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Combating HIV Among Black Gay and Bisexual Men

Combating HIV Among Black Gay and Bisexual Men. David Holtgrave, PhD, Professor and Chair Department of Health, Behavior & Society. Three-fold Project Aims. 1. Examine literature and epidemiology around HIV/AIDS among Black MSM with a focus on social determinants

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Combating HIV Among Black Gay and Bisexual Men

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  1. Combating HIV Among Black Gay and Bisexual Men David Holtgrave, PhD, Professor and Chair Department of Health, Behavior & Society

  2. Three-fold Project Aims 1. Examine literature and epidemiology around HIV/AIDS among Black MSM with a focus on social determinants 2. Review existing and on-going HIV interventions for Black MSM 3. Calculate the level of needed US investment to be made in HIV/AIDS prevention, care and housing services for Black MSM

  3. Aim 1: Methods • Key word search in PubMed, Scopus, Google Scholar • Identified all articles that focused on HIV among Black MSM  limited to six areas of inquiry • Behavioral, biomedical, structural, social contextual, psychosocial, social networks • Assessed 71 articles for eligibility  included 39

  4. Aim 1: Key findings • Disparities can’t be explained by differences in risk behavior or circumcision • Research on contribution of incarceration, discrimination, stigma, social isolation and mental health inconclusive • Peer support for condom use is a resiliency • High rates of STDs, high rates of undiagnosed HIV infection, and lower rates of HAART use and adherence help to explain disparities by race

  5. Aim 1: Conclusions • Additional research needed on complex and intertwined areas of incarceration, discrimination, stigma, social isolation and mental health • Resiliencies need to be indentified and studied • Research needed to understand barriers and facilitators of HIV (and STD) testing, linkage and retention in care

  6. In Press, BMC Public Health

  7. Aim 2: Methods • Searched Pubmed, Scopus, Google Scholar, CDC and NIH websites • Included research articles that assessed HIV interventions for Black MSM • Included experimental and non-experimental designs as well as formative research

  8. Aim 2: Methods (continued) 127 studies identified 84 excluded (title or abstract) 43 full text articles/records reviewed 20 excluded (non intervention focus, not focused on Black MSM) • 23 studies included • 16 articles (12 efficacy studies, 4 formative research) • 7 CDC/NIH study records

  9. Aim 2: Key findings • Identified 12 completed intervention studies for Black MSM • 8 aimed to reduce HIV risk behavior • 4 aimed to increase use of HIV services • Identified 4 formative research studies • Identified 7 on-going studies

  10. Aim 2: Key findings (continued) • Behavior change interventions have been found to be effective at reducing HIV risk behaviors among Black MSM • MSMW, youth, using drugs • Preliminary evidence suggests successful program models for increasing HIV testing and linkage to care, focus on young MSM

  11. Aim 2: Conclusions • Intensive behavioral interventions may face scalability challenges • Need for intervention studies to inform evidence based programming for HIV testing, linkage and retention in care among Black MSM of all ages • Systems level • Individual level

  12. Article Under Review

  13. Purpose of analysis for Aim 3 • To determine the scope of unmet HIV prevention, care and housing needs among Black MSM in the U.S. • To determine the costs of addressing these needs • To estimate the HIV infections averted by addressing these needs • To estimate the cost-effectiveness of addressing these needs

  14. Methods • The size of the population of Black MSM was estimated using U.S. Census Bureau and CDC information • The size of the population of Black MSM living with HIV was estimated using CDC epidemiologic information • The number of Black MSM living with HIV who were undiagnosed, had particular service delivery needs, had suppressed viral load, and who engaged in unprotected risk behavior in serostatus discordant partnerships was estimated using a wide variety of CDC and scientific literature sources • The costs of addressing unmet needs was estimated using standard economic micro-costing techniques and per client cost estimates from the literature • The cost-effectiveness of addressing unmet needs was estimated using standard economic evaluation, and mathematical modeling approaches based on HIV transmission rates

