BACK OF THE

LINEThe State of AIDS Among Black Gay Men in America 2012 Back of the Line: The State of AIDS Among Black Gay Men in America, 2012 is a publication of the Black AIDS Institute, 1833 West Eighth Street, Los Angeles, California 90057-4257, 213-353-3610, 213-989-0181 fax, ­[email protected], www.BlackAIDS.org.

© 2012 Black AIDS Institute. All rights reserved.

The slogan “Our People, Our Problem, Our Solution” is a trademark of the Black AIDS Institute.

Views and opinions expressed in this publication are not necessarily those of the Black AIDS Institute, its partners or the funders of this publication. Publication of the name or photograph of a person does not indicate the sexual orientation or HIV status of the person or necessarily constitute an en­dorse­ment of the Institute or its policies. Some photographs in this publication use professional models for illustrative purposes only.

Back of the Line: The State of AIDS Among Black Gay Men in America, 2012 is designed for educational purposes only and is not en­gaged in rendering medical advice or profession­al services. The information provided through this publication should not be used for diagnos­ing or treating a health problem or a disease. It is not a sub­stitute for profes­sional care.

This report was made possible, in part, by the generous support of the Elton John AIDS Foundation, Ford Foundation, M-A-C AIDS Fund, and Broadway Cares/Equity Fights AIDS.

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Deciding Moment: Connecting the Back of the Line: Back of the Line: Together We Are Dots: The State of AIDS The State of AIDS Greater Than The Fight Against Among Black Gay Among Black Gay AIDS AIDS Among Men in America Men in America Black Gay Men Executive and the Struggle Summary for Civil Rights 5 6 7 8

Worse Than Any A Physician At Risk No Matter Profiles: Other: Speaks: the Age: Risk Among Black More Heavily Health Care A Lifetime MSM Knows No Affected by Barriers for Black Challenge Age HIV Than Any MSM Population in the Developed World 9 10 11 12

The Best and New Hope, New An HIV Prevention Ending AIDS Worst: Opportunities: Leader Speaks: Among Black U.S. Cities Ranked But Will Black Growing AIDS MSM: MSM Benefit? Crisis Among How Do We Move Black MSM Forward?

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Profiles: Action Plan to Notes About Gone Too Soon End AIDS Among Black MSM: Priority Action Steps

Back of the Line 3 4 Back of the Line Deciding Moment 1 Together We Are Greater Than AIDS

By Phill Wilson President and CEO, Black AIDS Institute

“Black men loving Black men is a and over 30% of them are dead today. society as a whole—has largely moved call to action, an acknowledgement of I got involved in the fight against on, HIV/AIDS continues to be a responsibility. We take care of our own AIDS—the GRID, (Gay Related leading cause of death for Black men kind when the night grows cold and Immune Deficiency)—shortly after the who have sex with men. By the time silent. These days the nights are cold- first cases were diagnosed among five a Black gay man reaches age 25, he blooded and the silence echoes with white gay men at UCLA medical center stands a roughly one-in-four chance of complicity.” in 1982. being infected with HIV. By age 40, the Joseph Beam In the beginning, like most odds reach an astonishing 60%. Brother to Brother: Americans, I believed that AIDS was Moreover, at a moment when tens Words from the Heart a white gay disease. But very quickly, of thousands of scientists, advocates, I was disabused of that notion. On policy makers, journalists, and people was 24 years old when I became the ground a different story was living with HIV/AIDS from across infected with HIV. I’m 56 now. The being played out. In fact, from the the world gather in Washington, journey to prepare this report has very beginning of the epidemic the D.C., for the XIX International AIDS Ibeen a very personal one for me. I proportion of cases among Black gay Conference that will focus largely on am among a small number of Black men was more than double our share hopes of ending the AIDS epidemic, gay men who survived the darkest days of the national population. Today, HIV the problem among Black gay men of the AIDS epidemic. The first thing prevalence among Black gay men is is getting worse. Much worse. From I did when we decided to write this roughly double the prevalence among 2006 to 2009, the rate of new infections report was to take a long and hard look white gay men. among young Black gay men rose at two photographs hanging in the At a time when the LGBT by 48%. While transmission rates entryway of my house. community—and, indeed, American have declined in the U.S. overall, The first one is a photo of me with my friends Ken, Roger, and Steven. I Phill Wilson am the only one of us still alive. The second photo is of me and my friend David who died in 1998. The second thing I did was reread three very important books, In the Life: A Black Gay Anthology edited by Joseph Beam; Brother to Brother: New writings by Black Gay Men edited by Essex Hemphill; and Sojourner by the Other Countries collective. All of these books were published between 1986 and 1993. As I reread these anthologies, I was struck by how prolific Black gay writers were during the very worst years of the AIDS epidemic. It was as if they were writing for their lives. There were nearly 80 contributors to those three anthologies

