, onward. Our search will include PubMed/MEDLINE, EBSCO Host-CINAHL Plus, PsycInfo, EMBASE, and Cochrane Library databases to identify relevant articles. We will include studies of any design that describe racial/ethnic disparities associated with viral ARI conducted in the US. Primary outcomes include incidence, disease severity or complication, hospitalization, or death attributed to ARI. Secondary outcomes include uptake of preventive interventions including vaccination, handwashing, social distancing, and wearing masks. Two reviewers will independently screen all citations, full-text articles, and abstract relevant data. Data characterizing individual-, community-, and structural-level factors associated with these disparities will be abstracted to better understand the underlying structural inequities contributing to racial disparities in ARI. We will assess the methodological quality of all studies and will conduct meta-analyses using random effects models if appropriate. Discussion Findings from this systematic review will shed light on patterns of racial and ethnic disparities in viral ARI in the United States to support mathematical modeling of epidemic trajectories, intervention impact, and structural drivers of transmission, including structural racism. Moreover, data emerging from this review may reignite pandemic preparedness focused on communities with specific vulnerabilities related to living and working conditions given prevailing structural inequities, thus facilitating improved future pandemic responses to novel or endemic viral respiratory pathogens. Systematic review registration PROSPERO CRD42020219771

Purpose The purpose of this study was to ascertain COVID-19 transmission dynamics among Latino communities nationally. Methods We compared predictors of COVID-19 cases and deaths between disproportionally Latino counties (≥17.8% Latino population) and all other counties through May 11, 2020. Adjusted rate ratios (aRRs) were estimated using COVID-19 cases and deaths via zero-inflated binomial regression models. Results COVID-19 diagnoses rates were greater in Latino counties nationally (90.9 vs. 82.0 per 100,000). In multivariable analysis, COVID-19 cases were greater in Northeastern and Midwestern Latino counties (aRR: 1.42, 95% CI: 1.11–1.84, and aRR: 1.70, 95% CI: 1.57–1.85, respectively). COVID-19 deaths were greater in Midwestern Latino counties (aRR: 1.17, 95% CI: 1.04–1.34). COVID-19 diagnoses were associated with counties with greater monolingual Spanish speakers, employment rates, heart disease deaths, less social distancing, and days since the first reported case. COVID-19 deaths were associated with household occupancy density, air pollution, employment, days since the first reported case, and age (fewer Conclusions COVID-19 risks and deaths among Latino populations differ by region. Structural factors place Latino populations and particularly monolingual Spanish speakers at elevated risk for COVID-19 acquisition.

Black communities in the United States are bearing the brunt of the COVID-19 pandemic and the underlying conditions that exacerbate its negative consequences. Syndemic theory provides a useful framework for understanding how such interacting epidemics to develop under conditions of health and social disparity. Multiple historical and present-day factors have created the syndemic conditions within which Black Americans experience the lethal force of COVID-19. These factors include racism and its manifestations (e.g., chattel slavery, mortgage redlining, political gerrymandering, lack of Medicaid expansion, employment discrimination, and healthcare provider bias). Improving racial disparities in COVID-19 will require that we implement policies that address structural racism at the root of these disparities.

PurposeGiven incomplete data reporting by race, we used data on COVID-19 cases and deaths in US counties to describe racial disparities in COVID-19 disease and death and associated determinants.MethodsUsing publicly available data (accessed April 13, 2020), predictors of COVID-19 cases and deaths were compared between disproportionately (≥13%) black and all other (ResultsNearly ninety-seven percent of disproportionately black counties (656/677) reported a case and 49% (330/677) reported a death versus 81% (1987/2,465) and 28% (684/ 2465), respectively, for all other counties. Counties with higher proportions of black people have higher prevalence of comorbidities and greater air pollution. Counties with higher proportions of black residents had more COVID-19 diagnoses (RR 1.24, 95% CI 1.17-1.33) and deaths (RR 1.18, 95% CI 1.00-1.40), after adjusting for county-level characteristics such as age, poverty, comorbidities, and epidemic duration. COVID-19 deaths were higher in disproportionally black rural and small metro counties. The PAF of COVID-19 diagnosis due to lack of health insurance was 3.3% for counties with ConclusionsNearly twenty-two percent of US counties are disproportionately black and they accounted for 52% of COVID-19 diagnoses and 58% of COVID-19 deaths nationally. County-level comparisons can both inform COVID-19 responses and identify epidemic hot spots. Social conditions, structural racism, and other factors elevate risk for COVID-19 diagnoses and deaths in black communities.