  15. Results: I (Note: all content subject to change during peer review and publication process) • Estimated number of Black MSM living in U.S. • 735,690 in 2011 • Estimate based on the work of Spencer Lieb, updated from 2007 to 2011 reflecting general population growth in the U.S., and expanded to include 13 to 17 year old black MSM adolescents • Based on CDC estimates of HIV prevalence among Black MSM, this translate to approximately 195,313 Black MSM living with HIV in the U.S. • In the base case analysis, this further translates to • 50,196 Black MSM living with HIV who are not yet diagnosed • 67,625 Black MSM living with HIV who are diagnosed yet not in care • 19,545 Black MSM living with HIV who are diagnosed yet maybe engaging in unprotected risk behavior in serostatus discordant partnerships (behavior that could result in transmission of HIV)

  16. Results: II(Note: all content subject to change during peer review and publication process) • If we use the NHAS 2015 goals and applies these goals to the community of Black MSM in the U.S., we estimate the following unmet needs: • 3,708 Black MSM living with HIV in need of housing • 30,644 Black MSM living with HIV who are not yet diagnosed and in need of diagnostic services • 71,922 Black MSM living with HIV who have unmet HIV care and treatment needs • 19,545 Black MSM living with HIV who might benefit from behavioral prevention services

  17. Results: III(Note: all content subject to change during peer review and publication process) • Estimated HIV incidence per year among Black MSM • 10,800 • Estimated HIV transmission rate • 5.53 per 100 Black MSM living with HIV (to seronegative partners) • Caveat: this transmission rate estimate assumes all HIV transmission from Black MSM is to other Black MSM; this is an imperfect assumption and should be the focus of other future research • For unaware Black MSM, this transmission rate is about 11.50 • For aware Black MSM, this transmission rate is about 3.47 • With no risk behavior, or with suppressed viral load, the transmission rate is very, very low • With unprotected risk behavior and unsuppressed viral load, the transmission rate is roughly 36.71 • Both suppression of viral load and reduction of unprotected risk behavior are important pathways to addressing this transmission rate of 36.71

  18. Results: IV(Note: all content subject to change during peer review and publication process) • To address the estimated unmet needs among Black MSM living with HIV, approximately $2.475 billion is needed in new government funding, redirected government funding, and/or new private sector funding • $44.6 million for housing • $362.1 million for diagnostic services • $2.0 billion in care and treatment services • $26.6 million for prevention services for persons living with HIV • This substantial investment is estimated to have the potential to avert 6213 incident HIV infections • Note: this well exceeds the 25% incidence reduction goal in the NHAS • The cost per quality adjusted life year saved is approximately $20,032 which by usual economic standards would be considered highly cost-effective

  19. Results: V(Note: all content subject to change during peer review and publication process) • Sensitivity analysis • In the base case, we use CDC’s estimate of 25.7% undiagnosed HIV seropositivity among Black MSM in the US • However, if one uses CDC’s National Health Behavioral Survey data to make this estimate (and even if one uses an Emory study to adjust for potential over-reporting of lack of awareness of seropositivity), lack of awareness might be as high as 43.5% • In such a case, the overall costs of unmet needs rises to $3.4 billion, but the overall finding regarding cost-effectiveness of this investment remains the same • Important additional considerations • For all unmet service delivery needs, the relevant social determinants must be considered • Without a supportive context in place, it is very difficult to address unmet needs

  20. Conclusions • There appears to be very substantial unmet HIV housing, prevention, care and treatment needs among Black MSM in the U.S. • Investments to address these needs would be substantial…. • ….however, these investments have the potential for being cost-effective uses of funds…. • ….and have the potential to dramatically alter the HIV epidemic among Black MSM in this country

  21. As President Obama said on July 13, 2010…. “The question is not whether we know what to do, but whether we will do it.”

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