Back of the Line 5 new infections are rapidly increasing homes for Black gay men—the among young Black gay men. Black and LGBT communities— I wish I could report that these have similarly failed to prioritize startling patterns have prompted the AIDS fight among Black men newfound resolve and innovation to who have sex with men. And the reverse this crisis. But nothing could philanthropic sector, once a robust be further from the truth. presence in the AIDS fight, has First in line when it comes to withered away, with a mere handful need, Black gay men too often of funders continuing to support remain at the back of the line when community-based AIDS programs. it comes to assistance. While there If this report were nothing are mobilization efforts going on more than a clarion call for action to service they need. to increase testing and access to address an unconscionably neglected But more—much more—will need treatment, they are often being issue, it would be worth publishing. to be done. Those who ought to care implemented with little, if any, support But it’s more than that. It’s also about must care. And those in positions of from those who ought to care. hope—in a future without AIDS, for leadership must lead. As this report explains, state and all populations and in all settings. This report is dedicated to a vision local health departments are seriously Today, the tools are at our disposal of a world without AIDS. It’s dedicated under-prioritizing prevention and to bring this horrible epidemic to an to David, Roger, Ken, and Steven. It’s treatment programs for Black gay men. end. By combining new biomedical dedicated to the young Black gay men And the federal government doesn’t tools with strengthened prevention who call the Black AIDS Institute even track HIV expenditures for Black programs and support services that almost every week who just found out gay men. Compared to white gay men, contribute to the effectiveness of they are HIV-positive. They either Black gay men have more limited biomedical interventions, we can end didn’t know how to protect themselves access to HIV testing, are more likely AIDS. or didn’t know their lives were worth to lack access to care, and are less likely Black gay men won’t gain protecting. They usually know very to receive antiretroviral therapy when meaningful access to breakthrough little about the virus, don’t have health they are able to obtain health care. The HIV tools without dramatic changes care, and are often more afraid of the low-priority approach taken by many in service systems, funding patterns, stigma than they are of the disease. of our public health leaders would and legal frameworks. The Supreme We’ve attempted to provide seldom lead one to conclude that Black Court’s validation of the Affordable a blueprint for action, outlining gay men represent the only population Care Act in June 2012 offers an urgent steps that need to be taken in the U.S. in which new infections are important avenue for making some by government leaders, Black significantly increasing. of the changes needed to give Black communities, the LGBT community, Beyond government, the gay men a fighting chance to get the and private foundations. communities that are the natural This is one report that simply can’t gather dust on the shelves or remain unread on a flash drive. The problem it describes is too important, and the need for action too urgent. Let’s use the release of this report to renew our commitment, reinvigorate the national AIDS response, and show through action that Black gay men are part of the American family. We are at a deciding moment. Together we are greater than AIDS.

“I want to start an organization to save my life. If whales, snails, dogs, cats, Chrysler, and Nixon can be saved, the lives of Black men are priceless and can be saved.” Essex Hemphill For My Own Protection

