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July 2011

Background and Epidemiology

In the United States, gay, bisexual, and other men who have sex with men (MSM) comprise the group most affected by HIV. MSM is the only risk group in which new HIV infections have been steadily increasing since the early 1990s. CDC estimates that MSM represent approximately 2% of the US population, but accounted for more than half of all new HIV infections annually from 2006 to 2009 — 56% in 2006 (27,000), 58% in 2007 (32,300), 56% in 2008 (26,900), and 61% in 2009 (29,300). Since the beginning of the US epidemic, MSM have consistently represented the largest percentage of persons diagnosed with AIDS and persons with an AIDS diagnosis who have died.

Among MSM in 2009, white MSM represented the largest number of new HIV infections (11,400), followed closely by black/African American MSM (10,800) and Hispanic MSM (6,000). Among all men in 2009, MSM accounted for 86% of new infections among white men, 73% of new infections among black/African American men and 81% of new infections among Hispanic men.

Young black/African American MSM aged 13-29 are especially affected by the HIV/AIDS epidemic. While HIV incidence was relatively stable among MSM overall from 2006 through 2009, CDC estimates that new HIV infections among black/African American MSM aged 13 to 29 increased 48% during that four-year time period, with a statistically significant 12.2% estimated annual percentage increase. The number of new infections in 2009 among young black/African American MSM was more than twice that of either young white MSM or of young Hispanic/Latino MSM.

Estimated New HIV Infections in the U.S., 2009, for the Most-Affected Subpopulations

* The term men who have sex with men is used in CDC surveillance systems because it indicates the behaviors that transmit HIV infection, rather than how individuals self-identify in terms of their sexuality. Source: CDC

Published research does not provide definitive answers as to why the numbers of HIV infection among young black/African American MSM have increased. However, racial disparities in health, including HIV, are associated with broader social and economic factors. For example:

• The higher prevalence of HIV infection among black/African American MSM means there is a greater risk of being exposed to HIV with each risk event (e.g., sexual encounter, drug use) — especially in older age groups.
• Many black/African American MSM, in particular young MSM, with HIV are unaware of their HIV infection. Low awareness of HIV status among young MSM may reflect several factors: recent infection, underestimation of personal risk, fewer opportunities to get tested, or belief that HIV treatment minimizes the burden of HIV.
• Stigma and homophobia may have a profound effect on the lives of black/African American MSM, including both mental and physical health. Internalized homophobia may affect the ability to make healthy choices and/or access prevention services.
• Racism, poverty, and lack of access to health care are barriers to HIV prevention and treatment services.
• Complacency about HIV may also play a role. Since young MSM did not experience the severity of the early HIV epidemic, some may falsely believe that HIV is no longer a serious health threat because of treatment advances and decreased mortality.
• Sexual relationships with older men may increase risk of exposure to HIV because older gay men are more likely to be HIV-positive.
• Higher rates of undiagnosed/untreated STDs may increase the risk of both acquiring and transmitting HIV.

Highlights of CDC Program Activities

In fiscal year 2009, 44% of CDC’s Division of HIV/AIDS Prevention’s (DHAP) budget was targeted to HIV prevention activities for MSM. CDC’s approach to addressing the HIV epidemic among black/African American gay, bisexual and other MSM involves three areas of commitment:

1. Engaging black/African American gay, bisexual, and other MSM communities and strategic partners.
2. Expanding effective prevention strategies and programs.
3. Evaluating and disseminating information on strategies and programs.

