2011 National HIV Prevention Conference. Plenaries. Wednesday.

1. Disparities in HIV among MSM:
Role of Social Determinants
George Ayala, Executive Officer
The Global Forum on MSM & HIV

2. A key component of the shift from an emergency to a long-term
response to AIDS is a change in focus from HIV prevention
interventions focused on individuals to a comprehensive strategy
in which social/structural approaches are core elements. Such
approaches aim to modify social conditions by addressing key
drivers of HIV vulnerability that affect the ability of individuals to
protect 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.

3. HIV Prevalence Among MSM Compared with HIV
Prevalence in the General Population (Aged 15 and over) in
36 Low- and Middle-Income Countries
35
30
25
20
15
10
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 Have
Sex With Men in Low- and Middle-Income Countries: Diversity and Consistency. Epidemiol Review. 2010;32(1):137-51. Epub 2010 Jun
23.

4. Nearly80 countries around the world criminalize
homosexuality, five with the death penalty.
2% of global spending on HIV prevention programs is
specifically targeted to men who have sex with men in low and
middle-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)

5. HIV Prevention Spending Among MSM vs. Others
in 22 Low- and Middle-Income Countries (2009)

6. 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 –
6
2006. MMWR. 2008; 57(25): 681-686.

10. In 2009, there were 6,604 reported incidents of hate crimes in
the U.S.
50% were due to racial bias
19% were due to a person’s sexual orientation
Source: Federal Bureau of Investigations - 2010

11. Average FY2009 Funding
100%
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.

12. In 2009, the Division of HIV/AIDS Prevention (DHAP) targeted
43% of its funding to HIV prevention among MSM.
The smallest category of the U.S. President’s FY2012 budget
request for domestic HIV/AIDS spending was HIV prevention at
just 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.

13. Patrick Wilson
Glenn-Milo Santos
Pato Hebert
George Ayala

14. Study Aims
The 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

15. 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

16. 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

17. 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

18. 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%

19. 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

20. Modeling the impact of social discrimination
and financial hardship on the sexual risk for
HIV among Latino and Black MSM
George Ayala, Trista Bingham, Junyeop Kim, Darrell Wheeler,
and Greg Millet

21. Stigma: A dynamic process of devaluation that
significantly discredits an individual in the eyes of others.
Social Discrimination: Mean, unfair, or
unequal treatment (including acts of verbal or physical
violence) intended to marginalize or subordinate
individuals or communities based on their real or
perceived affiliation with socially constructed stigmatized
attributes.

22. 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

23. 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

24. RDS Schematic
SEED
……… Wave 6
Wave 1
Wave 2

25. 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

26. Associations between Social Discrimination, Lack of
Social Support, Difficult Sexual Situations & HIV Risk
UAI w/ Casual
Male Partner (past 3
months)
Yes No p-value
Homophobia
Full Scale (Cronbach’s alpha=.83) 9.11 8.15 <.0001
Racism
Full Scale (Cronbach’s alpha=.73) 8.18 7.30 <.0001
Financial Hardship (single item)
Ran out of money for basic needs 72% 60% <.0001
Lack of Social Support: Dichotomized item
Full scale (Cronbach’s alpha=.81) 46% 38% .0005
Difficult Sexual Situations: Dichotomized and Scale Items
Had anal sex for drugs/money/place to stay 30% 6% <.0001
Used illicit drugs in past 3 months 46% 29% <.0001
Sex in someone else’s home 39% 17% <.0001
Had a partner who was more masculine 38% 15% <.0001
Used alcohol or drugs before or during sex 54% 17% <.0001
Sum of potentially risky sexual situations (Sum of 5 items) 2.1 .8 <.0001

27. Modeling the Impact of Social Discrimination on the
Risk for HIV Among Latino and Black MSM
Predictor B p-value
Hypothesis 2: Social discrimination predicts lack of social support
Homophobia .50 <.0001
Racism .51 <.0001
Poverty .75 <.0001
R2 = .15, F = 128.57, p < .0001
Hypothesis 3: Social discrimination and lack of social support predict
difficult sexual situations
Homophobia .12 .0001
Racism .11 .006
Poverty .14 <.0001
Lack of social support .03 <.0001
R2 = .08, F = 47.5, p < .0001

28. Social Discrimination’s Impact on HIV Risk is
Mediated by Lack of Social Support and Difficult
Sexual Situations
Predictor OR 95% CI p-value
Homophobia 1.0 .88 -1.1 .94
Racism 1.2 1.0 -1.4 .03
Financial Hardship 1.1 .91 -1.4 .25
Lack of social support 1.0 .99 -1.0 .07
Difficult sexual situations (ref=none)* 1.0 -- --
One 2.6 2.0 -3.4 <.0001
Two 7.3 5.5 -9.7 <.0001
Three to Five 13 10 -18 <.0001

29. 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

30. Sources and types of discrimination matter ----
are cumulative ---- and may have differential
salience for different men of color.

32. A surprising amount of research remains to be done to understand
how sexual behavior among MSM is shaped by developmental
influences (e.g., early sexual experiences, coming out,
acceptance/rejection by family and friends, school
environment and policies), self concept, and mental health
aspects of sexuality (e.g., internalized homo-negativity,
body image, sexual compulsivity,
erotophobia/erotophilia, social anxiety), formation and
maintenance of primary relationships, sexual relationships
within and outside of primary relationships and sexual
satisfaction and physical function.
Source: Wolitski, RJ and Fenton KA. 2011. Sexual health, HIV, and sexually transmitted infections among gay , bisexual, and other men
who have sex with men in the United States. AIDS Behavior.

33. Holding Open Space

34. Sexual health is a state of physical, emotional, mental
and social well-being in relation to sexuality; it is not
merely the absence of disease, dysfunction or infirmity.
Sexual health requires a positive and respectful
approach to sexuality and sexual relationships, as well
as the possibility of having pleasurable and safe sexual
experiences, free of coercion, discrimination and
violence. For sexual health to be attained and
maintained, the sexual rights of all persons must be
respected, 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.