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High Risk for HIV Transmission in Black Men Who Have Sex With Men, and White
MSM
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Unrecognized HIV Infection, Risk Behaviors, and Perceptions of Risk Among
Young Black Men Who Have Sex with Men --- Six U.S. Cities, 1994--1998
CDC Weekly MMWR Report August 23, 2002
"In a preliminary analysis of 573 HIV-infected MSM aged 16--29 years sampled
in six U.S. cities.....91% of Black MSM were unaware of their infection
........ vs white 60% of MSM...... But, all young MSM with unrecognized HIV
infection..... perceived themselves at low risk for being infected (66%),
engaging in unprotected anal sex (54%), or not using condoms during anal
intercourse because of perceived low personal or partner risks for HIV
infection (46%)"...........
The incidence of human immunodeficiency virus (HIV) infection among young
black men who have sex with men (BMSM) is among the highest of all risk
groups in the United States (1--3). Two important strategies to reduce HIV
transmission among young BMSM are to increase the proportion of men who are
aware of their HIV infection and to increase the consistent use of condoms
among sexually active men (4,5). However, limited information is available to
help develop HIV-testing and condom-promotion programs for young BMSM. To
address this need, data from CDC's Young Men's Survey (YMS) were used to
evaluate the prevalence of unrecognized HIV infection, barriers to testing,
and reasons for nonuse of condoms among BMSM aged 15--22 years. This report
summarizes the results of the survey, which indicated that of the 16% of
young BMSM participants who were infected with HIV, nearly all were unaware
of their infection. Few young BMSM reported testing frequently for HIV, and
many reported engaging in behaviors that could transmit HIV because they
perceived themselves or their partners to be at low risk for infection. These
findings underscore the urgency of expanding and improving prevention efforts
for young BMSM by increasing the demand for and availability of HIV-testing
services and by providing high-quality prevention counseling that includes
assessment and clarification of perceived risks for infection.
YMS was a cross-sectional survey conducted during 1994--1998 of males aged
15--22 years who attended MSM-identified venues (e.g., shopping areas, dance
clubs, bars, and organizations) in Baltimore, Maryland; Dallas, Texas; Los
Angeles, California; Miami, Florida; New York, New York; the San Francisco
Bay Area, California; and Seattle, Washington (1). Extensive formative
research was conducted to construct monthly sampling frames of the days,
times, and venues attended by young BMSM. Each month, 12--16 venues and their
associated day/time periods were selected randomly and scheduled for
sampling. During sampling events, men were approached consecutively to assess
their survey eligibility. BMSM eligible for the survey were aged 15--22 years
and residents in one or more local counties. Participants were interviewed by
using a standard questionnaire, had blood drawn for HIV testing, were given
appointments to obtain test results, and were provided HIV-prevention
counseling and referral for care when needed.
Specimens were tested for HIV at local laboratories with standard assays.
Analyses were restricted to men who reported ever having sex with men and who
described their racial background as either being only black or having a
mixed background that included being black. Analyses excluded records of
duplicate participants, who were identified by using the Miragen antibody
profile assay (6). Records also were excluded from Seattle because few BMSM
had participated in that city.
In the six cities, 920 BMSM participated in YMS (range: 127--202). The
participation rate among eligible blacks was 61% (range: 53%--77%). Of the
920 participants, 150 (16%) tested positive for HIV (range: 13%--18%). Of the
150 HIV-infected BMSM, 139 (93%) were unaware of their infection (range:
88%--100%). Of those with unrecognized infection, 99 (71%) reported either
that there was no chance, that it was very unlikely, or that it was unlikely
that they were infected with HIV; 58 (42%) perceived themselves at low risk
for ever becoming infected; and 45 (32%) perceived themselves at low risk
both for being and for ever becoming HIV-infected.
