Disparities in HIV among MSM: Role of Social Determinants George Ayala, Executive Officer The Global Forum on MSM & HIV
A key component of the shift from an emergency to a long-termresponse to AIDS is a change in focus from HIV preventioninterventions focused on individuals to a comprehensive strategyin which social/structural approaches are core elements. Suchapproaches aim to modify social conditions by addressing keydrivers of HIV vulnerability that affect the ability of individuals toprotect themselves and others from HIV.Source: Auerbach, JD, Parkhurst, JO, and Caceres, CF. 2011. Addressing the social drivers of HIV/AIDS for the long-term response:Conceptual and methodological considerations. Global Public Health.
HIV Prevalence Among MSM Compared with HIVPrevalence in the General Population (Aged 15 and over) in36 Low- and Middle-Income Countries353025201510 5 0 HIV Prevalence Among MSM Population Prevalence of HIV (Ages >/= 15 years)Source: Beyrer C, Baral SD, Walker D, Wirtz AL, Johns B, Sifakis F. The Expanding Epidemics of HIV Type 1 Among Men Who HaveSex With Men in Low- and Middle-Income Countries: Diversity and Consistency. Epidemiol Review. 2010;32(1):137-51. Epub 2010 Jun23.
Nearly80 countries around the world criminalizehomosexuality, five with the death penalty.2% of global spending on HIV prevention programs isspecifically targeted to men who have sex with men in low andmiddle-income countries. In Latin America, 60% of people living with HIV are MSM, but only 0.5% of total HIV prevention spending is targeted at them (2004) Available resources led to between 7 – 17% coverage of basic HIV prevention services in the Asia-Pacific region among MSM (2006) Only 0.6% of total HIV prevention spending was targeted toward MSM in 55 low- and middle-income countries (2006)
HIV Prevention Spending Among MSM vs. Othersin 22 Low- and Middle-Income Countries (2009)
MSM and HIV in the U.S.: An Overview• MSM accounted for more than half (61%) of all new HIV infections in 2009.• The rate of new HIV diagnoses among MSM is more than 44 times that of other men and more than 40 times that of women (522-989 cases per 100,000 vs. 12 per 100,000 other men and 13 per 100,000 women).• Among people aged 13-29, only MSM experienced increases in HIV incidence between 2006-2009 . There was a 48% increase among Black MSM during the same period.• Unrecognized HIV infection is of particular concern especially among young Black and Latino MSM.Sources: Prejean, J., et al. Estimated Incidence in the U.S., 2006-2009. PloS ONE; 6(8): 1-13.Centers for Disease Control and Prevention. Subpopulation estimates from the HIV incidence surveillance system – United States,2006. MMWR. 2008; 57(36): 985-989.Centers for Disease Control and Prevention. Trends in HIV/AIDS diagnoses among men who have sex with men – 33 states, 2001 – 62006. MMWR. 2008; 57(25): 681-686.
In 2009, there were 6,604 reported incidents of hate crimes inthe U.S. 50% were due to racial bias 19% were due to a person’s sexual orientationSource: Federal Bureau of Investigations - 2010
Average FY2009 Funding100% 90% 80% 70% 60% $4,992,473 $5,099,351 $1,579,356 $10,106,396 50% Total 40% MSM 30% 20% 10% $1,146,330 $680,172 $199,441 $1,375,983 0% CDC HD Core CDC HD HIV State Funds All Sources Funding Testing Source: National Alliance of State and Territorial AIDS Directors. 2010. Black Gay Men and HIV/AIDS: Evaluating Our Progress to Reverse the Epidemic.
In 2009, the Division of HIV/AIDS Prevention (DHAP) targeted43% of its funding to HIV prevention among MSM.The smallest category of the U.S. President’s FY2012 budgetrequest for domestic HIV/AIDS spending was HIV prevention atjust under 4%.Sources: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD,and TB Prevention. 2011. Strategic Plan DHAP 2011 through 2015.Kaiser Family Foundation. 2012.
