Men Who Have Sex With Men and HIV/AIDS in the United States
Since the onset of the HIV/AIDS epidemic in the United States, AIDS incidence has been highest among men who have sex with men (MSM).1 Despite changes in the demographics of the epidemic and the growing proportion of total cases among women, MSM continues to account for the largest proportion of new AIDS cases each year. Most of these cases are among MSM of color, who face extraordinary barriers to HIV counseling and testing as well as to care.2
Surveillance
- In 2004, an estimated 31,024 men were diagnosed with AIDS in the United States. MSM was the HIV exposure category in 57 percent of those cases.3 MSM also accounted for 6.2 percent of reported AIDS cases related to the MSM/injection drug use (IDU) exposure category.3
- New AIDS cases related to the MSM exposure category have increased every year since 2000, rising an estimated 15.1 percent between 2000 and 2004.4 In contrast, MSM/IDU is estimated to have fallen by 8.7 percent between 2000 and 2004.5
- MSM was the HIV exposure category for 44.6 percent and MSM/IDU was the HIV exposure category for 6.1 percent of people estimated to be living with AIDS at the end of 2004.3
CRITICAL ISSUES
Many MSM, especially racial and ethnic minorities, face poor access to health care because of poverty, lack of health insurance, and fear of losing anonymity. In addition, MSM must cope with many types of stigma—for being an MSM, for being HIV positive and, often, for being an ethnic or racial minority. Many MSM face condemnation from their families, communities, and service providers.4
Many minority MSM do not self-identify as gay or bisexual. Thus, prevention and health outreach targeting sexual minorities may not be effective among this group—and MSM may be especially reluctant to seek services at organizations perceived to be gay oriented.4-6 Many minority MSM identify with their racial identity more than their sexual identity; thus, messages aimed at the gay community often do not reach them.7
Minority MSM become infected at earlier ages than Whites and are more likely to learn that they are HIV positive later in the course of infection. Moreover, a higher proportion of minorities than Whites have already progressed from HIV to AIDS at initial diagnosis.8,9
Some MSM harbor misconceptions about effective HIV treatment. Many are aware of the advancements in medical technology and the effectiveness of highly active antiretroviral therapy (known as HAART), but they overestimate its power.4 Others believe that HIV infection is inevitable and may do little to prevent it.4
Although many MSM indicate feeling initial discomfort discussing their sexual behavior with a counselor, respondents of one study reported that counseling increased their personal awareness about more healthful living and helped them feel more in control of their lives.10
Evidence indicates extraordinarily high seroprevalence rates among some MSM populations. Phase II of the Centers for Disease Control and Prevention (CDC)’s Young Men’s Study surveyed MSM ages 23 to 29 who frequented certain venues; the study discovered that 13 percent of study participants were HIV positive. Prevalence was 32 percent among Blacks, 17 percent among Whites, and 14 percent among Hispanics.11
In a study of 253 HIV-positive MSM with alcohol use disorders from the New York City metropolitan area, 80 percent of participants reported engaging in sexual behavior with casual partners, and 71.9 percent of those respondents did not know the HIV status of those partners. Respondents also indicated a relationship between sexual risk behaviors and the use of substances.12
Outreach initiatives may be more effective if they address the broad health concerns of MSM. Recent data indicate that among urban MSM, the presence of multiple health problems is significantly associated with high-risk sexual behavior and HIV infection.13
MSM AND THE RYAN WHITE CARE ACT
Experiences of providers funded through the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act have revealed program components that are key to reaching MSM. Providers must cultivate trust and then provide high-quality, nonjudgmental services that help MSM acknowledge their risk, get tested, and remain in care over time. The use of peer educators is often critical.14
MSM receive services through all CARE Act programs except for the Title IV program, which serves primarily women and children. The HIV/AIDS epidemic in the United States initially emerged among the MSM population; thus, MSM were instrumental in collaborating with Congress to create and pass the CARE Act in 1990.
Today, CARE Act grantees are making concentrated efforts to bring MSM into care in the earliest stages of the disease. Additionally, Title I and Title II grantees are striving to achieve greater involvement of MSM of color in the community planning process.
In collaboration with the African-American AIDS Policy and Training Institute, the Asian and Pacific Islander Health Forum, Bienstar, and the National Native American AIDS Prevention Center, the Health Resources and Services Administration (HRSA) conducted a research project involving key informant interviews and structured roundtable discussions to identify barriers to care for MSM of color and develop solutions. The results of the publication Improving Care for HIV-Positive Men of Color Who Have Sex With Men: Barriers and Recommendations are shaping the process through which HRSA and the Centers for Disease Control and Prevention (CDC) are collaboratively responding to the epidemic among young MSM of color.
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References
1 Centers for Disease Control and Prevention (CDC). HIV/AIDS Surveillance Report. 2004;16(1):12. Table 3.
2 CDC. HIV/AIDS Surveillance Report. 2004;16(1):19. Table 19.
3 CDC. HIV/AIDS Surveillance Report. 2004;16(1):20. Table 10.
4 HIV/AIDS Bureau. Improving Care for HIV-Positive Men of Color Who Have
Sex With Men: Barriers and Recommendations. Rockville, MD: Health Resources and Services Administration; 2002.
5 Miller M, et al. Drug-using men who have sex with men as bridges for HIV and other sexually transmitted infections: sexual diversity among black men who have sex with men in an inner-city community. J Urban Health. 2005;82(suppl 1);i26-i34.
6 MacKellar DA, et al. Unrecognized HIV infection, risk behaviors, and perceptions of risk among young men who have sex with men: opportunities for advancing HIV prevention in the third decade of HIV/AIDS. J Acquir Immune Defic Syndr. 2005;38(5):603-14.
7 Clarke-Tasker VA, et al. HIV risk behaviors in African American males. Assoc Black Nurs Faculty Jl. 2005;16(3):56-9.
8 CDC. HIV/AIDS among racial-ethnic minority men who have sex with men—United States, 1989-1998. MMWR Morb Mortal Wkly Rept. 2000;49(1):4-11.
9 CDC. HIV prevalence, unrecognized infection, and HIV testing among men who have sex with men—five U.S. cities. MMWR Morb Mortal Wkly Rept. 2005;54(24): 597-601.
10 Guest G, et al. HIV vaccine efficacy trial participation: men who have sex with men’s experiences of risk reduction counseling and perceptions of risk behaviour change. AIDS Care. 2005;17(1):46-57.
11 CDC. HIV incidence among young men who have sex with men—seven U.S. cities, 1994-2000. MMWR Morb Mortal Wkly Rept. 2001;50:440-4.
12 Parsons JT, et al. Sexual risk behaviors and substance use among alcohol abusing HIV-positive men who have sex with men. J Psychoactive Drugs. 2005;37(1): 27-36.
13 Stall R, et al. Association of co-occurring psychosocial health problems and increased vulnerability to HIV/AIDS among urban men who have sex with men. Am J Public Health. 2003;96(3): 939-42.
14 Reaching men of color who have sex with men. HRSA CAREAction. June 2003. Available at: ftp: //ftp.hrsa.gov/hab/june_2003_final.pdf.
15 CDC. HIV/AIDS Surveillance Report. 2004;16(1): 14. Table 5a.
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