This cross-sectional study examines the prevalence and risk factors associated with nonmedical prescription opioid use among transgender women and girls aged 16 to 29 years., Key Points Question What are the prevalence of and risk factors associated with lifetime nonmedical prescription opioid use among transgender adolescent girls and young women who are sexually active? Findings In this cross-sectional study of 297 transgender girls and young women, 35 participants (11.8%) reported lifetime nonmedical prescription opioid use. Risk factors for opioid use included smoking cigarettes and identifying as a sexual orientation other than gay, lesbian, or bisexual. Meaning These findings suggest that evidence-based services for substance use, particularly those specifically aimed at treating opioid use disorder, can and should be tailored comprehensively to transgender populations, particularly transgender girls and young women., Importance Nonmedical prescription opioid use is a pressing public health issue in the United States. Transgender youth, including adolescent girls and young women who were assigned male at birth and currently identify as women, female, transgender women, or another diverse gender identity along the transfeminine gender spectrum, are more likely than their cisgender peers to report illicit substance use and meet diagnostic criteria for substance use disorders. However, relatively little is known about the experiences of these populations in the current era of opioid addiction and misuse. Objective To report the prevalence of and risk factors associated with lifetime nonmedical prescription opioid use in a high-risk community sample of transgender adolescent girls and young women who are sexually active. Design, Setting, and Participants This cross-sectional study used 2012 to 2015 baseline data from Project LifeSkills, a randomized clinical trial of a behavioral intervention to reduce the risk of HIV acquisition and transmission among a diverse sample of transgender adolescent girls and young women recruited from Boston, Massachusetts, and Chicago, Illinois. A total of 297 transgender girls and women aged 16 to 29 years who were sexually active were included in this analysis. Data were analyzed from June 2019 to August 2019. Exposures Transgender woman identification. Main Outcomes and Measures Self-reported lifetime nonmedical prescription opioid use. Results Among 297 transgender adolescent girls and young women (mean [SD] age, 23.4 [3.5] years), 145 (48.8%) identified as non-Hispanic/Latinx black, 76 (25.6%) identified as non-Hispanic/Latinx white, 37 (12.5%) identified as Hispanic/Latinx, 7 (2.4%) identified as non-Hispanic/Latinx Asian, and 32 (10.8%) identified as multiracial or other race/ethnicity. Thirty-five participants (11.8%) reported lifetime nonmedical prescription opioid use. Young transgender women who smoked cigarettes monthly or less (adjusted odds ratio, 3.92; 95% CI, 1.10-13.89) and who smoked daily (adjusted odds ratio, 5.69; 95% CI, 1.87-17.33) had greater odds of nonmedical prescription opioid use compared with those who did not smoke. Additionally, participants who identified as a sexual orientation other than heterosexual, gay, lesbian, or bisexual had significantly greater odds of lifetime nonmedical prescription opioid use compared with those who identified as heterosexual (adjusted odds ratio, 3.69; 95% CI, 1.07-12.72). Conclusions and Relevance These findings suggest that transgender adolescent girls and young women have similar prevalence of lifetime nonmedical prescription opioid use compared with the US general population prevalence of 12.5%. These findings may serve as a call-to-action for public health surveillance studies and evidence-based interventions to be comprehensively tailored to examine and respond to specific trends of substance use, particularly opioid use disorder, among transgender populations.

Black men who have sex with men and women (BMSMW) are at increased HIV risk, but few efficacious interventions meet their unique needs. Three HIV prevention interventions were evaluated with a common protocol. Baseline data were pooled to describe sexual behavior involving transmission risk with male, female, and male-to-female transgender partners and identify factors associated with transmission risk. BMSMW from Los Angeles, Philadelphia, and Chicago who reported sexual risk and bisexual behavior in the past year were recruited via modified chain referral sampling and community recruitment. Baseline assessments were conducted via audio computer-assisted interview and sexual behaviors assessed over the past 3months. From December 2010 to November 2012, 584 BMSMW were enrolled across the three cities. More than half (55%) were recruited by other participants. Overall, the mean age was 43years. Seventy-five percent reported an annual income

Background National Strategic Plans (NSPs) for HIV have become foundational documents that frame responses to HIV. Both Global Fund and PEPFAR require coordination with NSPs as a component of their operations. Despite the role of NSPs in country planning, no rigorous assessment of NSP targets and performance outcomes exists. We performed a quantitative analysis of the quality of NSP indicators and targets and assessed whether historical NSP targets had been achieved. Methods All targets and indicators from publicly available NSPs from 35 countries are coded as structural, input, output, or impact indicators. Targets were evaluated for specificity, measurability, achievability, relevance, and being time-bound. In addition, progress toward achieving targets was evaluated using historical NSPs from 4 countries. Results NSPs emphasized output indicators, but inclusion of structural, input, or impact indicators was highly variable. Most targets lack specificity in target population, numeric baselines or targets, and a data source for monitoring. Targets were, on average, 205% increases or decreases relative to baselines. Alignment with international indicators was variable. Metrics of indicator quality were not associated with NSP funding needs. Monitoring of historical NSP targets was limited by a lack of defined targets and available data. Conclusions Country NSPs are limited by a lack of specific, measurable, and achievable targets. The low achievement of targets in historical NSPs corroborates that targets are often poorly defined and aspirational, and not linked to available data sources. NSP quality may be improved through better use of programmatic data and greater inclusion of targets for process measures.

