The HIV care continuum in black MSM in the USA.

In The Lancet HIV, Eli Rosenberg and colleagues report their reconstruction and population of the HIV care continuum from publicly available and nationally representative data of men who have sex with men (MSM) in the USA. Viral suppression, the penultimate desired eff ect on the continuum, is achieved in 16% of black and 34% of white MSM. After modelling various scenarios of how diff erences in viral suppression could aff ect the future course of the epidemic, the investigators reach the disappointing conclusion that even in the best-case scenario racial disparities in HIV prevalence will sustain a higher incidence in black MSM for decades to come. These disheartening conclusions show the long-term consequences of historical neglect. Immediately after the fi rst epidemiological investigations of HIV infection in MSM in the USA started in 1984, Samuel and Winkelstein not only reported racial disparities in HIV seroprevalence and incidence, but also that, contrary to their expectation, these disparities could not be accounted for by race-associated diff erences in HIV risk behaviour. Similarly, after all US states and territories had implemented AIDS case reporting in 1986, Bakeman and colleagues analysed and reported the AIDS Public Information Data Set from US Centers for Disease Control and Prevention (analogous to the rationale and approach used by Rosenberg to obtain and report the data presented in the current study) demanding interventions to stop the emerging and widening HIV/AIDS epidemic in black Americans. The racial disparity fi ndings in HIV/AIDS have been repeatedly corroborated in HIV case reporting, surveillance, and research. However, the fi rst US federally funded evidence-based HIV prevention intervention designed specifi cally for black MSM was not published until 2009—a quarter of a century after racial disparities in HIV infection were fi rst noted between black and white MSM. The increased federal investment in HIV prevention in black MSM is promising. However, the focus on HIV testing and biomedical interventions is unlikely to have the eff ect needed to end disparities in care. Black MSM are already as likely as or more likely than are white MSM to use condoms, to get tested for HIV, and even to use pre-exposure chemoprophylaxis. However, these preventive behaviours have not reduced racial disparities along the care continuum, nor have they reversed the increasing trend in HIV incidence. Indeed, Rosenberg and colleagues note that the same structural barriers aff ecting the HIV care continuum are likely to aff ect access to and use of any other biomedical HIV prevention measure. The researchers leave us with the dire prediction that short of “transformational biomedical advances”, such as an eff ective HIV vaccine or a cure, racial disparities in MSM will persist for the foreseeable future. While we wait for scientifi c process to take its course in delivering biomedical advances, the structural interventions and changes needed to facilitate aff ordable, eff ective, and unrestricted access to the new preventive methods can be started today. Positive structural changes in the organisation of the health-care system of the USA will help to improve overall access to quality health care in the country. However, this might not benefi t black Americans generally. Black MSM have lower rates of health insurance than do white MSM, starting with reduced access to health-care services. The Aff ordable Care Act has increased access to care for people who live in states that have elected to expand Medicaid. However, most states in southern USA (where most black Americans with HIV live) have rejected Medicaid expansion. A mandatory Medicaid expansion would likely increase health-care access for many black MSM who live in the south. However, even when such access would become available, structural interventions and change will still be needed to provide unrestricted and unhindered access to this expansion. High rates of poverty, incarceration, unemployment, and low education are driven by historical and current policies that disproportionally aff ect black people in the USA. These policies can be changed in ways that improve life circumstances that put black MSM at higher risk for HIV. For example, elimination of policies such as stop and frisk that target young black men would serve to reduce the number of black men in the criminal justice system, allowing them to spend more time on education, expanding employment opportunities, and reducing exposure to HIV in prison. Published Online November 18, 2014 http://dx.doi.org/10.1016/ S2352-3018(14)00008-3