Epidemiologic Data on Young Men of Color Who Have Sex with Men

Abstract

Young men of color who have sex with men (YMSM of color) have been disproportionately affected by the HIV/AIDS epidemic in the United States. Between 2001 and 2006, HIV/AIDS diagnoses increased 93.1% among African-American MSM aged 13–24 and 45.8% among Latino MSM aged 13–24. Many multisite studies have yielded valuable information on the behaviors associated with HIV infection in adolescents, MSM, African-Americans, and Latinos. Studies among adolescents found a high prevalence of risky sexual behaviors, including having multiple partners and unprotected intercourse and frequent substance use. Multisite studies of MSM also found frequent reports of alcohol and drug abuse, and one study found that nearly one-half (48%) of HIV-positive MSM were unaware of their infection. Similarly, two multisite studies of YMSM found high rates of unprotected sex, substance use, and HIV-infection among YMSM of color. Recognizing these challenges, the HIV/AIDS Bureau (HAB) of the Health Resources and Services Administration (HRSA) funded the first multisite study to improve engagement, linkage to HIV care, and retention in care for HIV-positive YMSM of color. The objective of this article is to review the epidemiologic data on HIV-positive YMSM of color from surveillance and multisite studies in order to identify the needs of this population and the gaps in the literature.

Introduction

I n 2004, the Health Resources and Services Administration's (HRSA) HIV/AIDS Bureau (HAB), through its Special Projects of National Significance (SPNS) Program, funded a multisite longitudinal study entitled Outreach, Care, and Prevention to Engage HIV Seropositive Young Men Who Have Sex with Men (YMSM) of Color. The purpose of this SPNS Initiative was to employ and evaluate innovative models that would engage HIV-positive YMSM, link them into HIV-related clinical care, and retain them in care.¹ Eight sites participated in the SPNS Initiative and are located throughout the United States: Bronx and Rochester, NY; Chapel Hill, NC; Chicago, IL; Detroit, MI; Houston, TX; Los Angeles, CA; Oakland, CA.

This article describes what is currently known about HIV/AIDS among YMSM of color, using national and site-specific surveillance data, as well as data collected through several national multisite studies that have been conducted over the past two decades. These data are used to discuss the specific needs of this population, as well as to identify the existing gaps in the literature related to YMSM of color.

HIV/AIDS Surveillance in the United States

Between 2001 and 2006, there was a 12.4% increase in HIV/AIDS diagnoses among all African-American MSM, and a 93.1% increase among African-American MSM aged 13–24.² To a lesser degree, HIV/AIDS diagnoses among all Latino MSM increased by 10.3%, and increased by 45.8% among Latino MSM aged 13–24.²

Among African-American men living in 37 states and 5 U.S. dependent areas, the leading mode of HIV transmission through 2008 was male-to-male sex, which was responsible for an estimated 64.0% of cases with known modes of transmission.³ Similarly, among Latino men, an estimated 69.1% of HIV cases diagnosed through 2008 with known modes of transmission were due to male-to-male sexual transmission.³

Local HIV/AIDS Surveillance

At the onset of the SPNS Initiative in 2004, each of the eight demonstration sites identified the number of YMSM of color living with HIV/AIDS in their service delivery areas through local surveillance. Of the 1298 MSM living with HIV/AIDS in Oakland CA at the end of 2004, 40 (3.1%) were African-Americans aged 13–24 years and 18 (1.4%) were Latino aged 13–24.⁴ Through the end of 2004, 2863 people living with HIV/AIDS in Bronx NY became infected through MSM behavior.⁵ Of these MSM, 153 were aged 13–24, and all but 3 of these males were African-American or Latino.⁶ Through the end of 2004, there were 6927 living HIV/AIDS cases in Harris County TX (Houston) attributed to MSM behavior.⁷ There were 151 African-American MSM aged 13–24 and 56 Latino MSM aged 13–24 living with HIV/AIDS through 2004.⁸ A high prevalence of HIV was first identified among young African-American and Latino MSM in Los Angeles (LA) County in the mid 1990s as part of the Young Men's Survey (YMS).^{9, 10} In YMS Phase I, conducted from 1994 to 1997 among 15- to 22-year-old MSM in Los Angeles, African-American MSM had a seroprevalence rate of 19% and Latino MSM had a seroprevalence rate of 9%.¹¹ In YMS Phase 2, conducted from 1999 to 2000 among 23- to 29-year-old MSM, an even higher seroprevalence of 25% was found among African-American MSM and 15% among the Latino MSM.¹² Of the people living with HIV/AIDS (excluding prisoners) in New York's Ryan White Region of Monroe County NY (Rochester) with a known mode of transmission, 696 (44.8%) were due to MSM behavior.¹³ There were 123 people (5.9%) aged 13–24 living with HIV/AIDS; 876 African-Americans (41.8%) and 291 Latinos (13.9%) were living with HIV/AIDS.¹³ Between 2000 and 2004, 115 MSM were diagnosed with HIV in Durham County, NC.¹⁴ Of these, 99 cases (86.1%) were among African-American or Latino MSM aged 17–24.¹⁵ Of the 3741 MSM living with HIV/AIDS in the Detroit Eligible Metropolitan Area (EMA), 1883 were African-American (50.3%) and 75 were Latino (2.0%).¹⁶ Additionally, 497 MSM (13.3%) living with HIV/AIDS were aged 13–24.¹⁶ Through the end of 2005, there were 9339 people living with HIV/AIDS in Chicago IL who became infected through MSM behavior and 3490 (37.4%) were African-American and 1550 (16.6%) were Latino.¹⁷ Project CHAT, Chicago's implementation of NHBS-MSM-1 in 2003–2004, found that of the 994 MSM sampled, 13% were HIV-positive, and 11% of African-American MSM and 9% of Latino MSM were HIV-infected.¹⁷ It is from this pool of HIV-infected YMSM of color that the SPNS Initiative demonstration sites recruited individuals to engage in HIV care and participate in a multisite cohort study.