6 Back of the Line Connecting the Dots 2 The Fight Against AIDS Among Black Gay Men and the Struggle for Civil Rights

By Ernest Hopkins Chair, National Black Gay Men’s Advocacy Coalition

hen the civil rights prejudices of the past than any earlier movement gathered generation. momentum more This report focuses on one group of Wthan a half-century Americans for whom the promise of ago, activists initially focused on genuine equality remains unfulfilled. the most basic of human rights—the Today, Black gay and bisexual men are right to vote, to have equal access to more heavily affected by HIV than any public accommodations, and to be other group in the entire developed free of daily indignities. The courage world. Indeed, it is difficult to find and perseverance of the millions of another population across the globe people who fought for basic civil rights that has suffered more as a result of resulted in the well-known landmarks this epidemic than Black gay men. of our country’s long journey toward Accounting for one in 500 greater fairness—the Supreme Court’s Americans, Black gay and bisexual 1954 decision in Brown v. Board of men represent nearly one in four new Education, enactment of the Civil infections. Worse still, rates of new Rights Act of 1964, and Congressional infections among Black gay men are endorsement of essential voting rights rapidly increasing. Ernest Hopkins in 1965. This report explains these shocking Although regarded by many as the patterns. While Black men are at the struggle until this scourge is eradicated culmination of decades of struggle, front of the line when it comes to for good. these milestones represented merely need, they remain at the back of the This report needs to be read, and a continuation of efforts to realize line when it comes to services. Black its recommendations heeded. With the promise of genuine equality in gay men are more likely than other infections rapidly rising, time is of the the Declaration of Independence. gay men to have undiagnosed HIV essence. We urge all those who ought The historic achievements of the infection, less likely to have access to care about this crisis—including civil rights movement moved our to life-saving HIV prevention and those who are engaged in the fight, country forward, but it left unsolved treatment services, and more likely as well as those who remain on the many of the more ingrained legacies to be deterred from seeking help due sidelines—to incorporate the lessons of American history—economic to the combined effects of poverty, in this important report and to take and social inequalities, unequal racism, and homophobia. action. All of us have a role to play. opportunity, and an unfortunate The AIDS crisis among Black gay tendency to erect walls to exclude men is a problem for Black America as those deemed to be outsiders. a whole. If this is our problem, we need In 2012, no one can reasonably to be part of the solution. We must deny the progress achieved in this find it within ourselves to summon long struggle—a Black President, the courage to confront our own empowered Black political leaders, and prejudices; to welcome our Black gay vibrant civil society in cities all across sons and brothers into our families, our country, and a new generation communities, and churches; and to that is more tolerant, more accepting renew our commitment to the fight of difference, less bound by the against AIDS, vowing to prioritize this

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executive summary

o population in the service systems, policy frameworks, New York City, Black MSM are 325 developed world has been programmatic approaches, and times more likely to be diagnosed as heavily affected by HIV political leadership, it is plain that with HIV than heterosexual Black Nas Black men in the U.S. the dream of ending AIDS among males. Nationally, HIV prevalence who have sex with other men (MSM). Black MSM will remain beyond our among Black MSM is roughly double Indeed, one could study the entire achievement. Black MSM are more the prevalence among white MSM. world and have difficulty finding likely than other populations to have Although AIDS is a nationwide crisis another group in which the HIV undiagnosed HIV infection, less for Black MSM, evidence indicates that burden is greater than among Black likely to be linked to care, less likely the problem is especially severe in the MSM. to receive antiretroviral therapy, and South, where new cases are rising most Yet despite the epidemic’s less likely to remain engaged in care rapidly. unparalleled impact among Black or to adhere to prescribed treatment HIV represents a lifetime challenge MSM, this grave health challenge regimens. for Black MSM. Among young men has failed to elicit the high-priority In short, Black MSM are at the ages 13-24, Black MSM are 14 times response it warrants. Those who front of the line when it comes to more likely to test HIV-positive than ought to care—government leaders at need, but at the very back of the line white MSM. One in four Black MSM federal, state, and local levels; leaders with respect to access to life-saving are already infected with HIV by the from Black America; the lesbian, gay, prevention and treatment services. time they reach age 25. By age 40, 60% bisexual, and transgender (LGBT) This report is animated by the of Black MSM are living with HIV. community; and private foundations— belief that this state of affairs can—and The AIDS crisis among Black have largely failed to exhibit needed must—change. It offers a blueprint MSM isn’t new. From the very leadership and commitment in fighting for an effective, evidence-driven, earliest epidemiological reports by AIDS among Black MSM. appropriately prioritized national the Centers for Disease Control and In the absence of a meaningful effort to end AIDS among Black MSM. Prevention (CDC), when the disease national response, the health crisis And it calls on all those who ought was still referred to as Gay-Related among Black MSM worsens with to care to resolve to work together to Immune Deficiency, it was clear that each passing year. The number of make the dream of a world without Black MSM were disproportionately new HIV infections among Black AIDS a reality for Black MSM. affected by the disease. Over the years, MSM rose by 20% from 2006 to reports in leading medical journals 2009, with an especially disturbing repeatedly emphasized the epidemic’s 48% increase among young Black Black MSM: More Heavily unparalleled effects on Black MSM. MSM. In comparison to their white Affected by HIV Than Any In 2005, CDC disclosed that 46% of MSM counterparts, Black MSM are Population in the Developed Black MSM surveyed in five U.S. cities significantly less likely to be alive three World were HIV-positive—a level of infection years after testing HIV-positive. more than twice as high as was found Research breakthroughs have Accounting for one in 500 people among white MSM. electrified the AIDS field, prompting living in the U.S., Black MSM make up Although HIV is transmitted some of the world’s leading scientific nearly one in four new HIV infections as a result of specific behaviors, it experts to advise that the tools now and one in six Americans living with does not appear that behavioral exist to end the AIDS pandemic—for HIV. Black MSM represent 9% of all patterns account for Black MSM’s all populations, and in all settings. MSM in the U.S., but account for 38% disproportionate risk. Studies have However, without marked changes in of new infections among MSM. In consistently found that Black MSM do