Specific activities include:

• Act Against AIDS (AAA) Communication Campaign. AAA is a five-year, multifaceted communication campaign designed to combat complacency about the HIV epidemic in the United States. The campaign is being planned and released in phases.
  • One phase of the campaign, Know Where You Stand, focuses on increasing HIV testing among 18- to 44-year-old black/African American MSM (BMSM). CDC developed Know Where You Stand with input from experts and advocates throughout the country who work with and represent gay, bisexual and other BMSM. The campaign encourages men to “know where they stand” and links them to hivtest.org, a CDC-funded website that provides information about HIV testing and allows people to enter their zip code and find nearby locations where they can be tested confidentially for HIV. Components of the Know Where You Stand phase of the AAA campaign include:
    • Online placement. Online banner ads that link men to local HIV testing resources were placed on websites that serve BMSM.
    • Outdoor placement. Working through existing national media partnerships, CDC placed ads on billboards and buses (interior and exterior) in Atlanta, Oakland, Detroit, Chicago, Memphis, Philadelphia, Baltimore, Dallas, Houston, Miami, San Francisco, New Orleans, St. Louis, Columbia and Jackson (Mississippi).
    • Community engagement. Know Where You Stand will be promoted at a variety of community events for MSM in coming months, including Black Pride events in Washington DC, Atlanta, Chicago, Oakland, and other events in Houston, Miami, and Fire Island, NY.
    • Partner engagement. CDC has made Know Where You Stand materials available to community-based organizations (CBOs) and local health departments for use in their own HIV awareness and prevention efforts. CDC partners, bloggers, webmasters, and the public can download web banners and posters directly from the Act Against AIDS website to participate in raising HIV awareness and promoting HIV testing among BMSM.
    • Act Against AIDS Leadership Initiative (AAALI) is a component of the AAA campaign that includes partnerships with organizations with a history of service to communities disproportionately affected by HIV, including BMSM. Under AAALI, these organizations will integrate HIV awareness, prevention, testing, and stigma reduction into their existing outreach and day-to-day program activities.
• Research. DHAP is actively involved in providing information through research to further understanding of HIV risk in affected populations. For example:
  • The National HIV Behavioral Surveillance System (NHBS) is a recurring interview-based system conducted in 21 US cities with high AIDS prevalence. Through the years, NHBS has provided important research on populations at risk of HIV infection. For example, a recent publication from this system found that differences in HIV infection between black and white MSM may be explained partially by less knowledge of partner HIV status and lower antiretroviral use among BMSM.
  • CDC conducted Brothers Y Hermanos from 2001–2006 in Los Angeles county and sites in New York City and Philadelphia to examine risk factors for Hispanic/Latino and black/African American MSM. A recent publication from this program found that, of men who reported that their last HIV test was negative or that they had never been tested or did not get the results of their last test, 17% of black and 5% of Latino MSM received a positive HIV test.2 In both groups, the three-month prevalence of unprotected anal intercourse (UAI) with HIV-negative or unknown serostatus partners was twice as high among men unaware of their HIV infection than men who knew they were HIV positive at the time of enrollment.
• Prevention Programs
  • HIV Prevention for Young Men Who Have Sex with Men and Young Transgender Persons of Color
    • The first five-year cooperative agreement supported 29 organizations to provide effective HIV prevention services to young men of color who have sex with men (YMCSM) and young transgender (YTG) persons of color and their partners who are at high risk for acquiring or transmitting HIV infection.
    • In 2011, CDC issued a new funding opportunity announcement, “HIV Prevention Projects for Young Men of Color Who Have Sex with Men and Young Transgender Persons of Color,” to provide effective HIV prevention services to YMCSM and YTG persons of color as well as their partners regardless of age, gender, and race/ethnicity.
  • Capacity Building Assistance to Address the HIV Prevention Needs of Racial/Ethnic Minorities and Other Individuals at High Risk for HIV Infection
    • This project provides support to 31 national and regional organizations that seek to build the capacity of the nation’s HIV prevention workforce, with a focus on capacity building for organizations serving racial and ethnic minorities and other individuals at high risk for HIV infection.
    • A significant number of these organizations focus on building the capacity of community-based organizations that serve black MSM.