Patrick WilsonGlenn-Milo SantosPato HebertGeorge Ayala
Study AimsThe goals of the survey were to: – provide a platform for MSM voices from around the globe – highlight key gaps in basic HIV prevention services – assess predictors of access and participation for those services – assess knowledge about emerging prevention strategies – identify potential challenges in implementation of prevention strategies
Methods• Online survey for MSM and service providers – Administered from June to August of 2010• MSMGF networks, list serves, e-mail blasts, website• Chinese, English, French, Russian, Spanish• Measures adapted from validated scales• Assessments included items from recommendations by governmental agencies, and advocacy organizations• Data Analysis – Identify disparities - Analysis of Variance (Anova) – Identify predictors - Regression models
Constructs Measured• Perceived stigma/external homophobia• Internalized homophobia• Self-esteem• Access to basic HIV prevention services• Access to emerging HIV prevention technologies• Knowledge of emerging technologies• Desire to learn about emerging technologies• PrEP knowledge• Attitudes about PrEP• Participation in HIV prevention activities• Exposure to HIV prevention messages• Venues in which HIV prevention materials were obtained
Sample Characteristics• Total sample = 5,066 – English (46%) – Chinese (40%)• Geographic Distribution – 56% from Asia-Pacific – 14% from North America – 11% from Central/South America and the Caribbean – 7% from Australia/New Zealand – 6% from Europe – 4% from Africa – 1% from the Middle East• Mean age was 34.3 years (range: 14-86 years)• 21% of the sample were health providers
Access to Basic HIV Prevention Services “this is easily accessible in my Prevention components community”Free HIV Testing 48%HIV Counseling 51%HIV Treatment 36%Sexual Transmitted Diseases STD)Testing 53%STD Treatment 47%Free Condoms 44%Condom-compatible lubricants 29%Sex Education Programs 25%
Key Findings• Basic HIV prevention interventions—including free condoms, condom-compatible lubricants, HIV testing—are not widespread and easily accessible globally for MSM – Rates lowest in Asia-Pacific, Middle East, Africa and Central/South America or the Caribbean• Youth lack access to basic HIV prevention interventions, have low knowledge of emerging interventions• Alarming levels of external homophobia – Rates highest in Africa, followed by Caribbean and Central/South America, Asia-Pacific, and the Middle East• External homophobia and younger age independently predict lower access to basic HIV prevention interventions• Overall knowledge of emerging HIV prevention strategies low across all regions – Strong desire to learn more about emerging ARV-based primary prevention interventions overall
Modeling the impact of social discriminationand financial hardship on the sexual risk forHIV among Latino and Black MSM George Ayala, Trista Bingham, Junyeop Kim, Darrell Wheeler, and Greg Millet
Stigma: A dynamic process of devaluation thatsignificantly discredits an individual in the eyes of others.Social Discrimination: Mean, unfair, orunequal treatment (including acts of verbal or physicalviolence) intended to marginalize or subordinateindividuals or communities based on their real orperceived affiliation with socially constructed stigmatizedattributes.