Back of the Line 9 not engage in higher levels of sexual Black MSM will demand aggressive community-based AIDS programs, risk behaviors than other MSM. implementation of policies and with a notable scarcity of foundations Indeed, some studies suggest that programs that are calculated to grounded in Black America or the levels of risk behavior may actually address the root causes of Black MSM’s LGBT community. be lower among Black MSM than disproportionate vulnerability to HIV. among white or Latino MSM. Other The centrality of biomedical strategies suggested sources for Black MSM’s to HIV prevention indicates that In the Midst of Failure, disproportionate risk—below-average access to effective HIV prevention will New Opportunities Emerge prevalence of circumcision among depend in large measure on access to Black MSM, or the fact that Black essential health care services. Although the picture is dire for Black MSM are somewhat less likely than MSM when it comes to AIDS, there white MSM to identify as gay—have is cause for hope. In 2011, researchers also been disproven. The National Response to funded by the National Institutes of Rather, there appear to be several AIDS Among Black MSM: Health reported that antiretroviral key reasons why Black MSM are so A Failure to Respond therapy reduces the odds of HIV much more heavily affected by HIV transmission by 96%. These findings than other populations: Notwithstanding the increasingly come on the heels of other study m Diminished health care access alarming tenor of official reports results indicating the pre-exposure and health service utilization among regarding the epidemic among Black use of antiretroviral drugs by HIV- Black MSM, reflected in late diagnosis MSM, this health crisis has failed to negative MSM substantially lowers the of HIV, sub-optimal receipt of life- elicit an appropriate response. Federal likelihood of HIV acquisition during prolonging and prevention-promoting agencies do not currently track HIV anal intercourse. antiretroviral treatment, and poorer resource allocations for Black MSM, These research results are inspiring, prognosis among those who are living although the limited evidence that but they are unlikely to hasten the w it h HIV. exists indicates that Black MSM are end of AIDS among Black MSM m High background prevalence severely under-prioritized when without major policy reforms and of other sexually transmitted diseases, it comes to HIV-related spending. improved programmatic success. Black which increase by several orders of Although MSM overall accounted for MSM confront multiple barriers to magnitude the likelihood that HIV 64% of new infections in 2009, state health care services, which in turn will be transmitted or acquired during and local health departments allocated diminish their ability to use emerging sexual intercourse. a mere 27% of CDC-supplied HIV biomedical tools to reduce the odds of m Sexual behavior patterns prevention dollars toward prevention HIV transmission. among young Black MSM, including and testing programs for MSM. A legacy of discrimination in early sexual debut and greater odds Available data indicate that Black health care settings against Black of having older (in some cases, even MSM are similarly under-prioritized MSM, combined with an acute modestly older) sex partners, and with respect to spending on HIV shortage of health care workers who m A syndemic among Black MSM treatment, care, and research. have been trained to provide culturally involving poverty, unemployment, Government leaders are not alone appropriate care, deters many Black violence, homelessness, experience in their failure to respond to the health MSM from routinely seeking the of childhood sexual abuse or other crisis among Black MSM. Even after services they need. Due to high rates trauma, experience of hostile home the release of CDC data indicating of poverty and unemployment—as environments and associated that nearly one in two Black MSM well as the fact that more than half disruption in education, and surveyed may be living with HIV and the states exclude single, childless disproportionate risk of incarceration. that young Black MSM are the only adults from Medicaid services—many Available evidence tells us a lot population in the U.S. in which new Black MSM lack coverage for essential about the AIDS challenge among infections are significantly increasing, health care. Black MSM are more likely Black MSM. Given that Black MSM’s very few major national initiatives than white MSM to be incarcerated, sexual behaviors don’t appear to have emerged from the leaders of which results in lifelong reductions explain the profoundly higher HIV Black America to confront this rapidly in social acceptance, employment rates among Black MSM, it stands to escalating crisis. The organized LGBT opportunities, and access to health and reason that reversing the epidemic community has also largely looked the social services. among Black MSM will require more other way, pretending that AIDS is a The effects of these obstacles on than incremental changes in Black thing of the past even as a crisis burns Black MSM’s health are painfully MSM’s sexual behaviors. Instead, an among Black MSM. Few philanthropic apparent. In a CDC-sponsored 21- effective push to end AIDS among funders remain engaged in funding city survey of MSM, 59% of Black