    • In 2010, an additional $1.4 million was awarded to nine of these agencies to substantially increase services provided to and community mobilization among BMSM.
  • Expansion of Effective HIV Prevention by Health Departments and Community-Based Organizations (CBOs)
    • DHAP funds 65 health departments at the state and local level to support HIV prevention efforts and programs for people living with HIV and people at risk for HIV, including black gay and bisexual men.
    • In 2009, CDC released supplemental funds to health departments to either develop a MSM prevention plan or enhance existing prevention programs for MSM. Fifty-one jurisdictions received these additional dollars.
    • In 2010, 51 state and city health department jurisdictions developed and submitted to CDC an MSM assessment plan for enhancing HIV prevention services for the MSM population within their jurisdiction. Health departments were funded to conduct 1) an assessment of activities necessary to prevent HIV infection and related risk factors, including STDs, drug use, access to HIV care and prevention services, and 2) the identification of additional activities or enhancements to the current activities that could be implemented to further prevent HIV infection among MSM population, which became a part of the state’s comprehensive HIV prevention plan.
    • CDC also directly funds 69 CBOs specifically serving BMSM to decrease HIV acquisition and transmission by conducting HIV prevention services for high-risk persons. Services consist of health education and risk reduction, counseling and testing, and public information services.
    • Through the Expanded Testing Initiative, CDC has increased focus on providing HIV testing to all MSM, regardless of race/ethnicity. In 2007, CDC funded 23 health department jurisdictions to expand testing efforts focused on African Americans. This program, which ran through fall 2010, identified 18,432 new HIV infections. Of those individuals for whom CDC has follow-up data, 75% were linked to care. In 2010, CDCs Expanded Testing Program provided funding to 30 jurisdictions to support HIV testing among all MSM, regardless of race/ethnicity. Results from this program are expected in 2011.
• Effective Behavioral Interventions
  • The Diffusion of Effective Behavioral Interventions (DEBI). The DEBI project was designed to bring science-based, community, group, and individual-level HIV prevention interventions to community-based service providers and state and local health departments. The goal is to enhance the capacity to implement effective interventions at the state and local levels, to reduce the spread of HIV and STDs, and to promote healthy behaviors. In 2010, significant activities included:
  • Repackaging Many Men, Many Voices (3MV), a multi-session, group-level intervention program to prevent HIV and sexually transmitted diseases among BMSM who may or may not identify themselves as gay.
  • Developing an adaptation guide for tailoring behavioral interventions with Black and Latino MSM.
  • Revising and updating the Mpowerment intervention kit, in part to reflect the lessons learned working with young gay men of color.
  • Previously, this program researched and developed important programs, such as Becoming a Responsible Teen (BART), a group-level, education and behavior skills training intervention designed to reduce risky sexualbehaviors and improve safer sex skills among African American adolescents.
  • Formative Studies to Develop and Pilot-Test New Behavioral Interventions Targeting MSM. CDC is conducting formative work to inform the development of new behavioral interventions and identify behavior change interventions with promising findings that would warrant further study. A number of formative studies focusing on black/African American gay, bisexual, and other MSM have been completed or are currently underway:
    • Latino and African American MSM Project (LAAMP) for high-risk Hispanic/Latino and black/African American MSM. Six sites were funded to evaluate the preliminary efficacy of newly developed behavioral interventions designed to reduce HIV acquisition and transmission among black/African American (four sites) and Hispanic/Latino (two sites) MSM. All sites developed innovative, culturally tailored group-level, multi-session interventions. Data collection was completed in 2010 and data dissemination is ongoing.
    • Entertainment-Education Serial Drama Intervention.“Reality Check” is a serial drama for African American youth that was designed for viewing on a public transportation system within a geographical area where community members are at elevated risk for HIV (e.g., public buses in Los Angeles). It consists of 27 three-minute “soap opera” style episodes with the HIV prevention goals of promoting norms, intentions, and behaviors around HIV testing, condom use, abstinence, and reducing homophobia and HIV stigma. One character is a black gay man and the scenarios address issues relevant to the BMSM community.
