AIDS 2012: Your Day-Two Dose of Science
Addressing Barriers to Health Care for Black Gay Men
Even at 7:00 a.m., “Equity for YMSM of Color in the USA: Ensuring Quality Cultural, Structural and Optimal Care and Research for Gay and Bi Men of Color” was a compelling session. The satellite (co-sponsored by San Francisco AIDS Foundation) addressed barriers to health care among young African-American gay and bisexual men, including stigmatized and untreated mental health issues such as depression.
Emory University’s David Malebranche observed that many of his own patients at an Atlanta HIV clinic face huge obstacles to accessing medical care and services, including poverty, depression and other mental health issues, and a lifetime’s accumulated traumas from homophobia and racism; he called for better training of health care workers—from the front desk to the primary care provider—to create the welcoming, safe environment necessary to engage these men in medical care, as well as more efficient care systems to keep them coming back.
In a similar vein, Ronald Stall of the University of Pittsburgh discussed “syndemics”—overlapping epidemics of psychosocial conditions that put gay men (and young gay men in particular) at high risk for HIV. Childhood sexual abuse, homophobic attacks, depression, and other psychosocial factors are intertwined with HIV risk for gay men, Stall explained. “Scientists are just obsessed with the area between the knee and the navel when it comes to gay men,” he said. Their heads and hearts, he continued, are understudied.
This may be cheating a bit because the abstract doesn’t actually come from AIDS 2012, but this excerpt from a recent journal article co-authored by panelist Ronald Stall illuminates the syndemics experienced by many black gay men—which is, of course, a necessary step toward changing them.
Application of Syndemic Theory to Black Men Who Have Sex with Men in the Multicenter AIDS Cohort Study
Dyer, T., and others. Journal of Urban Health. Published online March 2, 2012.
This study analyzed data from a large prospective epidemiologic cohort study among men who have sex with men (MSM), the Multicenter AIDS Cohort Study, to assess syndemic relationships among Black MSM in the cohort (N = 301). We hypothesized that multiple interconnections among psychosocial health conditions would be found among these men, defining syndemic conditions. Constituents of syndemic conditions measured included reported depression symptoms, sexual compulsiveness, substance use, intimate partner violence (IPV), and stress. We found significant evidence of syndemics among these Black men: depression symptoms were independently associated with sexual compulsiveness (odds ratios [OR]: 1.88, 95% CI = 1.1, 3.3) and stress (OR: 2.67, 95% CI = 1.5, 4.7); sexual compulsiveness was independently associated with stress (OR: 2.04, 95% CI = 1.2, 3.5); substance misuse was independently associated with IPV (OR: 2.57, 95% CI = 1.4, 4.8); stress independently was associated with depression symptoms (OR: 2.67, 95% CI = 1.5, 4.7), sexual compulsiveness (OR: 2.04, 95% CI = 1.2, 3.5) and IPV (OR: 2.84, 95% CI = 1.6, 4.9). Moreover, men who reported higher numbers of syndemic constituents (three or more conditions) reportedly engaged in more unprotected anal intercourse compared to men who had two or fewer health conditions (OR: 3.46, 95% CI = 1.4-8.3). Findings support the concept of syndemics in Black MSM and suggest that syndemic theory may help explain complexities that sustain HIV-related sexual transmission behaviors in this group.
Looking for resources for African-American gay and bi men? Start here, with the Black Gay Men’s Network.
Quick Update on Treatment as Prevention (More on the Way!)
As reported previously, the landmark HPTN 052 study of early vs. delayed antiretroviral therapy with serodiscordant (mixed-HIV-status) couples showed not just better health outcomes for partners who started treatment at higher CD4 cell counts (the “early” arm), but also a whopping 96% decrease in HIV transmission. Today investigator Kenneth Mayer of Boston’s Fenway Institute reported new data from HPTN 052 indicating that study participants in the early arm continued to have undetectable viral load 24 months into the study, and also reported lasting decreases in unprotected sex—two sustained benefits from early HIV treatment.
Sustained treatment as prevention: continued decreases in unprotected sex and increases in virological suppression after HAART initiation among participants in HPTN 052.
Mayer, K. and others. 19th International AIDS Conference. Washington, DC. July 22-27, 2012. Abstract MOPDC0106.
Background: HPTN 052 demonstrated a 96% decrease in HIV transmission when infected persons in serodiscordant relationships initiated HAART at study entry compared to those randomized to delayed treatment. However, this benefit could be attenuated if HIV-infected participants subsequently increased unprotected sex without virological control.
Methods: Between 06/2007 and 05/2010, 1763 HIV serodiscordant couples were enrolled in 9 countries in Africa, Asia and the Americas, and followed for a median of 2 years. The current analyses compared the sexual behavior of HIV-infected participants before and after they initiated HAART, and examined trends to evaluate whether risk taking changed over time by GEE models.
Results: At enrollment, 4.0% of HIV-infected participants in the early treatment group (E) and 5.7% in the delayed arm (D) self-reported unprotected vaginal intercourse (UVI) with their primary partner within the past week. At 3 months, 2.9% of E participants did, compared to 3.0% of D participants (p=0.9). Over 2 years, UVI decreased among all participants (β=-0.015, p=0.04), and the time trend was similar in both arms. Participants engaging in UVI were more likely to be female (AOR=1.6, 95%CI 1.1-2.4), from South America vs. Asia, AOR=16.0, 95%CI 8.2-31.3), from Africa vs. Asia(AOR=8.8, 95%CI 5.0-15.6), use substances (AOR=2.2,95% CI 1.3-3.9), and have a lower viral load at enrollment (AOR=0.7, 95% CI 0.6-0.9). After 2 years, 91% of E participants were virologically suppressed, compared with 22% of D participants. Self-reported unprotected anal intercourse was uncommon (< 0.3% at baseline, and no change over time).Only 21% of participants on HAART who engaged in UVI or UAI had detectable plasma viremia.
Conclusions: Participants randomized to early HAART and those who subsequently initiated HAART did not increase risk taking over several years. The decrease in sexual risk taking, coupled with effective virologic suppression, suggest that earlier initiation of HAART could have sustained effects in decreasing HIV transmission.
Want the backstory on treatment as prevention? Read it all here in BETA!
Reilly O’Neal is the editor of BETA.