Hypotheses• Experiences of social discrimination and lack of social support would each be positively associated with UAI with casual male partners• Experiences of social discrimination and financial hardship would be positively associated with lack of social support• Experiences of social discrimination, financial hardship, and lack of social support would each be associated with reports of being in situations that make safer sex more difficult• Participation in difficult sexual situations would mediate the associations between social discrimination, financial hardship, and lack of social support on UAI with casual male partners
Methods• Respondent driven sampling (RDS)• Traditional mediation analysis and path analysis• Chi-square and t-test stats to examine bi-variate associations• Linear and logistic regression analyses to examine associations between variables
Sample• Recruited 1,081 Latinos and 1,154 Black MSM from May 2005 through April 2006 in New York City, Philadelphia, and Los Angeles• Reported sex with another man in the past 12 months, irrespective of HIV serostatus• 57% of Latinos and 9% Blacks were born outside the U.S.• Latinos were younger than Blacks (median ages 32 and 43 respectively)• 58% Latinos and 33% Blacks reported being employed full or part time• 39% of Latinos and 53% of Blacks were HIV-positive based on HIV testing conducted during study, of which 2/3 reported receiving ARV therapy in the past 3 months
Associations between Social Discrimination, Lack of Social Support, Difficult Sexual Situations & HIV Risk UAI w/ Casual Male Partner (past 3 months) Yes No p-valueHomophobiaFull Scale (Cronbach’s alpha=.83) 9.11 8.15 <.0001RacismFull Scale (Cronbach’s alpha=.73) 8.18 7.30 <.0001Financial Hardship (single item)Ran out of money for basic needs 72% 60% <.0001Lack of Social Support: Dichotomized itemFull scale (Cronbach’s alpha=.81) 46% 38% .0005Difficult Sexual Situations: Dichotomized and Scale ItemsHad anal sex for drugs/money/place to stay 30% 6% <.0001Used illicit drugs in past 3 months 46% 29% <.0001Sex in someone else’s home 39% 17% <.0001Had a partner who was more masculine 38% 15% <.0001Used alcohol or drugs before or during sex 54% 17% <.0001Sum of potentially risky sexual situations (Sum of 5 items) 2.1 .8 <.0001
Modeling the Impact of Social Discrimination on the Risk for HIV Among Latino and Black MSMPredictor B p-value Hypothesis 2: Social discrimination predicts lack of social supportHomophobia .50 <.0001Racism .51 <.0001Poverty .75 <.0001 R2 = .15, F = 128.57, p < .0001 Hypothesis 3: Social discrimination and lack of social support predict difficult sexual situationsHomophobia .12 .0001Racism .11 .006Poverty .14 <.0001Lack of social support .03 <.0001 R2 = .08, F = 47.5, p < .0001
Social Discrimination’s Impact on HIV Risk is Mediated by Lack of Social Support and Difficult Sexual SituationsPredictor OR 95% CI p-valueHomophobia 1.0 .88 -1.1 .94Racism 1.2 1.0 -1.4 .03Financial Hardship 1.1 .91 -1.4 .25Lack of social support 1.0 .99 -1.0 .07Difficult sexual situations (ref=none)* 1.0 -- --One 2.6 2.0 -3.4 <.0001Two 7.3 5.5 -9.7 <.0001Three to Five 13 10 -18 <.0001
Associations between Social Discrimination and UAI among Latino and Black MSM Racism Among black MSM Among Latino MSM Lack of Social Support Sexual Risk Homophobia for HIV (UAI) Difficult Sexual Situations Financial Hardship Among Latino MSM
Sources and types of discrimination matter ----are cumulative ---- and may have differentialsalience for different men of color.
A surprising amount of research remains to be done to understandhow sexual behavior among MSM is shaped by developmentalinfluences (e.g., early sexual experiences, coming out,acceptance/rejection by family and friends, schoolenvironment and policies), self concept, and mental healthaspects of sexuality (e.g., internalized homo-negativity,body image, sexual compulsivity,erotophobia/erotophilia, social anxiety), formation andmaintenance of primary relationships, sexual relationshipswithin and outside of primary relationships and sexualsatisfaction and physical function.Source: Wolitski, RJ and Fenton KA. 2011. Sexual health, HIV, and sexually transmitted infections among gay , bisexual, and other menwho have sex with men in the United States. AIDS Behavior.
Sexual health is a state of physical, emotional, mentaland social well-being in relation to sexuality; it is notmerely the absence of disease, dysfunction or infirmity.Sexual health requires a positive and respectfulapproach to sexuality and sexual relationships, as wellas the possibility of having pleasurable and safe sexualexperiences, free of coercion, discrimination andviolence. For sexual health to be attained andmaintained, the sexual rights of all persons must berespected, protected and fulfilled.Source: World Health Organization. Defining sexual health: report of a technical consultation on sexual health 28-31 January 2002,Geneva. Geneva: World Health Organization; 2006.