Summary Background In the USA, men who have sex men (MSM) are at high risk for HIV, and black MSM have a substantially higher prevalence of infection than white MSM. We created a simulation model to assess the strength of existing hypotheses and data that account for these disparities. Methods We built a dynamic, stochastic, agent-based network model of black and white MSM aged 18–39 years in Atlanta, GA, USA, that incorporated race-specific individual and dyadic-level prevention and risk behaviours, network attributes, and care patterns. We estimated parameters from two Atlanta-based studies in this population (n=1117), supplemented by other published work. We modelled the ability for racial assortativity to generate or sustain disparities in the prevalence of HIV infection, alone or in conjunction with scenarios of observed racial patterns in behavioural, care, and susceptibility parameters. Findings Race-assortative mixing alone could not sustain a pre-existing disparity in prevalence of HIV between black and white MSM. Differences in care cascade, stigma-related behaviours, and CCR5 genotype each contributed substantially to the disparity (explaining 10·0%, 12·7%, and 19·1% of the disparity, respectively), but nearly half (44·5%) could not be explained by the factors investigated. A scenario assessing race-specific reporting differences in risk behaviour was the only one to yield a prevalence in black MSM (44·1%) similar to that observed (43·4%). Interpretation Racial assortativity is an inadequate explanation for observed disparities. Work to close the gap in the care cascade by race is imperative, as are efforts to increase serodiscussion and strengthen relationships among black MSM particularly. Further work is urgently needed to identify other sources of, and pathways for, this disparity, to integrate concomitant epidemics into models, and to understand reasons for racial differences in behavioural reporting. Funding The Eunice Kennedy Shriver National Institute of Child Health and Development, the National Institute of Allergy and Infectious Diseases, the National Institute of Minority Health and Health Disparities, and the National Institute of Mental Health.

Providing clean needles through syringe services programs (SSPs) prevents the spread of disease among people who inject drugs (PWID). The recent HIV outbreak in Scott County, Indiana was a wakeup call with particular significance because modeling suggests that Scott County is but one of many counties in the United States highly vulnerable to an HIV outbreak among PWID. It is a painful recognition that some policy makers ignored the evidence in support of SSPs when it was primarily blacks in inner cities that were affected, yet swung into action in the wake of Scott County where 99% of the cases were white. Too many Americans have been taught to shame and shun drug users (irrespective or race or ethnicity). Therefore, we need lessons that afford benefits to all communities. We need to understand what made opinion leaders change their views and then change more hearts and minds before, not after the next outbreak.

Author(s): Bekker, Linda-Gail; Alleyne, George; Baral, Stefan; Cepeda, Javier; Daskalakis, Demetre; Dowdy, David; Dybul, Mark; Eholie, Serge; Esom, Kene; Garnett, Geoff; Grimsrud, Anna; Hakim, James; Havlir, Diane; Isbell, Michael T; Johnson, Leigh; Kamarulzaman, Adeeba; Kasaie, Parastu; Kazatchkine, Michel; Kilonzo, Nduku; Klag, Michael; Klein, Marina; Lewin, Sharon R; Luo, Chewe; Makofane, Keletso; Martin, Natasha K; Mayer, Kenneth; Millett, Gregorio; Ntusi, Ntobeko; Pace, Loyce; Pike, Carey; Piot, Peter; Pozniak, Anton; Quinn, Thomas C; Rockstroh, Jurgen; Ratevosian, Jirair; Ryan, Owen; Sippel, Serra; Spire, Bruno; Soucat, Agnes; Starrs, Ann; Strathdee, Steffanie A; Thomson, Nicholas; Vella, Stefano; Schechter, Mauro; Vickerman, Peter; Weir, Brian; Beyrer, Chris

Objectives. To assess the impact of the expansion of Medicaid eligibility in the United States on the opioid epidemic, as measured through increased access to opioid analgesic medications and medication-assisted treatment. Methods. Using Medicaid enrollment and reimbursement data from 2011 to 2016 in all states, we evaluated prescribing patterns of opioids and the 3 Food and Drug Administration–approved medications used in treating opioid use disorders by using 2 statistical models. We used difference-in-differences and interrupted time series models to measure prescribing rates before and after state expansions. Results. Although opioid prescribing per Medicaid enrollee increased overall, we observed no statistical difference between expansion and nonexpansion states. By contrast, per-enrollee rates of buprenorphine and naltrexone prescribing increased more than 200% after states expanded eligibility, while increasing by less than 50% in states that did not expand. Methadone prescribing decreased in all states in this period, with larger decreases in expansion states. Conclusions. The Medicaid expansion enrolled a population no more likely to be prescribed opioids than the base Medicaid population while significantly increasing uptake of 2 drugs used in medication-assisted treatment.

Purpose Respondent-driven sampling (RDS) was used to recruit four samples of Black and Latino men who have sex with men (MSM) in three metropolitan areas to measure HIV prevalence and sexual and drug use behaviors. We compared demographic and behavioral risk characteristics of participants across sites, assessed the extent to which the RDS statistical adjustment procedure provides estimates that differ from the crude results, and summarized our experiences using RDS. Methods From June 2005 to March 2006 a total of 2,235 MSM were recruited and interviewed: 614 Black MSM and 516 Latino MSM in New York City, 540 Black MSM in Philadelphia, and 565 Latino MSM in Los Angeles County. Crude point estimates for demographic characteristics, behavioral risk factors and HIV prevalence were calculated for each of the four samples. RDS Analysis Tool was used to obtain population-based estimates of each sampled population’s characteristics. Results RDS adjusted estimates were similar to the crude estimates for each study sample on demographic characteristics such as age, income, education and employment status. Adjusted estimates of the prevalence of risk behaviors were lower than the crude estimates, and for three of the study samples, the adjusted HIV prevalence estimates were lower than the crude estimates. However, even the adjusted HIV prevalence estimates were higher than what has been previously estimated for these groups of MSM in these cities. Each site faced unique circumstances in implementing RDS. Conclusions Our experience in using RDS among Black and Latino MSM resulted in diverse recruitment patterns and uncertainties in the estimated HIV prevalence and risk behaviors by study site.

