Elsevier

The Lancet

Volume 380, Issue 9839, 28 July–3 August 2012, Pages 341-348
The Lancet

Articles
Comparisons of disparities and risks of HIV infection in black and other men who have sex with men in Canada, UK, and USA: a meta-analysis

https://doi.org/10.1016/S0140-6736(12)60899-XGet rights and content

Summary

Background

We did a meta-analysis to assess factors associated with disparities in HIV infection in black men who have sex with men (MSM) in Canada, the UK, and the USA.

Methods

We searched Embase, Medline, Google Scholar, and online conference proceedings from Jan 1, 1981, to Dec 31, 2011, for racial comparative studies with quantitative outcomes associated with HIV risk or HIV infection. Key words and Medical Subject Headings (US National Library of Medicine) relevant to race were cross-referenced with citations pertinent to homosexuality in Canada, the UK, and the USA. Data were aggregated across studies for every outcome of interest to estimate overall effect sizes, which were converted into summary ORs for 106 148 black MSM relative to 581 577 other MSM.

Findings

We analysed seven studies from Canada, 13 from the UK, and 174 from the USA. In every country, black MSM were as likely to engage similarly in serodiscordant unprotected sex as other MSM. Black MSM in Canada and the USA were less likely than other MSM to have a history of substance use (odds ratio, OR, 0·53, 95% CI 0·38–0·75, for Canada and 0·67, 0·50–0·92, for the USA). Black MSM in the UK (1·86, 1·58–2·18) and the USA (3·00, 2·06–4·40) were more likely to be HIV positive than were other MSM, but HIV-positive black MSM in each country were less likely (22% in the UK and 60% in the USA) to initiate combination antiretroviral therapy (cART) than other HIV-positive MSM. US HIV-positive black MSM were also less likely to have health insurance, have a high CD4 count, adhere to cART, or be virally suppressed than were other US HIV-positive MSM. Notably, despite a two-fold greater odds of having any structural barrier that increases HIV risk (eg, unemployment, low income, previous incarceration, or less education) compared with other US MSM, US black MSM were more likely to report any preventive behaviour against HIV infection (1·39, 1·23–1·57). For outcomes associated with HIV infection, disparities were greatest for US black MSM versus other MSM for structural barriers, sex partner demographics (eg, age, race), and HIV care outcomes, whereas disparities were least for sexual risk outcomes.

Interpretation

Similar racial disparities in HIV and sexually transmitted infections and cART initiation are seen in MSM in the UK and the USA. Elimination of disparities in HIV infection in black MSM cannot be accomplished without addressing structural barriers or differences in HIV clinical care access and outcomes.

Funding

None.

Introduction

One of the most striking HIV infection disparities in the USA is the disproportionate toll on black men who have sex with men (MSM). Although representing less than 1% of the total population, nearly a quarter of new HIV infections in 2009 were in black MSM.1, 2 The US Centers for Disease Control and Prevention has announced that new HIV cases increased by 48% in young US black MSM from 2006 to 2009.2 In the past decade, several important investigations in the US have helped to clarify the factors that might contribute to disproportionate infection rates in black MSM.3, 4, 5, 6

Despite these previous investigations, important gaps remain in scientific publications. Although a previously published meta-analysis5 provided evidence for several postulated reasons for greater HIV disparities in black MSM than in other MSM, other relevant hypotheses were not examined because of insufficient published studies at that time. Additional pertinent research has been published in the intervening years, however, and data from these studies might yield a more comprehensive review of the evidence. A second gap in publications is a meta-analysis of risk factors associated with HIV infection in young black MSM. Whether factors that raise infection risk for black MSM overall are similar or different for young black MSM is unknown. In view of scientific advances showing that early HIV diagnosis and entry into care improve clinical outcomes and greatly reduce risk of sexual transmission to sex partners,7 a third gap in published work is a meta-analysis documenting racial disparities in HIV-positive MSM associated with access and use of clinical care. Last, another prominent gap is the degree to which disparities associated with HIV infection in US black MSM are also applicable to black MSM in other high-income countries.

The aims of the current quantitative review are to: (1) explore factors associated with greater HIV transmission risks in young black MSM than in other young MSM across studies; (2) assess the degree to which access to clinical care and other disparities exist in HIV-positive black MSM relative to other HIV-positive MSM; (3) examine HIV-related disparities for black MSM relative to other MSM in Canada and the UK; and (4) gauge the degree to which HIV-related racial disparities are similar or different in black MSM in Canada, the UK, and the USA.

Section snippets

Search strategy and selection criteria

We searched Medline, Embase, and Google Scholar for relevant reports from Jan 1, 1981, to Dec 31, 2011. Key words and Medical Subject Headings (US National Library of Medicine) relevant to race (ie, “black”, “African”, “Caribbean”, “Afro”, “African-American”) were cross-referenced with citations pertinent to homosexual men (ie, “homosexual”, “bisexual”, “men who have sex with men”, “MSM”, “gay”, “HIV”, “AIDS”) in English and French. Particular attention was paid to Canadian, UK, and US studies

Results

In total, our search resulted in 194 articles, abstracts, or personal communications. We assessed seven studies from Canada, 13 from the UK, and 174 from the USA.

In the USA, 174 studies of black MSM were compared with other MSM of other races or ethnic origins (table 1). Black MSM across studies were less likely to report gay identity or to report disclosing their sexuality to others, including health-care providers (table 1). Overall, however, black MSM engaged in fewer HIV risk behaviours

Discussion

A clear and paradoxical pattern of similar or less risk behaviour and risk of HIV or STI emerged in the USA and UK such that black MSM reported similar serodiscordant or receptive UAI, similar or fewer male sex partners, and had a greater likelihood of HIV infection than did other MSM. Although in Canada black MSM are not more likely to have HIV than are white MSM, it is notable that black MSM reported less substance use than did other MSM but remained equally likely to be diagnosed with HIV

References (22)

  • SO Aral et al.

    Understanding and responding to disparities in HIV and other sexually transmitted infections in African Americans

    Lancet

    (2008)
  • RM Viner et al.

    Adolescence and the social determinants of health

    Lancet

    (2012)
  • D Binson et al.

    Prevalence and social distrbution of men who have sex with men: United States and its urban centers

    J Sex Res

    (1995)
  • J Prejean et al.

    Estimated HIV incidence in the United States, 2006–2009

    PloS One

    (2011)
  • T Bingham et al.

    The effect of partner characteristics on HIV infection among African American men who have sex with men in the Young Men's Survey, Los Angeles, 1999–2000

    AIDS Ed Prev

    (2003)
  • DA MacKellar et al.

    Unintentional HIV exposures from young men who have sex with men who disclose being HIV negative

    AIDS

    (2006)
  • GA Millett et al.

    Explaining disparities in HIV infection among black and white men who have sex with men: a meta-analysis of HIV risk behaviors

    AIDS

    (2007)
  • GA Millett et al.

    Greater risk for HIV infection of black men who have sex with men. A critical literature review

    Am J Public Health

    (2006)
  • MS Cohen et al.

    Prevention of HIV-1 infection with early antiretroviral therapy

    NEJM

    (2011)
  • LV Hedges et al.

    Fixed and random effects models in meta-analysis

    Psychol Meth

    (1998)
  • The Canadian Medical Protective Association

    Treating non-residents of Canada. August 2008

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