At the end of 2015, the U.S. Centers for Disease Control announced that diagnoses of HIV in the United States declined significantly over the last decade. On the surface, it was good news: rates of new diagnoses for the general population dropped 19 percent between 2005 and 2014. With some populations hard hit by HIV, we saw even greater improvements: new diagnoses are down 42 percent among Black women over the past decade, down 35 percent among heterosexuals, and down 65 percent among people who inject drugs. White gay and bisexual men experienced an 18 percent decline in new diagnoses.
But Black and Latino gay and bisexual men actually saw increases in HIV diagnoses of 22 percent and 24 percent, respectively, over the same time period. New diagnoses for 13-24 year old Black men who have sex with men (MSM) were up 87 percent from 2005 to 2014. Even though there are about six White gay and bisexual men for every Black gay or bisexual man in the U.S., in 2014 about 10,000 Black MSM of all ages were diagnosed with HIV, compared with about 8,000 White MSM.
As we marked National Black AIDS Awareness Day on February 7, it’s worth digging into the reasons for these disparities. First, given the moral narratives often associated with HIV, it’s important to understand that higher rates of HIV among Black MSM are not due to higher rates of risk behaviors. Black gay and bisexual men have fewer sexual partners than White gay and bisexual men, and are less likely to use substances before sexual activity that might disinhibit their behavior and lead to taking greater sexual health risks.
The factors that make Black gay and bisexual men more vulnerable to HIV infection than White gay and bisexual men have built up over decades and are directly related to lower rates of health insurance and access to health care. They include higher rates of undiagnosed and untreated sexually transmitted infections that can facilitate HIV infection, higher rates of undiagnosed HIV infection, and lower rates of antiretroviral treatment adherence if diagnosed with HIV. As a result, there is a greater per capita pool of non-virally suppressed HIV-positive men in Black gay male social and sexual networks.
There are three things we should do to reduce HIV burden among Black gay and bisexual men. First, we need to improve health care for them. A study published last year in the American Journal of Public Health found that 29 percent of a sample of 544 Black MSM experienced stigma related to race and/or sexual orientation in health care, and 48 percent expressed mistrust toward the medical establishment.
Even as we applaud the expansion of health care access brought about by the Affordable Care Act—which disproportionately helps Blacks and Latinos, LGBT people, and people living with HIV—we must ensure that health care providers are trained to provide culturally competent and affirming care to Black gay and bisexual men. This includes discussing pre-exposure prophylaxis (PrEP) for HIV prevention and encouraging Black gay men to consider this option to help them prevent HIV infection. Such training is offered by The National LGBT Health Education Center through webinars, online educational workshops, and site visits.
Second, we need a renewed focus on educating young people about HIV. There is a lack of comprehensive sexuality education in schools; only 22 states and the District of Columbia require that sexuality education be taught in public schools. Even in liberal cities like Boston and New York City, sex education has started only recently, within the last few years, and in many parts of the country there is no sex education at all.
Eight states, most in the South, have laws prohibiting any mention of homosexuality or same-sex behavior that is not condemnatory. In many school systems principals have a great deal of autonomy, so there is significant variation from school to school in terms of whether or not young people learn how to protect themselves against sexually transmitted infections (STIs) and HIV. So gay and bisexual adolescents, particularly young Black and Latino men, who need to understand how they can protect their sexual health simply aren’t getting the information they need.
Third, we must support efforts to expand Medicaid eligibility in the South. Of three million Americans who are too poor to afford subsidized insurance but not poor enough to qualify for Medicaid, 89 percent live in the South. Several conservative states have recently expanded Medicaid, including North Dakota and Louisiana. Virginia is again considering the expansion.
Efforts to promote expansion of Medicaid eligibility up to 138 percent of the poverty line will disproportionately benefit Black Americans, half of whom live in the South, and could help Black gay and bisexual men and Black heterosexuals access the preventive health care they need and deserve.