OBJECTIVES To examine the associations of homophobia, racism, and resiliency with differences in prevalent HIV infection in black and white men who have sex with men (MSM). METHODS The Involve[ment]t study is a cohort of black and white MSM aged 18-39 years in Atlanta, GA, designed to evaluate individual, dyadic, and community level factors that might explain racial disparities in HIV prevalence. Participants were recruited irrespective of HIV serostatus from community-based venues and from Internet advertisements and were tested for HIV. We assessed respondents' demographics, whether they had engaged in unprotected anal intercourse (UAI) within the past 6 months, and attitudes about perceived homophobia, perceived racism, and personal resiliency. RESULTS Compared with white MSM, black MSM were less likely to report UAI in the past 6 months [odds ratio (OR): 0.59, confidence interval (CI): 0.44 to 0.80], more likely to be HIV positive (OR: 5.05, CI: 3.52 to 7.25), and--among those HIV positive--more likely to report not being aware of their HIV infection (OR: 2.58, CI: 1.18 to 5.65). Greater perceived racism was associated with UAI in the black sample (partial odds ratio: 1.48, CI: 1.10 to 1.99). Overall, perceived homophobia, perceived racism, and resilience were not associated with prevalent HIV infection in our samples. Greater resilience was associated with less perceived homophobia in both black and white samples (Spearman r = -0.27, P < 0.001, for both). CONCLUSION Future studies of social discrimination at the institutional and network level, than at the individual level, may explain differences in HIV infection in black and white MSM.

Little research has been conducted to examine whether correlates of sexual risk vary by nativity among Latino men who have sex with men (MSM). We used cross sectional data collected from 870 Latino MSM recruited with respondent-driven sampling techniques. For each sub-sample (US-born and foreign-born), we assessed the association between each of the potential correlates (substance use, acculturation, social support, and social discrimination) and sexual risk behavior. Illicit drug use was associated with increased odds of sexual risk behavior in both US-born (OR = 2.17, 95 % CI 1.17–4.03) and foreign-born (OR = 1.86, 1.14–3.05) subgroups. Multivariate correlates specific to foreign-born men included binge drinking (OR = 1.91, 1.17–3.14), 15 years or longer spent in the US (OR = 1.79, 1.06–3.03) and exposure to social discrimination (OR = 2.02, 1.03–3.99). Given the diversity of Latino MSM, information from research that identifies both common and different HIV risk factors across subgroups of Latino MSM may help better tailor HIV prevention programs.

Gay, bisexual, and other men who have sex with men (MSM) have been disproportionately affected by HIV and AIDS since the beginning of the epidemic in the United States and in many other parts of the world. The HIV epidemic is inextricably tied to other health problems that disproportionately affect gay, bisexual, and other MSM including psychological comorbidities, substance use, sexual victimization, stigmatization, and multiple forms of discrimination. These interrelated health problems and social issues can be characterized as a syndemic of mutually reinforcing conditions or epidemics. Moreover, the syndemic is directed by biological, behavioral, psychosocial, and structural determinants. Addressing HIV within the context of a larger syndemic will require a more holistic approach to HIV prevention and treatment that recognizes the interplay between biological, behavioral, psychosocial, and structural factors that affect the health and well-being of sexual minority men.

Summary Pooled estimates from across the African diaspora show that black men who have sex with men (MSM) are 15 times more likely to be HIV positive compared with general populations and 8·5 times more likely compared with black populations. Disparities in the prevalence of HIV infection are greater in African and Caribbean countries that criminalise homosexual activity than in those that do not criminalise such behaviour. With the exception of US and African epidemiological studies, most studies of black MSM mainly focus on outcomes associated with HIV behavioural risk rather than on prevalence, incidence, or undiagnosed infection. Nevertheless, black MSM across the African diaspora share common experiences such as discrimination, cultural norms valuing masculinity, concerns about confidentiality during HIV testing or treatment, low access to HIV drugs, threats of violence or incarceration, and few targeted HIV prevention resources.

Objectives. We examined the impact of social discrimination and financial hardship on unprotected anal intercourse with a male sex partner of serodiscordant or unknown HIV status in the past 3 months among 1081 Latino and 1154 Black men who have sex with men (MSM; n = 2235) residing in Los Angeles County, California; New York, New York; and Philadelphia, Pennsylvania. Methods. We administered HIV testing and a questionnaire assessing 6 explanatory variables. We combined traditional mediation analysis with the results of a path analysis to simultaneously examine the direct, indirect, and total effects of these variables on the outcome variable. Results. Bivariate analysis showed that homophobia, racism, financial hardship, and lack of social support were associated with unprotected anal intercourse with a serodiscordant or sero-unknown partner. Path analysis determined that these relations were mediated by participation in risky sexual situations and lack of social support. However, paths between the explanatory variable and 2 mediating variables varied by participants’ serostatus. Conclusions. Future prevention research and program designs should specifically address the differential impact of social discrimination and financial hardship on lack of social support and risky sexual situations among Latino and Black MSM.

