ArticlesComparisons of disparities and risks of HIV infection in black and other men who have sex with men in Canada, UK, and USA: a meta-analysis
Introduction
One of the most striking HIV infection disparities in the USA is the disproportionate toll on black men who have sex with men (MSM). Although representing less than 1% of the total population, nearly a quarter of new HIV infections in 2009 were in black MSM.1, 2 The US Centers for Disease Control and Prevention has announced that new HIV cases increased by 48% in young US black MSM from 2006 to 2009.2 In the past decade, several important investigations in the US have helped to clarify the factors that might contribute to disproportionate infection rates in black MSM.3, 4, 5, 6
Despite these previous investigations, important gaps remain in scientific publications. Although a previously published meta-analysis5 provided evidence for several postulated reasons for greater HIV disparities in black MSM than in other MSM, other relevant hypotheses were not examined because of insufficient published studies at that time. Additional pertinent research has been published in the intervening years, however, and data from these studies might yield a more comprehensive review of the evidence. A second gap in publications is a meta-analysis of risk factors associated with HIV infection in young black MSM. Whether factors that raise infection risk for black MSM overall are similar or different for young black MSM is unknown. In view of scientific advances showing that early HIV diagnosis and entry into care improve clinical outcomes and greatly reduce risk of sexual transmission to sex partners,7 a third gap in published work is a meta-analysis documenting racial disparities in HIV-positive MSM associated with access and use of clinical care. Last, another prominent gap is the degree to which disparities associated with HIV infection in US black MSM are also applicable to black MSM in other high-income countries.
The aims of the current quantitative review are to: (1) explore factors associated with greater HIV transmission risks in young black MSM than in other young MSM across studies; (2) assess the degree to which access to clinical care and other disparities exist in HIV-positive black MSM relative to other HIV-positive MSM; (3) examine HIV-related disparities for black MSM relative to other MSM in Canada and the UK; and (4) gauge the degree to which HIV-related racial disparities are similar or different in black MSM in Canada, the UK, and the USA.
Section snippets
Search strategy and selection criteria
We searched Medline, Embase, and Google Scholar for relevant reports from Jan 1, 1981, to Dec 31, 2011. Key words and Medical Subject Headings (US National Library of Medicine) relevant to race (ie, “black”, “African”, “Caribbean”, “Afro”, “African-American”) were cross-referenced with citations pertinent to homosexual men (ie, “homosexual”, “bisexual”, “men who have sex with men”, “MSM”, “gay”, “HIV”, “AIDS”) in English and French. Particular attention was paid to Canadian, UK, and US studies
Results
In total, our search resulted in 194 articles, abstracts, or personal communications. We assessed seven studies from Canada, 13 from the UK, and 174 from the USA.
In the USA, 174 studies of black MSM were compared with other MSM of other races or ethnic origins (table 1). Black MSM across studies were less likely to report gay identity or to report disclosing their sexuality to others, including health-care providers (table 1). Overall, however, black MSM engaged in fewer HIV risk behaviours
Discussion
A clear and paradoxical pattern of similar or less risk behaviour and risk of HIV or STI emerged in the USA and UK such that black MSM reported similar serodiscordant or receptive UAI, similar or fewer male sex partners, and had a greater likelihood of HIV infection than did other MSM. Although in Canada black MSM are not more likely to have HIV than are white MSM, it is notable that black MSM reported less substance use than did other MSM but remained equally likely to be diagnosed with HIV
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