National Studies

Since the HIV/AIDS epidemic has disproportionately affected MSM,^2,3 especially YMSM of color,^2,3 it has become critically important to investigate the reasons contributing to their elevated risk of HIV infection. HRSA, the CDC, the National Institutes of Health (NIH), and other institutions have funded several national, multisite studies to assess behaviors associated with HIV acquisition among high-risk populations, including adolescents, African-Americans, Latinos, and MSM.

Adolescents

In 1993, HRSA funded 10 Adolescent Care Projects across the U.S. to investigate predictors of HIV risk in a sample of adolescents and young adults aged 12–24 who were HIV-positive or at risk for becoming HIV-infected.^{18
19} Between 1993 and 1998, sites recruited 8196 clients (4111 males and 4085 females). HIV prevalence among males was 9.0%, and most males were either African-American (36.9%) or Latino (26.7%).²⁰ Adolescent men reported a number of risky behaviors, including survival sex (7.8%), sex with an HIV-positive individual (8.7%), and a history of sexually transmitted infections (STIs) (17.0%).²⁰ Eight percent reported use of injection drugs and 43.7% reported use of alcohol or other drugs in the past.²⁰

Between 1996 and 1999, adolescents aged 12–18 who were either HIV-positive or at high risk for HIV acquisition were enrolled in the multisite REACH (Reaching for Excellence in Adolescent Care and Health) Project, funded by the National Institute of Child Health and Human Development (NICHD).²¹ Of the 496 adolescents enrolled by September 1999, 34.5% were males and among those tested, 83 (67.5%) were HIV-positive.²¹ Most of the HIV-positive males (68.4%) had at least 8 different sex partners in their lifetimes and drank alcohol in the past 3 months (62.5%). One-half (50.0%) reported marijuana use in the past 3 months, and 16.9% reported hard drug use in the past 3 months.²¹ Additionally, researchers found that nearly one-half (48.7%) of the overall cohort was depressed and that there was a significant association between depression and unprotected sex at last encounter (OR=1.49, 95% CI: 1.09, 2.02).²²

In 2001, the NICHD established the Adolescent Medicine Trials Network for HIV/AIDS Interventions (ATN). This multisite study conducted research on a cohort of males and females aged 12–24 who were HIV-positive or at risk for becoming HIV-infected.²³ Comparing 195 MSM to 176 women who have sex with men (WSM), the mean number of lifetime sex partners was much higher for MSM [97.8; standard deviation (SD)=251.8] than for WSM (20.3; SD=32.9).²³ A larger proportion of MSM than WSM reported sex with an HIV-positive individual (49.5% versus. 26.0%) and participated in exchange sex (31.9% vs. 16.6%).²³ In the Connect to Protect (C2P) project conducted between 2005 and 2006 and supported by the ATN, 1217 adolescents and young adults were sampled using venue-based sampling (VBS). ^23
–25 HIV prevalence was much higher among MSM than among WSM (15.3% vs. 0.3%, respectively).