During the 6 months preceding the survey, the 920 BMSM reported a median of
two male sex partners (interquartile range: one to three), 712 (77%) reported
having anal intercourse with another man, and 342 (37%) reported having
unprotected anal intercourse (UAI). Of the 79 BMSM with unrecognized HIV
infection who had UAI, 41 (52%) reported not using condoms for one or more of
the following reasons: they "knew" they were HIV-negative (24%), they "knew"
their partners were HIV-negative (20%), or they thought their partners were
at low risk for infection (35%); 34 (43%) also reported not using condoms
because none were available.
Of the 920 BMSM, 585 (64%) had ever tested previously for HIV, but few had
tested frequently (median number of tests: one; interquartile range: zero to
two). Of those who had tested previously, 536 (92%) reported last testing
HIV-negative, and of these, 87 (16%) were found to be infected with HIV. The
332 (36%) men who had not tested previously gave the following reasons for
not testing (more than one reason could be given): low risk for infection
(45%), fear of learning their results (41%), and fear of needles (21%). Of
those who had not tested previously, 42 (13%) were HIV-infected. Of the 148
men who had not tested previously because of perceived low risk, 122 (82%)
ever had anal intercourse with a man, 99 (67%) had at least three lifetime
male partners, and 11 (7%) were HIV-infected.
Compared with their noninfected peers, young BMSM with unrecognized infection
were more likely to report engaging in UAI and not testing previously because
of fear about learning their results. Noninfected young BMSM were more likely
to perceive themselves at low risk for infection and not to have tested
previously because of this perception.
Reported by: T Bingham, MPH, Los Angeles County Dept of Health Svcs, Los
Angeles; W McFarland, MD, San Francisco Dept of Public Health, San Francisco,
California. DA Shehan, Univ of Texas Southwestern Medical Center at Dallas,
Texas. M LaLota, MPH, Florida Dept of Health. DD Celentano, ScD, Johns
Hopkins Univ School of Hygiene and Public Health, Baltimore, Maryland. BA
Koblin, PhD, New York Blood Center; LV Torian, PhD, New York City Dept of
Health, New York. DA MacKellar, MPH, LA Valleroy, PhD, GS Secura, MPH, RS
Janssen, MD, Div of HIV/AIDS Prevention--Surveillance, and Epidemiology; GW
Roberts, PhD, Div of HIV/AIDS Prevention--Intervention, Research, and
Support, National Center for HIV, STD, and TB Prevention, CDC.
Editorial Note: The findings in this report are consistent with previous studies suggesting
that in several U.S. cities, the majority of young HIV-infected MSM,
particularly BMSM, were unaware of their infection (1,7). In a preliminary
analysis of 573 HIV-infected MSM aged 16--29 years sampled in six U.S.
cities, proportionally more BMSM were unaware of their infection than were
white MSM (91% versus 60%) (7). However, among all young MSM with
unrecognized HIV infection, no racial or ethnic differences were observed
among those perceiving themselves at low risk for being infected (66%),
engaging in UAI (54%), or not using condoms during anal intercourse because
of perceived low personal or partner risks for HIV infection (46%) (7). These
findings underscore the urgency of improving HIV-prevention efforts for all
young MSM by 1) increasing the demand for and availability of HIV-testing
services and 2) providing young MSM with high-quality HIV- and STD-prevention
services that include assessment and clarification of personal risks for
infection.
In accordance with recently revised guidelines, health-care providers should
assess the HIV risks of their patients routinely and encourage all MSM at
risk for HIV to test at least annually (8,9). Findings from this report
indicate that demand for testing by young BMSM might be increased by
implementing efforts that increase personal risk perceptions; addressing
concerns about testing positive by conveying the benefits of early diagnosis
and HIV care; and marketing the availability of oral fluid, urine-based, or
finger-stick HIV tests that do not require venipuncture (9). Use of testing
services also might be increased by offering testing in nonclinical settings
that serve or are attended by young BMSM and by providing high-quality
partner referral services for all those who test positive (5,9).