Objective To identify demographic, behavioral, and psychological variables associated with being HIV positive unaware among black and Latino men who have sex with men (MSM). Methods Participants recruited in 3 cities completed a computer-assisted interview and were tested for HIV infection (OraSure Technologies, Bethlehem, PA). HIV-positive unaware MSM were compared with MSM who tested HIV negative in bivariate and multivariate analyses. Results Of 1208 MSM (597 black and 611 Latino), 11% were HIV-positive unaware (18% black; 5% Latino). In multivariate analysis of the Latino MSM, being HIV-positive unaware was associated with nongay identity, high perceived risk of currently being HIV positive, and belief that sex with other Latino men reduces HIV transmission risk. Among black MSM, being HIV-positive unaware was associated with gay identity, moderately higher income, having health insurance, sexuality disclosure to a current health care provider, fewer than 3 lifetime HIV tests, high perceived risk of testing HIV positive, and belief that sex with other black men reduces HIV transmission risk. Conclusions HIV prevention efforts should address misperceptions among those black and Latino MSM who believe that assortative (ie, intraracial) sexual mixing reduces risk of HIV infection. Our findings also revealed missed opportunities to diagnose black MSM with HIV infection who were already engaged in care and had disclosed their sexuality to their health care provider. Clinicians should offer HIV testing to all MSM, particularly black MSM, who disclose engaging in recent sex with other men to facilitate earlier diagnosis of HIV infection and reduce transmission risk to sexual partners.

We examined the hypothesis that black and Latino men who have sex with men (MSM) who have supportive social relationships with other people are less likely to have unrecognized HIV infection compared with MSM of color who report lower levels of social support. We interviewed 1286 black and Latino MSM without known HIV infection in three metropolitan areas who were recruited using respondent driven sampling. Participants completed a computer-administered questionnaire and were tested for HIV. Unrecognized HIV infection was found in 118 men (9.2%). MSM who scored higher on the supportive relationship index had significantly lower odds of testing HIV-positive in the study. The mediation analysis identified two possible behavioral pathways that may partially explain this association: men who had strong supportive relationships were more likely to have had a test for HIV infection in the past 2 years and less likely to have recently engaged in high-risk sexual behavior. The findings illuminate the protective role of social relationships among MSM of color in our sample.

The success of male circumcision in reducing HIV acquisition among African heterosexuals has led to renewed interest in this biological intervention for HIV/sexually transmissible infection (STI) prevention in men who have sex with men (MSM). This review summarizes the available data on the association of circumcision and HIV/STI among MSM populations.Results of observational studies indicate that circumcision has limited impact on HIV/STI acquisition among MSM populations overall. Longitudinal data suggest that circumcision may reduce the risk of incident syphilis, but there is little evidence of a protective effect for other STIs. The subgroup of MSM who predominantly practise the insertive role in anal intercourse may be at lower risk of HIV, although the relative inefficiency of HIV acquisition for insertive compared with receptive partners has resulted in imprecise estimates of effect.The evidence that circumcision reduces HIV and other STIs among MSM is weak and inconsistent. However, recent studies have found that circumcised MSM who predominantly take the insertive role in anal intercourse may be at a lower risk of HIV infection. Although MSM may be willing to undergo adult circumcision, should it be proven to reduce HIV acquisition risk, there is substantial potential that behavioural disinhibition could offset any benefits achieved by a circumcision intervention.

Male circumcision (MC) has been associated with a reduced risk for female–male HIV transmission in observational and ecological studies, as well as clinical trials. Three recent randomized, controlled trials in sub-Saharan Africa demonstrated a 50–60% reduction in HIV incidence among men randomized to circumcision compared with uncircumcised men. In 2007, WHO/UNAIDS recommended that MC be recognized as an additional efficacious intervention to prevent sexual transmission of HIV from women to men. This article reviews information on the potential role of MC for HIV prevention in the USA where, compared with the African clinical trial countries, the prevalence of HIV infection is lower, the main route of HIV transmission is male–male sex rather than heterosexual sex and the prevalence of MC is higher.

Black men “on the down low” have been considered prime agents of HIV transmission in the Black community despite little empirical evidence. We assessed the relationship between down-low identification and sexual risk outcomes among 1151 Black MSM. Down-low Identification was not associated with unprotected anal or vaginal sex with male or female partners. Future HIV prevention programs and research should target sexual risk behaviors of Black men, irrespective of identity, and not focus on the “down low.”

Latino gay men report experiences of racial discrimination within and outside the gay community. This study focused on correlates of racism within general and gay contexts. Racism was assessed in a probability sample of 911 Latino gay men recruited from 3 U.S. cities. Factor analysis of the 10-item scale produced 2 factors: (a) General Racism Experiences, and (b) Racism Experiences in Gay Contexts. The scale and each factor showed adequate reliability and validity. Latino gay men with darker skin, more Indian features, more time in the United States, and low self-esteem reported more racism in both general and gay contexts. The authors examine the psychometric properties of a measure that assesses interpersonal racism among Latinos, report correlates of racism within a gay context, and provide an assessment tool for understanding the role of racism in the lives of Latino gay men.

HIV sexual transmission risk behaviors were examined among 1,065 Latino and 1,140 black men who have sex with men (MSM). Participants completed a computer-administered questionnaire and were tested for HIV infection. Of men who reported that their last HIV test was negative or that they had never been tested or did not get the result of their last test, 17% of black and 5% of Latino MSM tested HIV-positive in our study. In both ethnic groups, the three-month prevalence of unprotected anal intercourse (UAI) with HIV-negative or unknown serostatus partners was twice as high among men unaware of their HIV infection than men who knew they were HIV seropositive at the time of enrollment. UAI exclusively with HIV-positive partners was more prevalent among HIV-positive/aware than HIV-positive/unaware men. The findings advance understanding of the high incidence of HIV infection among black MSM in the U.S.

