Stuck : Contextualizing the U.S. HIV epidemic among black MSM. Greg Millett amfar April 2, 2015

Transcription

1 Stuck : Contextualizing the U.S. HIV epidemic among black MSM Greg Millett amfar April 2, 2015

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4 New HIV Infections, Women: 21% decrease MSM: 12% increase Young MSM: 22% increase

5 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:

6 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: ; MMWR, 2011

7 HIV Prevelance Summary Odds Ratio HIV Disparities among Black MSM vs. White MSM, Black Community, and U.S. Population X 0 vs. White MSM vs. Black community vs. U.S. population (Millett et. al, The Lancet, 2012; Slide courtesy G Millett)

8 HIV Prevelance Summary Odds Ratio HIV Disparities among Black MSM vs. White MSM, Black Community, and U.S. Population X X 0 vs. White MSM vs. Black community vs. U.S. population (Millett et. al, The Lancet, 2012; Slide courtesy G Millett)

9 HIV Prevelance Summary Odds Ratio HIV Disparities among Black MSM vs. White MSM, Black Community, and U.S. Population X X X 0 vs. White MSM vs. Black community vs. U.S. population (Millett et. al, The Lancet, 2012; Slide courtesy G Millett)

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14 HIV Prevalence Projected HIV Prevalence among MSM Throughout Lifespan Age-Specific HIV Prevalence 100% 90% 80% 70% Black MSM MSM overall 60% 50% 40% 30% 20% 10% 0% Age MSM overall IR 1.9%;AA MSM IR 4.0% Stall, AIDS Behav, 2007 (Stall, 2009)

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16 Estimated probability of being exposed to HIV by at least 1 partner Black MSM 60% (Kelley, 2013; Slide courtesy G Millett)

17 Estimated probability of being exposed to HIV by at least 1 partner Black MSM 60% 50% (Kelley, 2013; Slide courtesy G Millett)

18 Estimated probability of being exposed to HIV by at least 1 partner Black MSM 60% 50% White MSM 50% (Kelley, 2013; Slide courtesy G Millett)

19 Meta-Analysis: Where are HIV-Related Disparities Greatest Between Black vs. Other MSM? (174 US studies) (Millett, The Lancet, 2012)

20 HIV incidence Factor Incidence/ 100 PY Rate Ratio (95% CI) Black participant (1.7, 9.9) Social determinants Individual risk behaviors Partner pool / network White participant 1.7 ref. Health Insurance 2.6 ref. No health Insurance (1.2, 5.0) UAI (1.5, 24) No UAI 1.1 ref. Older partners ( 10 y) (1.2, 6.1) No older partners 3.1 ref. Black partners (2.1, 10) No black partners 1.9 ref. (Rosenberg et al, 2015)

21 Covariate Health Insurance UAI Older partners ( 10 y) Black partners HIV incidence Age-scaled Cox PH models Black vs. White HR (95% CI): HR Race = 3.0 (1.3, 6.7) (Older partners) HR Race = 2.9 (1.3, 6.5) (no covariate adjustment) 2.6 HR Race = 3.3 (1.4, 7.5) (UAI) HR Race = 2.6 (1.3, 6.5) (Health Ins.) (Rosenberg et al, 2015)

22 Covariate Health Insurance UAI Older partners ( 10 y) Black partners HIV incidence Age-scaled Cox PH models Black vs. White HR (95% CI): HR Race = 3.0 (1.3, 6.7) (Older partners) HR Race = 2.9 (1.3, 6.5) (no covariate adjustment) 2.6 HR Race = 3.3 (1.4, 7.5) (UAI) HR Race = 2.6 (1.3, 6.5) (Health Ins.) HR Race = 1.6 (0.6, 4.2) (Black partners) HR Race = 1.5 (0.6, 3.9) (Black P, Health Ins.) HR Race = 1 (Rosenberg et al, 2015)

23 Disparities persist between black and other MSM throughout treatment cascade (24 comparative studies) Undiagnosed HIV 6x HIV Detection Diagnosed HIV+ 3x ART utilization/ access 40% less >200 CD4 cells/mm 3 before ART initiation 60% less Healthcare visits 40% less ART adherence 50% less HIV suppression OR, 0.51 ( ) Viral Suppression (Millett, 2012; slide courtesy G Millett)

24 Disparities persist between black and other MSM throughout treatment cascade (24 comparative studies) Undiagnosed HIV 6x HIV Detection Diagnosed HIV+ 3x ART utilization/ access 40% less >200 CD4 cells/mm 3 before ART initiation 60% less Healthcare visits 40% less ART adherence 50% less HIV suppression OR, 0.51 ( ) Viral Suppression (Millett, 2012; slide courtesy G Millett)

25 Black Clinicians and HIV Testing (Jordan, 2013)

26 (Rosenberg, 2014)

27 (Rosenberg, 2014)

28 (Rosenberg, 2014)

29 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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34 Aligning Our Research Investments with the Epidemic Are research dollars aligned with populations where HIV is most concentrated? Is participation in research trials reflective of these populations? Figure NIH FY 2010 HIV/AIDS Funding by risk group

35 96 intervention studies Selection criteria (1) been published between 1991 and 2010 (inclusive) (2) Interventions for HIVnegative youth (13-24 yrs) MSM overwhelming majority new HIV infections among youth MSM only group where HIV rates increasing

36 Making Smarter Investments: CDC Modeling for Philadelphia 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 Behavioral intervention for HIVpeople 594,796 (10) 700,005 (11) 97,410 (6) 15,642,127 (14) 2,931,406 (13) 327,210 (9) 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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38 Attitudes are changing a new era?

39 HIV Prevalence Summary Odd Ratio Structural-Level Experiences &Resiliency, U.S. Black MSM vs. Other MSM < HS Education Lower Income Ever Incarcerated Unemployed Any Structural Barrier (Total) Any Resilient Behavior Resiliency (young BMSM) (Millett, 2012)

40 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 racial, LGBT equality and reducing discrimination)