The Continuum of HIV Care in the Urban United States: Black Men Who Have Sex With Men (MSM) Are Less Likely Than White MSM to Receive Antiretroviral Therapy

(See the brief report by Hoots et al, on pages 808–12.)

The US Centers for Disease Control and Prevention houses the Division of HIV/AIDS Prevention within the National Center for HIV, Viral Hepatitis, STD, and TB Prevention, renamed in late 2016 to highlight hepatitis. Its National HIV Behavioral Surveillance (NHBS) study is a vital vehicle through which epidemiologists and behavioral scientists mine periodically collected NHBS data to track components of the continuum of human immunodeficiency virus (HIV) care. The NHBS was begun in 2003 by the Centers for Disease Control and Prevention “to conduct behavioral surveillance among persons at high risk for HIV infection” [1]. The surveillance is conducted yearly in 1 at-risk population (men who have sex with men [MSM], persons who inject drugs, or heterosexuals at increased risk for HIV infection); that is, 1 of the 3 populations is surveyed every year, such that each of the 3 populations is surveyed every 3 years and there is a single annual survey of 1 population.

The NHBS permits tracking health system components that are needed to optimize both clinical care for persons living with HIV/AIDS and prevention of HIV transmission to others [2–4]. The continuum of care begins with testing and confirmatory diagnosis to identify infected persons [5]. After diagnosis, a person living with HIV must be linked to care, retained in care, promptly prescribed antiretroviral therapy (ART), and be highly adherent to the ART regimen [6]. The ultimate goal of this care cascade is viral suppression, to both slow HIV disease progression and minimize viral transmission to others.

In this issue of The Journal of Infectious Diseases, Hoots and colleagues [7] from the NHBS Study Group team estimated 2 elements of the care continuum among HIV-infected MSM in the United States, the prevalence of linkage to care and ART coverage. In 2008, a total of 1144 men participated and were included in the linkage analysis, increasing to 1338 in 2011 and 1716 in 2014, with 2 fewer participating in each study year for the ART analysis, that is, 2 missing ART data for each of the years. From 2008 to 2014 surveys, 14% fewer white MSM participated and 13% more black MSM were included. There were no significant differences in education, income, or region across the time period, but insurance coverage rose steadily, from 7% in 2008 to 86% in 2014, and the median age of participants was younger in more recent surveys.

Both linkage to care and ART coverage improved over time, consistent across all groups studied by Hoots et al [7]. However, a conspicuous health disparity was rediscovered, namely, that black MSM were less likely to secure ART in each of the 3 NHBS MSM study years of 2008, 2011, and 2014. This finding (a 9% coverage gap in 2014) persisted even after controlling for other predictors of lower access, namely, less education, lower income, and lack of health insurance. In this pithy report, other potential contributors to the racial differences were not addressed, including substance and alcohol use, mental health, disclosure of HIV status, whether sexual orientation was open or clandestine, incarceration experience, stigma and community attitudes, or social support and network phenomena. Hence, a more nuanced interpretation of why black men are less likely than white men to access ART must be sought elsewhere [8–36].

When racial or ethnic disparities in access to care are well documented, which programs can reduce such disparities? This remains a conspicuous priority for current research in the United States, whether focused primarily on care for persons living with HIV/AIDS or for prevention of HIV infection [37,38]. Innovative programs suggest that the gap may be bridged using community outreach and participation, community health workers and peers, Internet-based engagement, short messaging system reminders, and bridging from significant transitions into care (eg, self-disclosure of sexual orientation, gender identity, or HIV status; incarceration; adolescent changes; or learning of one’s own or a partner’s HIV seropositive status) [39–53]. Use of incentives linked to contingencies of adherence are promising but lack societal commitment for sustainable funding. Structural barriers loom large as a new administration takes over under our 45th president. Elimination of the Patient Protection and Affordable Care Act (ie, “Obamacare” or the ACA), a likely reduction in Medicare and Medicaid expenditures, and a potential reduction in Ryan White Act investments would all be expected to exacerbate racial/ethnic health disparities. This is assumed given that all are focused on lower-income, middle-class, or older individuals with limited resources for private insurance or self-funding of healthcare.

Methodological challenges are rife in this complex health services research arena [54–57]. The link between treatment and prevention introduces the desirability to measure the ultimate continuum of care outcome of viral suppression among all HIV-infected persons; a further goal is assessing the extent to which HIV transmission declines at varying levels of ART saturation within communities [58–62]. If we could identify and successfully treat all HIV-infected persons, then the risk of further HIV transmission would diminish, analogous to strategies used in the control of sexually transmitted infections and tuberculosis.

Although regional differences were not noted to be predictors of linkage or ART initiation, independent of other factors, the NHBS Study Group authors did well to acknowledge special challenges in the southeastern United States [7]. The disproportionate disease burden, lower state health investments, and challenging contextual elements are all elements fueling the southern HIV epidemic [63–69]. It may also be true that progress has been made in this part of the nation, given that this NHBS study failed to find regional disparities [70].

The research agenda for reducing HIV disparities in access to care is a substantial one. Such groups and projects as the HIV Prevention Trials Network, YMSM of color Special Projects of National Significance Initiative Study Group, Medical Monitoring Project, NYC M2M Study, the Mpowerment Project, the Adolescent Trials Network, and weCARE (to name but a few) are all striving to discover better and more effective models of outreach for HIV testing and care, with the goal of sustained viral suppression. Still, jurisdictions struggle with only limited success to solve their black-Hispanic-white disparities in HIV risk and access to care. The issues involved are often as much societal as medical, as with access to housing and education, employment and adequate income, substance use and mental health services, and other social determinants of health. How health systems can be improved and linked to communities of need without addressing these overarching issues remains a massive challenge for investigators and implementers alike.

Notes

Financial support. This work was supported by the National Institutes of Health (grantP30 AI110527).

Potential conflicts of interest. Author certifies no potential conflicts of interest. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.