Black men who have sex with men and women (MSMW) are at high risk for HIV infection and transmission. This study compared the sexual risk behaviors of Black MSMW who self-reported being HIV-positive with those who reported being HIV-negative and those who did not know their HIV status. Respondent-driven sampling (RDS) was used to recruit 1,154 Black MSM in Philadelphia and New York who completed an audio computer-assisted self-interview (ACASI). Of these men, 212 had engaged in anal sex with male partners and vaginal or anal sex with female partners in the past 3 months. A quarter (23.6%; n = 50) of MSMW self-reported testing positive for HIV at their last test, 59.4% (n = 126) reported testing negative for HIV at their last test, and 17.0% (n = 36) reported never having an HIV test. Multivariate logistic regression analysis revealed that HIV-positive MSMW were much less likely than HIV-negative men and never-tested men to have engaged in unprotected intercourse with main male and main female partners perceived to be HIV-negative or of unknown serostatus. However, HIV-positive men were equally as likely as HIV-negative men to have unprotected intercourse with non-main male and non-main female partners perceived as HIV-negative or of unknown serostatus. Our findings indicate that some HIV-positive MSMW engage in unprotected sex that places female and male partners at risk for HIV infection. However, MSMW who have never taken an HIV test, or who have not been recently tested, may be a greater source of HIV transmission to their female and male partners.

It is estimated that nearly half of all African-American men who have sex with men (AAMSM) living in major U.S. cities are already infected with HIV. Without a substantial and committed investment in research in HIV prevention among AAMSM and subsequent evidence-based policies and community programs, it is unlikely that we will ever be able to curtail the HIV epidemic among African Americans in general, regardless of gender, age or sexual orientation. In this paper, we briefly review what is known and what research questions remain in order to curtail the epidemic among AAMSM. Finally, we provide recommendations for future research that include the: 1) development of a national cohort of young AAMSM to prospectively study biological, behavioral, social and contextual factors that place AAMSM at risk for infection with HIV and other STDs; 2) adapting existing interventions in HIV prevention to the unique characteristics of AAMSM and evaluating their effectiveness; 3) evaluating factors such as intracommunity and familial discrimination against AAMSM that may lead to lack of disclosure; and 4) enhancing our understanding of how cultural and social factors can be used in a positive and self-affirming way to strengthen HIV prevention and care for AAMSM.

Objective: To identify factors that contribute to the racial disparity in HIV prevalence between black and white men who have sex with men (MSM) in the United States. Methods: A comprehensive literature search of electronic databases, online bibliographies, and publication reference lists yielded 53 quantitative studies of MSM published between 1980 and 2006 that stratified HIV risk behaviors by race. Meta-analyses were performed to compare HIV risks between black and white MSM across studies. Results: Compared with white MSM, black MSM reported less overall substance use [odds ratio (OR), 0.71; 95% confidence interval (CI), 0.53‐0.97], fewer sex partners (OR, 0.64; 95% CI, 0.45‐0.92), less gay identity (OR, 0.29; 95% CI, 0.17‐0.48), and less disclosure of same sex behavior (OR, 0.42; 95% CI, 0.30‐0.60). HIV-positive black MSM were less likely than HIV-positive white MSM to report taking antiretroviral medications (OR, 0.43; 95% CI, 0.30‐0.61). Sexually transmitted diseases were significantly greater among black MSM than white MSM (OR, 1.64; 95% CI, 1.07‐2.53). There were no statistically significant differences by race in reported unprotected anal intercourse, commercial sex work, sex with a known HIV-positive partner, or HIV testing history. Conclusions: Behavioral risk factors for HIV infection do not explain elevated HIV rates among black MSM. Continued emphasis on risk behaviors will have only limited impact on the disproportionate rates of HIV infection among black MSM. Future research should focus on the contribution of other factors, such as social networks, to explain racial disparities in HIV infection rates.

Objectives To estimate the percentage of men who have sex with men (MSM) who have used the Internet to look for sex partners and to examine the prevalence of risky sex among MSM who have and have not sought partners online. Methods Meta-analyses were conducted on findings from published English-language studies. High-risk sex was self-reported unprotected anal intercourse (UAI). Analyses were stratified by method of study recruitment (online versus offline venues) and participants' human immunodeficiency virus (HIV) status. Results In studies that recruited MSM offline, a weighted mean, based on 15 findings, indicated that 40% (95% confidence interval [CI], 35.2%-45.2%) of MSM had used the Internet to look for sex partners. In 3 findings from offline studies that stratified by participant HIV status, the weighted-mean percentage was higher among HIV-positive (49.6%; 95% CI, 44.9%-54.3%) than HIV-negative/unknown MSM (41.2%; 95% CI, 36.8%-45.6%). UAI with male sex partners was more likely among MSM who sought partners online than MSM who did not (odds ratio, 1.68; 95% CI, 1.18-2.40; k = 11). This group difference was observed for UAI with HIV-serodiscordant as well as HIV-seroconcordant partners, particularly among HIV-positive study participants. HIV-serodiscordant UAI was not more prevalent with partners met online than offline. Conclusions A substantial percentage of MSM use the Internet to look for sex partners, and those who do are more likely to engage in unprotected sex. Additional research is needed to determine whether the Internet may increase risk behavior beyond that which occurs when men meet partners at offline venues.

