In 2017, the Centers for Disease Control and Prevention (CDC) released a first-of-its-kind report assessing the lifetime risk of HIV in the United States. Not surprisingly, people who live in the South (the region known to have the highest rate of new HIV infections) were seen to be at greatest lifetime risk.
What surprised many was the fact that one specific group—Black men who have sex with men (MSM)—was reported to have a startling one-in-two chance of getting HIV in a lifetime, irrespective of their age or geographic location.
This article takes a closer look at the CDC findings and outlines the various factors contributing to the exceptionally high risk of HIV in gay and bisexual Black men in the United States.
What the CDC Report Found
The CDC report analyzed national HIV surveillance data from 2009 to 2013. The aim of the research was to identify disparities in HIV infection rates by region, age, biological sex, sexual orientation, race/ethnicity, and injecting drug use.
Part of the intent of the research was to identify where resources need to be directed in order to overcome these historical disparities. This not only includes increasing treatment access for at-risk communities but also overcoming barriers to HIV testing (including HIV stigma and homophobia).
Of the estimated 1.2 million people living with HIV in the United States, around 13% have not been tested and are unaware of their HIV status.
Among the findings of the CDC report:
- The lifetime risk of HIV is one in 68 for males and one in 253 for females, the disparity of which is mainly due to high rates of HIV among MSM.
- By race, the lifetime risk is one in 22 for Black males, one in 51 for Latinx males, and one in 140 for White males.
- As a group, MSM have a one-in-six lifetime risk of HIV. The group with the lowest risk is heterosexual males with a lifetime risk of one in 524.
- White MSM have a one-in-11 lifetime risk of HIV.
- Latinx MSM have a one-in-five lifetime risk of HIV.
- Black MSM have a one-in-two lifetime risk of HIV, by far the highest rate of all risk groups.
Causes of HIV Risk in Black MSM
The causes of the disparity in Black MSM are neither simple nor straightforward. The knee-jerk response may be to assume that sexual practices (namely anal sex) paired with cultural attitudes are the sole factors that place Black MSM at such exceptionally high risk.
But, the simple fact is that Black MSM are at the epicenter of numerous intersecting vulnerabilities that, together, compound their risk of infection.
HIV Stigma
From a historical perspective, epidemics almost invariably hit stigmatized populations harder than other population groups. This is because there is often little to stop the spread of infection among groups who regularly face healthcare discrimination and/or lack access to culturally specific healthcare services.
So, when infection rates begin to rise, negative stereotypes and prejudices are often reinforced. This may include suggesting that entire groups are "irresponsible," "promiscuous," or somehow to blame for their infection.
This can send gay and bisexual men into hiding for fear of disclosure of not only their HIV status but their sexual orientation as well.
Physiological Vulnerabilities
There are also physical vulnerabilities that place MSM at a higher risk of HIV overall. Chief among these is anal sex.
Biologically, the anus and rectum are lined with only a single column of cells, called epithelial cells. that serve as a barrier to infection. By contrast, the vagina has many. As result, anal sex is the most efficient means of HIV infection overall.
Anal sex is associated with an 18-fold greater risk of HIV transmission when compared to vaginal sex.
Other Sexually Transmitted Infections
Having a sexually transmitted infection (STIs) only increases a person's chance of getting HIV. This is because certain STIs like syphilis can cause sores that allow the virus easier access into the body. Others like chlamydia and gonorrhea cause an inflammatory response that attracts the very immune cells, called CD4 T-cells, that HIV targets for infection.
The CDC reports that syphilis, chlamydia, and gonorrhea in Black MSM occur at rates 4.5, 6.6, and 8.9 times greater than in White MSM.
Poverty
High rates of poverty in Black communities are inherently linked to higher rates of HIV. Poverty not only limits access to healthcare and health insurance but also increases the likelihood of incarceration, substance abuse, and housing insecurity, all of which are risk factors for HIV.
In 2018, the poverty rate among Black people in the United States was 22% compared to 9% of White people. Many southern states exceed these figures, such as Louisiana where 30% of the Black population lives in poverty.
Sexual Networks
According to the CDC, gay and bisexual men of color tend to have sex with their own race, meaning that their sexual networks are smaller and more exclusive. As such, the likelihood of transmission is increased simply because there is already a higher rate of HIV within that network.
Gay men of color also tend to have sex with older men as a result of their smaller sexual networks. As older men are more likely to have HIV, Black MSM tend to get infected at a younger age than their heterosexual male counterparts.
Distrust in Institutions
The historical failure of social, judicial, and public health services within lower-income communities tends to fuel a general distrust in governmental institutions. This is especially true among Black MSM and Black men in general.
This includes mistrust in public health facilities offering HIV testing and treatment. Even if treatment is accessed, there is a greater likelihood that a Black MSM will eventually drop out.
Among Black MSM, only 59% of those who access treatment for HIV remain in treatment.
Distrust of public health authorities can also reinforce negative attitudes about HIV prevention and treatment, enabling AIDS denialism and conspiracy theories.
Summary
A 2017 study from the Centers for Disease Control and Prevention (CDC) reported that Black men who have sex with men (MSM) have a one-in-two chance of getting HIV in a lifetime. Today, Black MSM in the United States are at the greatest risk of HIV compared to all other population groups.
The causes for this disparity are many, including HIV stigma, homophobia, smaller sexual networks, distrust in government institutions, and higher rates of poverty and sexually transmitted infections.
A Word From Verywell
Irrespective of the CDC findings, getting HIV is not an inevitability. If you are a gay or bisexual Black man, it is important to identify your personal risks of HIV infection and take steps to minimize them. This includes confronting the HIV stigma still common in many communities of color.
There are advocacy and awareness groups that can help, like the CDC-supported Black Men's Xchange (BMX), which has 11 chapters in the United States, and the Center for Black Equity, which works closely with many Pride organizations.
To find HIV services within your community, contact your regional 24-hour AIDS hotline. To access free, confidential HIV testing, contact 800-CDC-INFO (800-232-4636) or use the AIDSVu HIV testing site locator managed by the Rollins School of Public Health at Emory University.
