Original articleExplaining racial disparities in HIV incidence in black and white men who have sex with men in Atlanta, GA: a prospective observational cohort study
Introduction
Human immunodeficiency virus (HIV) epidemiology in the United States is driven by an unrelenting epidemic among men who have sex with men (MSM) [1], [2] and is remarkable for black versus white disparities in HIV among MSM [3] and for expanding subepidemics among young black MSM. There is an emerging consensus that factors beyond individual risk behaviors (e.g., structural factors [4], access to health care [4], and features of sexual networks [5]) are key to understanding black versus white disparities. HPTN (HIV prevention trials network) 061 described HIV incidence among black MSM in six U.S. cities and identified younger age and unprotected anal intercourse (UAI) as associated with incidence, but did not have a nonblack comparison group, and therefore could not explore reasons for disparities [6].
How we think about reasons for black versus white disparities among U.S. MSM was elegantly framed by Millet et al. in 2006 [7]; this conceptual framework has guided the scientific agenda in the field for nearly a decade. We conducted a prospective, cohort study of black and white MSM in Atlanta that systematically measured the domains suggested by Millett et al. [7] to assess their potential to explain racial differences in HIV incidence. We recently reported on the baseline findings from this cohort study [3]. Here, we present HIV incidence among HIV-negative men followed prospectively and explore which factors might account for observed black and white disparities in HIV incidence. In addition, we consider the implications of how nonbehavioral factors associated with risk relate to eligibility criteria for pre-exposure prophylaxis (PrEP) and risk for new HIV infections.
Section snippets
Recruitment
Involvement was a prospective cohort study designed to assess the multilevel factors associated with disparities in HIV incidence between black and white MSM in Atlanta. The study recruitment, baseline procedures, and baseline results are described elsewhere [3]. MSM were recruited from 2010 to 2012 via venue-time-space sampling and Facebook [3], [8]. Eligible MSM self-reported black or white race, non-Hispanic ethnicity, were male at birth, lived in the Atlanta Metropolitan Statistical Area,
Results
Of the 803 black and white MSM who enrolled in the study, 237 had a reactive HIV rapid test at baseline (Fig. 1). Of the remaining 566 MSM, four were administratively discontinued at the baseline visit: 562 MSM (260 black, 302 white) were followed prospectively for 853 person-years (PY), with 843 PY counting toward HIV incidence estimation and 79% cumulative retention, with no difference by race [8]. Two participants were discontinued administratively during prospective follow-up (one white and
Discussion
In Atlanta, MSM and especially young black MSM face high-incidence epidemics of HIV. Overall incidence among MSM in Atlanta was 3.8%—higher than estimated incidence for MSM in the United States overall [17]. More than one in 10 young black MSM Atlantans acquired HIV per year during our study period. We report a local depiction of the national trends toward a dramatic HIV epidemic among young black MSM [18]. These data illustrate an ongoing, inadequately addressed public health emergency that
Acknowledgments
The authors gratefully acknowledge the contributions of the Involvement participants. The authors recognize the expert contributions of many dedicated public health professionals who worked to design, launch and monitor the study, and to provide services to participants: Deborah Abdul-Ali, Catherine Finneran, Lee Glover, Laura Gravens, Jess Ingersoll, Loree Jackson, Jennifer Norton, Brandon O'Hara, Craig Sineath, Marcus Stanley, Tyree Staple, Jess Ingersoll, Deborah Ali, and Shauni Williams.
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