HIV testing should be accompanied by high-quality prevention counseling that
includes an in-depth personalized risk assessment, clarification of risk
perceptions, and negotiation of steps to reduce risks (9). Because 16% of
young BMSM who reported being HIV-negative were found to be HIV-infected,
providers should encourage young BMSM to use condoms consistently with all
partners, including those who have tested negative previously. In negotiating
risk reduction with young BMSM, providers should be prepared to address
alcohol, drug, and partner influences on condom use and to help young BMSM
cope with emotional responses in high-risk situations. Providers should refer
clients who have difficulty in initiating or sustaining safer behavior for
more intensive individualized prevention counseling and support services (9,10
). Finally, managers of prevention programs should consider increasing the
availability of condoms in settings where young BMSM are likely to encounter
sex partners.
The findings in this report are subject to at least three limitations. First,
findings might not be applicable to young BMSM who do not attend
MSM-identified venues or reside in the six participating cities. Second,
because approximately 39% of eligible young BMSM chose not to participate,
selective nonparticipation could have biased reported findings. Finally, data
were collected during face-to-face interviews and are subject to disclosure
biases. The finding that nearly all HIV-infected young BMSM in this survey
were unaware of their infection might be attributed, in part, to one or more
of these biases. However, a high proportion of young BMSM who are unaware of
their infection is likely given the high HIV incidence and low frequency of
testing among young BMSM (2).
In partnership with state and local health departments, nongovernment
organizations, community stakeholders, and other federal agencies, CDC is
taking steps to reduce HIV transmission and unrecognized infection among
young MSM, particularly BMSM. Since September 2001, five national
consultations have helped identify current prevention needs of MSM, including
young minority MSM. In 2001, additional resources were made available to
expand HIV counseling and testing, outreach services, and behavioral
risk-reduction interventions for young minority MSM. Ongoing prevention
efforts also are being strengthened through capacity development for minority
community-based organizations serving young MSM, and through recently
released guidelines calling for expanded risk assessment and HIV testing for
homosexual and bisexual men (8,9). Finally, new research efforts, including
rapid ethnographic assessments, have been initiated to identify additional
factors that influence HIV-acquisition risks among young minority MSM. These
and similar efforts signal the increased priority at national, state, and
local levels to reduce the considerable racial disparities in HIV morbidity
and unrecognized infection among young MSM.
References
1. Valleroy LA, MacKellar DA, Karon JM, et al. HIV prevalence and associated
risks in young men who have sex with men. JAMA 2000;284:198--204.
2. CDC. HIV incidence among young men who have sex with men---seven U.S.
cities, 1994--2000. MMWR 2001;50:440--4.
3. Karon JM, Fleming PL, Steketee RW, De Cock KM. HIV in the United States
at the turn of the century: an epidemic in transition. Am J Public Health
2001;91:1060--8.
4. CDC. HIV prevention strategic plan through 2005. Atlanta, Georgia: U.S.
Department of Health and Human Services, CDC, 2001.
5. Janssen RS, Holtgrave DR, Valdiserri RO, Shepherd M, Gayle HD, De Cock
KM. The serostatus approach to fighting the HIV epidemic: prevention
strategies for infected individuals. Am J Public Health 2001;91:1019--24.
6. Unger TF, Strauss A. Individual-specific antibody profiles as a means of
newborn infant identification. J Perinatol 1995;15:152--4.
7. MacKellar D, Valleroy L, Secura G, et al. Unrecognized HIV infection,
risk behavior, and mis-perception of risk among young men who have sex with
men---6 U.S. cities, 1994--2000 [Abstract]. Barcelona, Spain: 14th
International AIDS Conference, July 2002.
8. CDC. Sexually transmitted diseases treatment guidelines 2002. MMWR
2002;51(no. RR-6):7--10.
9. CDC. Revised guidelines for HIV counseling, testing, and referral, and
revised recommendations for HIV screening of pregnant women. MMWR 2001;50(no.
RR-19).
10. CDC. HIV prevention case management, literature review and current
practice. Atlanta, Georgia: U.S. Department and Health and Human Services,
CDC, 1997:1--30.
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