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Black MSM and
HIV: What are we
Missing?DAVID MALEBRANCHE, MD, MPH
MOREHOUSE SCHOOL OF MEDICINE
HIV PREVENTION SUMMIT – BIRMINGHAM, AL
SEPTEMBER 29, 2017
Agenda
EPI
Disparity explanations
Continuum of Care
What’s missing?
Summary/Questions/Discussion
Sounding the alarm? Really?
Valleroy et al., 2000 – “1 in 3”
MMWR, 2005 – 46% prevalence
MMWR, 2009 – Jackson, MS – 93% increase
MMWR, 2011 – Milwaukee, WI – 144% increase
WHY?
Proposed factors
HIV testing
Access to care
Condomless sex rates
Incarceration
Racism in white gay communities
Sexual prejudice
Substance abuse
Black church/religion
Sexual networks
Mental health
Masculine socialization
Poverty
Lack of insurance
Non-disclosure of sexual
orientation
Dishonesty with providers
MOST RESEARCH STILL FOCUSES ON INDIVIDUAL LEVEL BEHAVIOR
Why the racial disparity?
STI prevalence difference
Undiagnosed seropositivity
Access to care and treatment services
Linkage to care
Retention in care
Use of ART
Maulsby et al., 2014
Continuum of
care
This is Us…
When the CDC
finally
acknowledges
U = U
Common denominator?
CULTURAL HUMILITY
HIV Testing
Over-screening of Black MSM
Approaches incorporating “Black MSM = HIV”
“HIV fatigue”
Missed opportunities
Assumptions based on race, masculinity, marriage
No sexual history discussion
“You don’t need that”
Linkage to
Care
Lack of adequate area resources
Provider/staff fatigue
Provider apathy
Not following through
Engagement/Retention in Care
Crowded facilities
Stigma of the clinic itself
Overworked staff
Institutional/individual rules
Staff/provider attitudes
Prescribed
ARV
therapy/Viral
Suppression
Provider bias and assumptions
Not listening to our patients
Adherence “testing” phase
Inadequate preparation for potential side effects
Barriers to contacting us with questions
Have we done a
sufficient evaluation
of ourselves?
Pre-exposure Prophylaxis (PrEP)
PrEP
Black MSM unaware of PrEP reported:
Lower rates of HIV testing knowledge
Fewer HIV testing experiences
Higher rates of transactional sex
Medical students’ PrEP assumptions and prescribing
practices
Black patients rated more likely than white patients to
engage in condomless sex if prescribed PrEP
Reduced willingness to prescribed PrEP to Black
patients compared to white patients
Eaton et al., 2016; Calabrese et al., 2014
PrEP – why the slow uptake?
• Insufficient PrEP knowledge
• Competing needs among Black MSM
• Insufficient access to PrEP due to cost or provider-related issues
• Inaccurate HIV risk perceptions
• Community opposition to PrEP
• HIV, race, and MSM stigma
• Provider resistance and perceived incompetence with prescribing PrEP
• Inconsistent criteria for identifying at-risk PrEP candidates
• Lack of culturally tailored messaging on uptake and adherence to PrEP
California HIV/AIDS Policy Research Centers, 2016
My week…
Patient at HIV clinic
Working at Fulton County Jail
Friends in need
Human aspect of sex
“Trauma informed care”
Racial, masculine, and sexual trauma
Sex not as just “potential for disease”
Love
Pleasure
Release
Connectedness
Healing
“Fund love”
What can WE
do better?
OUTSIDE THE ACADEMIC BUBBLE…
The Counter Narrative: www.thecounternarrative.org
Thrive: www.thrivess.org
National Alliance of State and Territorial AIDS Directors (NASTAD):
HIS HEALTH: www.hishealth.org
WELL VERSED: www.wellversed.org
Kaiser Family Foundation:
#speakoutHIV
#asktheHIVDOC series
www.greaterhan.org
Summation
HIV racial disparity persists among Black MSM
Asset-based approaches needed
Honest conversations/approaches about race and Black MSM
Different approaches to sexual health through the whole person
Behavioral research/interventions should accompany the
biomedicalization of HIV prevention