Summary Background Disparities in HIV incidence and prevalence between black and white men who have sex with men (MSM) in the USA remain largely unexplained. We assessed the effect of interventions for black MSM that might reduce disparities in HIV care continuum and incidence in MSM. Methods Using data from the US Centers for Disease Control and Prevention (CDC), we constructed the HIV care continuum for black and white MSM for 2009–10. These data were used in a deterministic model to estimate race-specific transmissions, transmission rates, incidence rate, and rate ratios. Findings Disparities were noted throughout the care continuum, with 28 251 (16%) of 180 477 black MSM and 83 223 (34%) of 243 174 white MSM achieving viral suppression. An estimated 9833 and 9710 new HIV transmissions per year were attributable to HIV-positive black and white MSM, respectively (transmission rate ratio 1·36 and incidence rate ratio 7·92). In a model in which black and white MSM had identical care outcomes, the transmission rate ratio was 1·00 and incidence rate ratio was 5·80. In scenarios of 95% diagnosis, 95% retention, and concurrent 95% diagnosis and 95% retention, the transmission rate ratios were 1·00, 1·02, and 0·56, respectively, and incidence rate ratios were 5·81, 5·93, and 3·28, respectively. Interpretation Disparities in the rates of HIV transmission could be reduced by improving the outcomes of the HIV care continuum, but racial disparities in HIV prevalence are likely to continue sustaining the higher incidence in black MSM for decades to come. Funding US National Institutes of Health.

Self-reported HIV-negative black and Latino MSM who engaged in serosorting or strategic positioning were less likely to have unrecognized HIV infection than men who engaged in unprotected anal intercourse without using these risk-reduction strategies.

Objectives. We report lessons derived from implementation of the Social Network Strategy (SNS) into existing HIV counseling, testing, and referral services targeting 18- to 64-year-old Black gay, bisexual, and other men who have sex with men (MSM). Methods. The SNS procedures used in this study were adapted from a Centers for Disease Control and Prevention–funded, 2-year demonstration project involving 9 community-based organizations (CBOs) in 7 cities. Under the SNS, HIV-positive and HIV-negative men at high risk for HIV (recruiters) were enlisted to identify and recruit persons from their social, sexual, or drug-using networks (network associates) for HIV testing. Sites maintained records of modified study protocols for ascertaining lessons learned. The study was conducted between April 2008 and May 2010 at CBOs in Washington, DC, and New York, New York, and at a health department in Baltimore, Maryland. Results. Several common lessons regarding development of the plan, staffing, training, and use of incentives were identified across the sites. Collectively, these lessons indicate use of SNS is resource-intensive, requiring a detailed plan, dedicated staff, and continual input from clients and staff for successful implementation. Conclusions. SNS may provide a strategy for identifying and targeting clusters of high-risk Black MSM for HIV testing. Given the resources needed to implement the strategy, additional studies using an experimental design are needed to determine the cost-effectiveness of SNS compared with other testing strategies.

The President's Emergency Plan for AIDS Relief (PEPFAR), which began in 2003, initially responded to the global AIDS epidemic by applying lessons learned in treating the disease in the United States to addressing the emergency abroad. As the program expanded, it evolved to support interventions increasingly tailored to local needs in countries receiving PEPFAR assistance. This global experience has created a knowledge base of how to provide HIV/AIDS prevention, care, and treatment services in low-resource settings. It underscored the importance of treatment adherence, family-centered care, and integration of HIV into broader health care delivery systems. Applying these lessons can help US policy makers address existing gaps in HIV care in the United States, where the availability of HIV treatment has at times masked the continued need for testing, early diagnosis, targeted prevention for key populations, and a solid array of social services for people living with HIV/AIDS and their families. This article identifies PEPFAR practices that merit further exploration for adoption in the United States, including strategies to increase adherence to drug treatment regimens and to ensure that HIV services are broadly integrated with other aspects of health care.

We investigated whether the experience of homophobic events increases the odds of engaging in unprotected anal intercourse (UAI) among black men who have sex with men (MSM) and whether social integration level buffered the association. Participants (N = 1,154) reported homophobic events experienced in the past 12 months. Social integration measures included social support, closeness with family members and friends, attachment to the black gay community, openness about sexuality within religious communities, and MSM social network size. Logistic regression analyses indicated that experiencing homophobia was associated with (1) UAI among men not previously diagnosed with HIV and (2) sexual HIV transmission risk behavior among men who knew they were HIV-infected. None of the social integration measures buffered these associations. Homophobia may promote acquisition and transmission of HIV infection among black MSM. Interventions are needed to reduce homophobia experienced by black MSM.

