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Stuck: Contextualizing the U.S. HIV epidemic among black MSM Greg - - PowerPoint PPT Presentation
Stuck: Contextualizing the U.S. HIV epidemic among black MSM Greg - - PowerPoint PPT Presentation
Stuck: Contextualizing the U.S. HIV epidemic among black MSM Greg Millett amfAR April 2, 2015 New HIV Infections, 2010 2008-2010 Women: 21% decrease MSM: 12% increase Young MSM: 22% increase Lifetime Risk of HIV Diagnosis
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New HIV Infections, 2010
2008-2010 Women: 21% decrease MSM: 12% increase Young MSM: 22% increase
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Lifetime Risk of HIV Diagnosis by Race
- Whites
– 1 in 104 for men – 1 in 588 for women
- Hispanics
– 1 in 35 for men – 1 in 114 for women
- Blacks
– 1 in 16 for men – 1 in 30 for women
Hall et al. JAIDS. 2008; 49: 294-297
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Lifetime Risk of HIV Diagnosis by Race
- Whites
– 1 in 104 for men – 1 in 6 MSM – 1 in 588 for women
- Hispanics
– 1 in 35 for men – 1 in 5 MSM – 1 in 114 for women
- Blacks
– 1 in 16 for men – 1 in 3 MSM – 1 in 30 for women
Hall et al. JAIDS. 2008; 49: 294-297; MMWR, 2011
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HIV Disparities among Black MSM vs. White MSM, Black Community, and U.S. Population
10 20 30 40 50 60 70 80 90
- vs. White MSM
- vs. Black community
- vs. U.S. population
HIV Prevelance Summary Odds Ratio
(Millett et. al, The Lancet, 2012; Slide courtesy G Millett)
3X
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HIV Disparities among Black MSM vs. White MSM, Black Community, and U.S. Population
10 20 30 40 50 60 70 80 90
- vs. White MSM
- vs. Black community
- vs. U.S. population
HIV Prevelance Summary Odds Ratio
(Millett et. al, The Lancet, 2012; Slide courtesy G Millett)
3X 22X
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HIV Disparities among Black MSM vs. White MSM, Black Community, and U.S. Population
10 20 30 40 50 60 70 80 90
- vs. White MSM
- vs. Black community
- vs. U.S. population
HIV Prevelance Summary Odds Ratio
(Millett et. al, The Lancet, 2012; Slide courtesy G Millett)
3X 22X 72X
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Age-Specific HIV Prevalence
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 20 25 30 35 40 45 50 55 60 Age HIV Prevalence Stall, AIDS Behav, 2007
Black MSM MSM overall
MSM overall IR 1.9%;AA MSM IR 4.0%
Projected HIV Prevalence among MSM Throughout Lifespan
(Stall, 2009)
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Estimated probability of being exposed to HIV by at least 1 partner
60%
Black MSM
(Kelley, 2013; Slide courtesy G Millett)
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Estimated probability of being exposed to HIV by at least 1 partner
60% 50%
Black MSM
(Kelley, 2013; Slide courtesy G Millett)
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Estimated probability of being exposed to HIV by at least 1 partner
60% 50% 50%
Black MSM White MSM
(Kelley, 2013; Slide courtesy G Millett)
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Meta-Analysis: Where are HIV-Related Disparities Greatest Between Black vs. Other MSM? (174 US studies)
(Millett, The Lancet, 2012)
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HIV incidence
Factor Incidence/ 100 PY Rate Ratio (95% CI) Black participant 6.6 3.8 (1.7, 9.9) White participant 1.7 ref. Health Insurance 2.6 ref. No health Insurance 6.3 2.4 (1.2, 5.0) UAI 5.3 4.8 (1.5, 24) No UAI 1.1 ref. Older partners (≥10 y) 8.6 2.8 (1.2, 6.1) No older partners 3.1 ref. Black partners 8.6 4.5 (2.1, 10) No black partners 1.9 ref.
Social determinants Partner pool / network Individual risk behaviors
(Rosenberg et al, 2015)
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HIV incidence
Covariate Health Insurance UAI Older partners (≥10 y) Black partners
HRRace = 2.9 (1.3, 6.5)
(no covariate adjustment)
Age-scaled Cox PH models Black vs. White HR (95% CI):
2.6
HRRace = 3.3 (1.4, 7.5)
(UAI)
HRRace = 2.6 (1.3, 6.5)
(Health Ins.)
