By Derrick D. Matthews, PhD, MPH
Despite constituting a small fraction of the population, Black men who have sex with men (MSM) constitute almost a quarter of all new HIV infections in the US. Millett et al. systematically reviewed the literature and found that while individual behaviors such as condom-less anal intercourse increase one’s risk of HIV infection, Black MSM are no more likely to engage in these behaviors than other MSM.
The issue seems, rather, to be related to what happens when Black MSM do become HIV-positive. Upon their HIV infection Black MSM take longer to become diagnosed, and are ultimately less likely to achieve viral suppression, the health state achieved upon sustained successful antiretroviral treatment. This health state not only keeps HIV-positive persons healthy, but also doubles as an effective way to prevent sexual transmission of HIV to HIV-negative partners. Yet this alone doesn’t sufficiently explain the stark disparities we see in HIV infection. To understand that infectious disease epidemiology requires we also look at sexual networks. There are exceptions of course, but generally, the data show that we all tend to choose sexual partners who are more like us with respect to a variety of characteristics, including race.
Upon their HIV infection Black MSM take longer to become diagnosed, and are ultimately less likely to achieve viral suppression
So to tie this all together – what is responsible for HIV disparities if not differences in individual risk behaviors? Here’s what the research has demonstrated:
- MSM are more likely to have sex with men of their same race than other races
- Therefore, Black MSM are more likely to have sex with someone living with HIV
- Black HIV-positive MSM are less likely to be virally suppressed
- HIV infection spreads quickly in a smaller more interconnected network
So while networks appear associated with health disparities, there remains a dangerously large gap between public health science and public health practice. Upon reviewing the explosion of research about the sexual networks of Black MSM in the last decade, we decided it was appropriate to critique how public health was communicating sexual network research. In short – scientists frequently have discussed Black MSM sexual networks and the high HIV prevalence within them as the cause for these disparities rather than an effect of those systems truly responsible for this epidemic.
Data shows we all tend to choose sexual partners who are more like us with respect to many characteristics, including race
But how much does the way we simply talk about something matter? A great deal. The research that we distilled into the previous bullet points has been further simplified when disseminated across online and print media. It matters that we describe variables such as the demographics of one’s sexual partners as “risk factors” because some people may oversimply “racial-demographic risk factors” and consequently believe sorting sexual partners by race to be an easy (but ineffective) HIV prevention strategy. Such a practice simultaneously fails to provide an actionable intervention target.
When pressed, many scientists would likely point to the use of networks as risk factors as a sort of public health shorthand (i.e., proxy for other structural determinants), but we must be proactive in articulating a causal mechanism that appropriately situates the role of Black MSM sexual networks. Failure to do so runs the risk of this literature falling prey to misinterpretation whereby the manifestation of disparities becomes confused with its cause.
The challenge before us now is how we in public health think about and employ language around sexual networks that both maintains scientific utility and values the lived experiences of Black MSM. Although here we have only focused specifically to HIV and the sexual networks of Black MSM, many areas face similar problems that communicate and frame risk in multiple public health settings. If sexual networks are a road sign pointing to the cause of disparities, it is incumbent upon us to continue the destination to its end. Sexual networks do not cause disparities in HIV infection; they are the effect of fundamental causes that cause disparities in HIV infection.
Finally, we have to be remember these sexual networks cannot be reduced to disease vectors when they are themselves a response to the very inequities that produced the contemporary HIV epidemic. In his seminal 1986 essay “Brother to Brother: Words From the Heart,” Black gay author and activist Joseph Beam famously wrote, “Black men loving Black men is the revolutionary act.” Public health researchers must continue in the advancement of science and action, but not at the expense of reframing acts of love. Instead, we researchers must find ways to partner with Black MSM to leverage the resources of science, action, and love to promote health.
NOTE: This research was supported by the National Institute of Mental Health (T32MH094174). The content of this posting is the responsibility of the author and does not necessarily represent the official views of National Institutes of Health.
About the Author
Derrick D. Matthews, PhD, MPH is an Assistant Professor in the Department of Infectious Diseases and Microbiology at the University of Pittsburgh Graduate School of Public Health. He received his PhD from The University of North Carolina at Chapel Hill, and subsequent postdoctoral training in HIV-related health disparities among men who have sex with men (MSM) at the University of Pittsburgh. His research is focused upon the disproportionate burden the HIV epidemic has on Black gay, bisexual, and other men who have sex with men (MSM) in the US. Particularly, his current research is focused on integrating biological indicators of HIV health status, such as viral suppression, alongside behavioral data when conducting anonymous HIV surveillance studies with Black MSM in order to more fully understand disparities in the HIV care continuum. More information can be found on his University of Pittsburgh faculty profile.