    • Development and Testing of an HIV Prevention Intervention Targeting Black Men Who Have Sex with Men and Women (MSM/W). Under this four-year project time period, three grantees were funded to develop and test an HIV prevention intervention for black MSM/W. Each grantee will enroll at least 250 men and randomly assign them to an intervention or control condition. The intervention condition will focus on sexual risk reduction (e.g., unprotected sex, sexual partner concurrency) and the importance of self-care, including the benefits of routine HIV/STD testing. Process data will be collected from participants in both the intervention and control conditions to document recruitment progress, intervention acceptability, and attrition.
  • Evaluating Recruitment Strategies for Improving the Effectiveness of HIV Testing Programs among MSM (African American MSM Testing Project). This project was funded to evaluate the relative effectiveness of three recruitment strategies — alternate venue testing, the social network strategy and partner counseling and referral services (now partner services) for identifying and motivating 18- to 64-year-old, BMSM to be tested for HIV and linked to appropriate prevention services. Four sites — one health department and three community-based organizations — located in Atlanta, Baltimore, Washington DC, and New York City were funded to conduct this project. Data collection completed in 2010 and data dissemination activities are ongoing.
  • Evaluating Locally Developed Behavioral Interventions Targeting MSM. CDC supports the rigorous evaluation of “homegrown” or locally developed behavioral interventions as a way to identify innovative strategies developed by the community and for the community, that are effective in reducing HIV risk among high-risk individuals.
    • CDC recently completed one such evaluation study identifying an evidence-based intervention developed for BMSM — 3MV (see Wilton et al., 2009).
    • CDC is supporting the evaluation of two locally developed interventions for BMSM — the Critical Thinking and Cultural Affirmation (CTCA) intervention, developed by Black Men’s Exchange Program in New York City; and My Life My Style, developed by In the Meantime Men’s Group, Inc. in Los Angeles.
    • CDC is evaluating adapted interventions to meet the needs of BMSM. MPowerment is a community-level intervention based on an empowerment model where a core group of young gay men from the community design and carry out the prevention activities throughout their community. An adaptation of Mpowerment for young BMSM (18-29 years) is currently being conducted and evaluated in Dallas and Houston.
• Organizational Initiatives to Support Focus on Most-Affected Populations. CDC has created structures within its organization that aid in addressing the HIV epidemic among MSM, including BMSM.
  • The CDC/ATSDR Sexual and Gender Minorities (SGM) Workgroup. The goals of this agency-wide workgroup are to improve understanding of SGM health disparities and needs, increase two-way communication with key SGM external partners, and promote SGM program services, education and communication products, data collection, and research. The primary purpose of the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) MSM Executive Committee is to provide a forum for discussion and coordination of activities related to the prevention of HIV/AIDS, viral hepatitis, and other STDs among gay, bisexual, and all other MSM. The Executive Committee is responsible for providing input on emerging issues that affect risk for sexually transmitted infections among MSM. These issues should be addressed in surveillance, research, prevention programs, capacity building, policy, monitoring and evaluation, and communications to NCHHSTP staff, external partners, and consumers.
  • The Office of Health Equity within NCHHSTP. The mission of the Office of Health Equity (OHE) in the Office of the Director in NCHHSTP is to support health equity in Center research and surveillance, health communication and marketing, health policy, prevention programs, capacity building and partnership activities. The Office of Health Equity works to improve the health of populations disproportionately affected by HIV, viral hepatitis, STDs, TB and related diseases and conditions and eliminate health inequities.
  • DHAP’s Office of Health Equity. DHAP’s Office of Health Equity was established in 2010 to provide leadership on understanding the determinants of and strategies for addressing HIV and AIDS inequities, and coordinate and monitor the Division’s activities related to reducing health inequities among populations most disproportionately affected by the epidemic. The office will employ a coordinator for activities targeting gay, bisexual and other MSM, including BMSM.

These activities show CDC’s ongoing efforts to better focus on the populations most affected by HIV. Additionally, CDC’s Division of HIV/AIDS Prevention’s new HIV prevention strategic plan, expected in 2011, and the National HIV/AIDS Strategy, released in 2010, provide direction to prioritize MSM, particularly young black/ African American and Hispanic/Latino MSM, and engage in strategies to reduce HIV incidence, increase access to care and optimize health outcomes, and reduce HIV-related health disparities.