Gender role conflict may influence condom use among black MSM. We examined relationships between the Gender Role Conflict Scale (GRCS), social/demographic variables and condom use among 456 black MSM. Higher total GRCS scores did not predict unprotected insertive anal intercourse (UIAI) or unprotected receptive anal intercourse (URAI) with men, but were associated with unprotected vaginal or anal intercourse (UVI/UAI) with women among bisexually active participants (n = 69). Higher perceived HIV risk reduced the likelihood of both UIAI and URAI with men. Internet recruitment venues, sexual discrimination experiences, higher numbers of sex partners and UVI/UAI with women all increased the likelihood of UIAI with men, while education (college/technical school or college degree) was associated with URAI with men. Future sexual health interventions for black MSM should emphasize broader social/demographic and alternative gender role variables with male sexual partners, while traditional GRCS variables may prove useful among those with female sexual partners.

Objectives The authors examine whether young black and Latino men who have sex with men (MSM) who have older sex partners are more likely than those who do not have older sex partners to have unrecognised HIV infection. The authors examine whether the association stems from (1) increased sexual risk behaviour with male partners of any age, (2) heightened risk of being exposed to HIV infection by older partners or (3) a combination of these two factors. Methods The analytical sample consisted of 723 black and Latino MSM, aged 18–35 years, who were HIV negative or of unknown serostatus at study entry. Participants completed a self-administered questionnaire and were tested for HIV infection. Men who reported having a male sex partner who was at least 4 years older than themselves were compared with those who did not. Outcomes included unprotected receptive anal intercourse (URAI) with male partners of any age (past 3 months) and having unrecognised HIV infection. Results Men with older partners reported a higher prevalence of URAI (AOR=1.50, 95% CI 1.02 to 2.21). A second model found that men with older partners had increased odds of having unrecognised HIV infection (AOR=2.51, 95% CI 1.18 to 5.34) after controlling for the number of URAI partners of any age, which remained an independent predictor. Conclusions Young black and Latino MSM who had older male sex partners were at increased risk of having unrecognised HIV infection. This heightened risk was associated with sexual risk behaviour with partners of any age as well as possible increased exposure to HIV infection from older partners.

Using cross-sectional data collected from 1081 Latino men who have sex with men (MSM) recruited with respondent-driven sampling (RDS) techniques from Los Angeles and New York, we examined the extent to which Latino MSM reported exposure to social discrimination (i.e., experienced both homophobia and racism, homophobia only, racism only, or neither homophobia nor racism). More than 40% of respondents experienced both homophobia and racism in the past 12 months. Los Angeles participants, those with lower income, and those who reported being HIV-positive were more likely to report experiencing both types of social discrimination. Adjusting for potential confounders, men exposed to both homophobia and racism were more likely than men exposed to neither form of discrimination to report unprotected receptive anal intercourse with a casual sex partner (AOR = 1.92, 95% CI, 1.18–3.24) and binge drinking (AOR = 1.42, 95% CI, 1.02–1.98). Our findings suggest the presence of a syndemic of adverse social experiences and call for more intervention research to address both homophobia and racism experienced among Latino MSM in the United States.

Objective 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. Design The 2008 National HIV Behavioral Surveillance System (NHBS), a cross-sectional survey conducted in 21 US cities. Methods 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. Results 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). Conclusion 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.

In July 2010, the Obama Administration released a National HIV/AIDS Strategy for the United States to refocus national attention on responding to the domestic HIV epidemic. The goals of the strategy are to reduce HIV incidence; to increase access to care and optimize health outcomes among people living with HIV; and to reduce HIV-related disparities. The strategy identifies a small number of action steps that will align efforts across federal, state, local, and tribal levels of government, and maximally impact the domestic HIV epidemic. In this article, we outline key programmatic and research issues that must be addressed to accomplish the prevention goals of the National HIV/AIDS Strategy.

Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention (CDC), Atlanta, Georgia. Background: Human immunodeficiency virus (HIV) disproportionately affects black women. Nearly two-thirds of all female HIV cases reported to the CDC are black, and HIV is the leading cause of death among black women aged 25 to 34 years. The greatest HIV transmission risk among black women is sexual intercourse with a man, although the role of bisexual men is not clear. Methods: The CDC and collaborating partners conducted behavioral surveys at 7 historically black colleges and universities from January 2005 to April 2007. Results: Of the 2705 black female students aged 18 to 29 years who were surveyed, 2040 (75%) reported being sexually active in the previous 12 months and, among sexually active women, 291 (14%) reported having sex with a bisexual man in the previous 12 months. Women who reported sex with a bisexual man were more likely than women who did not to report having at least 2 sex partners in the previous 12 months, having male and female sex partners, not using a condom at last intercourse, being in a committed relationship, never or infrequently attending church, and believing they were at increased risk for HIV infection. Conclusion: Heterosexually active black women who have engaged in sexual intercourse with bisexual men have a different HIV risk profile than other heterosexually active black women.

This article examines the sociodemographic/behavioral variables associated with low peer support of condom use and the relation between low peer support of condom use and unprotected anal sex for Black and Latino MSM in cities heavily impacted by the HIV/AIDS epidemic. Our findings indicate that perceived low peer support of condom use is associated with increased odds of recent unprotected anal intercourse (UAI) among Black and Latino MSM, regardless of male partner type. Although many participants reported having high peer support of condom use, this analysis highlights a considerable subgroup of Black and Latino MSM, 21% and 30%, respectively, who report low peer support of condoms. Given the prevalence of low peer support of condom use and its association with UAI in these highly impacted MSM populations, we recommend future intervention work that draws upon Black and Latino MSM's peer and social network members to reduce HIV risk behaviors.