Men who have sex with men (MSM)

The EXPLORE study sponsored by the HIV Prevention Network of the National Institute of Allergy and Infectious Diseases (NIAID) was a randomized trial to test the efficacy of a behavioral intervention to prevent HIV acquisition among MSM, and was conducted between 1999 and 2001 in 6 U.S. cities.²⁶ More than three-quarters of the 4295 participants (78.1%) had unprotected sex with a male in the past 6 months, and over one-quarter (28.4%) reported sex with an HIV-positive partner.²⁶ Substance use in the prior 6 months was common, with many men reporting the use of marijuana (46.3%), poppers (36.6%), hallucinogens (24.0%), cocaine (19.3%), amphetamines (12.9%), and injection drugs (10.2%).^26,27 Additionally, the youngest age group of the sample (16–25 years) had the highest mean depression scores (Center for Epidemiologic Studies Depression scale mean=13.84).²⁸

The CDC developed its multisite National HIV Behavioral Surveillance (NHBS) System to collect behavioral data on populations at elevated risk for HIV acquisition.²⁹ Data are collected in cycles of approximately 3 years, focusing on three populations: MSM, injection drug users (IDUs), and heterosexuals at high risk for HIV acquisition (HET). Data for NHBS-MSM-1 were collected between 2003 and 2005 using VBS, ^29,30 and data from five sites showed that 25% of the 2261 MSM recruited were HIV-positive, with 48% of HIV-infected MSM unaware of their infection.³¹ African-American MSM had the highest HIV prevalence (46%) and had the highest proportion who were unaware of their infection (67%).³¹ HIV prevalence was lowest among 18- to 24-year-old MSM (14%), yet they were the most likely age group to be unaware of their infection (79%).³¹

YMSM

The CDC's Young Men's Survey (YMS) Phase I was conducted between 1994 and 1998 in 7 U.S. metropolitan areas to estimate the prevalence of HIV and risk behaviors among venue-attending YMSM aged 15–22.³² Over the course of the study, 3492 YMSM were enrolled and the HIV prevalence in the sample was 7.2%.^10,33 African-Americans (OR=4.8; 95% CI: 3.3, 7.1), mixed or other race (OR=4.2; 95% CI: 2.8, 6.6), and Latino YMSM (OR=2.2; 95% CI: 1.5, 3.2) had significantly higher odds of being HIV-positive than white YMSM.¹⁰ YMSM aged 20–22 were significantly more likely to be HIV-positive than those aged 15–19 (OR=1.6; 95% CI: 1.2, 2.1).¹⁰ Use of alcohol, amphetamines, poppers, and cocaine were each significantly associated with both unprotected receptive and unprotected insertive anal sex among YMSM.³⁴

YMS Phase II used similar methodology to recruit and enroll 2942 MSM aged 23–29 between 1998 and 2000, and 13% were found to be HIV-positive.³³ The majority of this sample of YMSM (74.3%) considered themselves at low lifetime risk for acquiring HIV.³⁵ However, many of these individuals had behaviors that put them at higher risk for becoming HIV-infected, including having at least 20 lifetime male sex partners (46.7%) and having engaged in unprotected anal intercourse (UAI) with a male of unknown HIV serostatus (17.6%).³⁵ African-Americans and Latinos were less likely than whites to have a private doctor (51% versus 77%, p<0.0001; and 70% versus 76%, p=0.051, respectively), but were significantly more likely to use a hospital (24% versus 7%, p<0.0001; and 14% versus 8%, p=0.0036).³⁶

Another national study using VBS to recruit YMSM was the Community Intervention Trial for Youth (CITY), which evaluated an HIV-prevention intervention for YMSM aged 15–25 and was conducted between 1999 and 2002.³⁷ Of the 2621 MSM enrolled in 1999, 30% had engaged in UAI in the last 3 months, 12% had traded sex for drugs or money in the last year, and 3% were IDUs.³⁸ Of the 2624 young MSM in 2000 who reported sexual contact with a male partner in the last 3 months, 18.6% reported being high during sex with a main partner, and 29.3% reported being high during sex with a non-main partner.³⁹ Additionally, 25.0% reported UAI with a main partner and 12.3% reported UAI with a non-main partner.³⁹

African-American/Latino MSM

The Brothers y Hermanos Study was conducted between 2005 and 2006 among Latino and African-American MSM aged 18 and older, with 1065 Latino MSM recruited in LA County and New York City, and 1140 African-American MSM recruited in New York City and Philadelphia.⁴⁰ The majority of Latino MSM (71%) was under 40, while most African-American MSM (65%) were 40 or older. Additionally, there was a high prevalence of HIV in both Latino MSM (39%) and African-American MSM (53%).⁴⁰ More African-American MSM were unaware of their HIV infection than were Latino MSM (17% versus 5%).⁴⁰ Of the 865 MSM who were aware of their HIV infection, 23% engaged in UAI with a male partner who was HIV-negative or had an unknown serostatus. Of the 1198 MSM who were HIV-negative, 19% engaged in UAI with HIV-positive or unknown serostatus male partners.⁴⁰ Similar proportions of African-American MSM (42%) and Latino MSM (43%) had engaged in UAI with a man in the past 3 months.⁴⁰

Gaps in the Literature

Partial baseline data from this HAB-funded multisite study collected through September 2008 was previously published ⁴¹, and final data collected through the end of August 2009 will be presented later in this issue. Prior to the initiation of this study, there were no studies that focused exclusively on African-American and Latino MSM aged 13–24. However, many studies mention this population within the context of its broader sample, providing insightful information.

