It’s about more than just sex

In the US, there have been approximately 50,000 new HIV infections every year for more than a decade according to the Centers for Disease Control and Prevention. Do the math. Gay, bisexual, and other men who have sex with men (MSM) account for about 2% of the US population, but account for more than 50% of people living with HIV. Black and Latino gay and bisexual men have higher rates of diagnoses compared to other groups of MSM. This is a large gap—a really large gap—and this important difference has been receiving increasing attention in the past several years as many ask “why?” Thankfully several talented epidemiologists, such as Greg Millett, have shed some light for us on why these disparities exist. Although multiple sexual partners and condomless anal sex are important risk factors for HIV infection, multiple studies have documented that Black and Latino MSM have less risky sexual behavior than other groups. Studies also show lower rates of drug and heavy alcohol use (also known drivers of new HIV infections) among Black and Latino MSM.

These are important points to note because the opposite is often reported and perpetuated in mainstream media and it is a harmful message that simply has not been shown to be true.

So if it’s not about sex and drugs, what is it about? One important driver of the racial/ethnic imbalance in new HIV infections that we see in US is a significant difference in the percentage of men who are aware of their HIV infection. In a national survey of MSM, 54% of Black MSM, 63% of Latino MSM, and 86% of White MSM who were found to be HIV positive reported being aware of their infection. The first step for person getting connected to care is knowing their HIV status and then they can take additional steps to protect their partners. So, direct efforts to increase access to regular and routine HIV testing and linkage to care are important interventions to eliminate this disparity.

Taking it to an even higher level, the main drivers of the increased HIV infections appear to be a social and structural—the same social inequities that drive racial/ethnic disparities in numerous life areas within the US. Examples of these factors include fewer educational opportunities, lower income, stigma, homophobia, and much higher rates of incarceration (as high as 60% in some groups). The impact of mass incarceration of Black and Latino men is of particular concern given the often severe limits placed on access to housing, job opportunities, and other services post–release. To eliminate these disparities—and end HIV—we must also begin to address these social and structural barriers that are driving new infections.