HRRace = 3.0 (1.3, 6.7)
(Older partners)
(Rosenberg et al, 2015)
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HIV incidence
Covariate Health Insurance UAI Older partners (≥10 y) Black partners
HRRace = 1 HRRace = 2.9 (1.3, 6.5)
(no covariate adjustment)
Age-scaled Cox PH models Black vs. White HR (95% CI):
2.6
HRRace = 3.3 (1.4, 7.5)
(UAI)
HRRace = 2.6 (1.3, 6.5)
(Health Ins.)
HRRace = 3.0 (1.3, 6.7)
(Older partners)
HRRace = 1.6 (0.6, 4.2)
(Black partners)
HRRace = 1.5 (0.6, 3.9)
(Black P, Health Ins.)
(Rosenberg et al, 2015)
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Undiagnosed HIV 6x >200 CD4 cells/mm3 before ART initiation 60% less ART adherence 50% less HIV suppression OR, 0.51 (0.31-0.83) Healthcare visits 40% less
HIV Detection Viral Suppression
(Millett, 2012; slide courtesy G Millett)
Diagnosed HIV+ 3x
Disparities persist between black and other MSM throughout treatment cascade (24 comparative studies)
ART utilization/ access 40% less
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Undiagnosed HIV 6x >200 CD4 cells/mm3 before ART initiation 60% less ART adherence 50% less HIV suppression OR, 0.51 (0.31-0.83) Healthcare visits 40% less
HIV Detection Viral Suppression
(Millett, 2012; slide courtesy G Millett)
Diagnosed HIV+ 3x
Disparities persist between black and other MSM throughout treatment cascade (24 comparative studies)
ART utilization/ access 40% less
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Black Clinicians and HIV Testing
(Jordan, 2013)
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(Rosenberg, 2014)
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(Rosenberg, 2014)
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(Rosenberg, 2014)
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Among HIV-negative Black MSM, experiencing stigma from health care providers was associated with longer gaps in time since last HIV care appointment
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Aligning Our Research Investments with the Epidemic
- Are research dollars
aligned with populations where HIV is most concentrated?
- Is participation in
research trials reflective
- f these populations?
Figure NIH FY 2010 HIV/AIDS Funding by risk group
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96 intervention studies Selection criteria (1) been published between 1991 and 2010 (inclusive) (2) Interventions for HIV- negative youth (13-24 yrs)
- MSM overwhelming majority
new HIV infections among youth
- MSM only group where HIV
rates increasing
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Untargeted interventions Cost per new infection averted (rank)
Testing in clinical settings
51,293 (3)
Partner services
99,105 (7)
Linkage to care
114,644 (8)
Retention in care
75,665 (5)
Adherence to ART
42,753 (2) Targeted interventions HRH IDU MSM
Testing in non-clinical settings
866,272 (12) 53,935 (4) 17,965 (1)
Behavioral intervention for HIV+ people
594,796 (10) 700,005 (11) 97,410 (6)
Behavioral intervention for HIV- people
15,642,127 (14) 2,931,406 (13) 327,210 (9)
Making Smarter Investments: CDC Modeling for Philadelphia
ART, Antiretroviral therapy HRH, High risk heterosexuals IDU, Injection drug users MSM, Men who have sex with men Sansom et al, CDC Grand Rounds August 21, 2012
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Attitudes are changing… a new era?
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Structural-Level Experiences &Resiliency, U.S. Black MSM vs. Other MSM
0.5 1 1.5 2 2.5 3 3.5 4 4.5 5 < HS Education Lower Income Ever Incarcerated Unemployed Any Structural Barrier (Total) Any Resilient Behavior Resiliency (young BMSM)
HIV Prevalence Summary Odd Ratio
(Millett, 2012)
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The moment is now…
The current administration prioritizes our lives:
- Leaders at highest level of
government
- My Brother’s Keeper
initiative
- LGBT civil rights prioritized
- White House prioritizes HIV
- Justice Dept (focused on