To date, there have been no published articles on multisite studies focusing exclusively on Latinos or African-Americans, particularly on adolescents. The Brothers y Hermanos study provides valuable insight on one portion of this population, but findings are not necessarily generalizable to adolescent Latinos and African-Americans, especially YMSM of color.

Additionally, there is little data, especially multisite data, on male-to-female (MTF) transgender youth, who comprise a subpopulation within the YMSM category. In the SPNS YMSM of Color initiative, about 4.4% of the participants reported non-male gender variant sexual identities, including some who individuals performed in balls- social events with a competitive element that are frequented by YMSM of color and transgender youth.^42,43 Although the CDC does not report separate HIV surveillance figures for transgender people, who are counted as MSM, a Chicago study⁴⁴ of 54 young MTF transgender people aged 16–25 found HIV prevalence at 22%. Another study⁴⁵ conducted in Chicago and LA of 151 transgender youth aged 15–24 found HIV prevalence at 19%. These rates compare with data from studies conducted in 11 U.S. cities of MTF transgender people of all ages finding HIV prevalence rates ranging from 14% to 68%.^{46

–56} A meta-analysis⁵⁷ conducted by members of the CDC Prevention Research Synthesis Team estimated HIV prevalence among transgender women to be 11.8% by participants in 18 studies who self-reported their status, but 27.7% in those who were actually tested in 4 studies. This suggests that over one-half (57%) of HIV-positive transgender women may be unaware of their status. African-American MTFs had the highest HIV prevalence rates, ranging from 41% to 63%,^{48,49,58
–60} followed by rates among Latina MTFs ranging from 14% to 49%.^{48,49,52,59,60}

Like YMSM, MTF transgender youth have been found to be at high risk for HIV and STD transmission, with risk factors including unsafe sexual behaviors and substance abuse.^44,45,61 Exchange sex has also been reported among YMSM, and many transgender youth engage in survival sex where sexual behavioral risks increase.^62
–64 Gender identity affirmation through unprotected sex has also been implicated as an HIV/STD risk factor among transgender women.^65

–68 Like older transgender adults, transgender youth also experience HIV and hepatitis C (HCV) transmission risks through needle sharing from injection drug use,^63,64 and hormones and silicone injections.^44,61
–63

Given the small numbers of gender variant persons within the SPNS YMSM sample, we did not separate them further in this study. However, the need for additional research in this subpopulation is evident, and has been recommended by the American Public Health Association (APHA) since 1999.⁶⁹

Discussion/Conclusion

Adolescents, MSM, African-Americans, and Latinos are four populations that have been severely affected by the HIV/AIDS epidemic. YMSM of color are at an especially elevated risk for becoming HIV-infected due to their status as racial, ethnic, and sexual minorities. It is therefore extremely important to understand the behaviors of these populations so that health care providers, researchers, and HIV prevention workers can tailor their programs to meet the specific needs of YMSM of color.

National surveillance data show that although HIV/AIDS rates among most high-risk populations are remaining steady or decreasing, they continue to increase among young MSM, and this increase is more striking when studying YMSM of color. Each of the eight sites in this SPNS Initiative have identified a significant population of YMSM of color in their service areas, demonstrating the need for a better understanding of what has been driving the epidemic among this population.

Many national multisite studies have examined the epidemic among adolescents, MSM, African-Americans, and Latinos, and each have consistently found HIV/AIDS rates that were higher than in the general population. Additionally, several studies found that the majority of HIV-infected individuals were unaware of their infection. Members of these populations reported many risky sexual behaviors, including having multiple partners, frequent UAI, and survival or exchange sex. They also report a high prevalence of substance abuse, including injection drug use, and depression is common among this group.

Since YMSM of color are members of these high risk populations, many of the findings from these earlier studies apply to them. However, prior to the SPNS Initiative, there were no known multisite studies that focused solely on HIV-positive YMSM of color. Assuredly, many behaviors exclusively associated with adolescents, MSM, or men of color may not apply to a subset of the population. Therefore, it is important to develop a better perspective on how HIV/AIDS has affected YMSM of color and see how this population is similar to and different from broader populations.

A better understanding of transgender youth, especially MTFs, also is important since they have traditionally been considered a subset of MSM. These youth are often at heightened risk of HIV acquisition and face many other challenges. Fear of discrimination by health care providers, including HIV/STD counseling and testing staff, is also a serious concern.^44,61,63 Yet when HIV prevention programs develop specialized services for transgender youth, program participation and retention may be at high levels.⁷⁰ The subsequent articles in this supplement describe in detail the behaviors and characteristics of a multisite sample of YMSM of color in order to address these issues.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

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