10 Back of the Line MSM found to be HIV-positive were MSM. With biomedical prevention with targeted social marketing previously unaware of their infection, tools taking center stage in efforts to strategies that position knowledge compared to only 26% of white MSM. prevent new infections, future success of HIV status as a fundamental Among MSM in care, Black MSM have will depend on closing Black MSM’s social norm for Black MSM. Uptake fewer clinical visits than other MSM, gaps in health care access. of routine HIV testing in health are less likely to receive antiretroviral care settings must be improved, in treatment, and are also less likely The following action steps are part through intensive training and to adhere to prescribed treatment essential: capacity-building support for diverse regimens. In 2008-2010, 70% of HIV- health care providers. positive Black MSM on antiretroviral Demonstrate leadership in the treatment had viral suppression, fight against AIDS for Black Maximize the preventive compared to 84% of white MSM. MSM and therapeutic benefits of Every stakeholder in the AIDS antiretroviral therapy response—including government Gaps at each stage of the HIV Ending AIDS Among Black leaders, Black institutions, LGBT treatment continuum need to be MSM: How Do We Move organizations, philanthropic agencies, closed in order to optimize the benefits Forward? the private sector, and the organized of antiretroviral therapy. Linkage AIDS establishment—must recognize to care for people who test HIV- The National HIV/AIDS Strategy seeks the fight against AIDS among Black positive must be ensured and verified, to cut the number of new infections by MSM as a central priority. guidelines to improve retention in 25% by 2015 and to generate concrete care and treatment adherence must improvements in HIV testing, linkage Achieve saturation HIV testing be fully implemented, and enhanced to care, and treatment adherence. This among Black MSM efforts are needed to eliminate laudable goal will be impossible to CDC leadership in establishing disparities in Black MSM’s receipt of achieve without major progress toward a robust national network of testing antiretroviral therapy. Timely, effective reversing the epidemic among Black options needs to be complemented implementation of the Affordable

Back of the Line 11 Care Act has the potential to ensure Black MSM’s access to essential health services. Increasing the number of health care providers with the demonstrated cultural competence to care for Black MSM is an urgent necessity. Programs are also vital to increase Black MSM’s HIV science and treatment literacy and demand for health services.

Dramatically reduce STDs among Black MSM An intensive national effort is required to dramatically lower rates of STDs among Black MSM. Community education and provider training are central components of a comprehensive national initiative to prevent STDs among Black MSM.

Introduce pre-exposure prophylaxis No population has greater need for effective uptake of pre-exposure prophylaxis (PrEP) than Black MSM. A major NIH-funded clinical trial is planned to obtain answers to key questions on the best strategies for introducing PrEP among Black MSM. In light of the legacy of mistrust of mainstream health systems in many sustained leadership from Black vaccines, and a cure for HIV. Black communities, strong, consistent, MSM themselves. Unfortunately, the and respectful community engagement community infrastructure among Implement a national plan to and leadership are essential to the Black MSM is extremely weak, in part reduce the vulnerability of success of HPTN 073 and to future due to the failure of most funders to Black MSM uptake of PrEP. provide support for general operations, Comprehensive efforts are needed organizational development, and to address the root causes of Black Effectively target Black MSM professional skills development. Black MSM’s vulnerability to HIV—poverty, with high-impact prevention gay organizations themselves need to lack of educational and employment Black MSM deserve access to prepare to adapt to a changing health opportunities, racism, homophobia, prevention funding commensurate care marketplace, especially given the and social isolation. Such a national with their share of the national importance of biomedical strategies effort will require extensive legal epidemic. Prevention programs for to the prevention of new infections reform, efforts to alter social norms, Black MSM need to be carefully among Black MSM. and empowerment of Black MSM to targeted, address key misconceptions draw on their considerable sources of that hinder effective risk reduction, Develop new prevention tools resilience to overcome the obstacles and prioritize education on the risks for Black MSM they face. for young MSM associated with sex The historic underfunding of with older men. intervention research for Black MSM must end. Focused research is urgently An Action Plan to End AIDS: Build sustainable community needed to inform implementation Priority Action Steps capacity of existing tools for Black MSM and AIDS will not be reversed among to develop critical new tools, such To effectively deploy the tools available Black MSM without robust and as rectal microbicides, preventive to end AIDS among Black MSM,

12 Back of the Line the Black AIDS Institute offers the culturally appropriate health and service organizations within following priority recommendations and social services through full the respective LGBT and Black and urges their immediate adoption: implementation of the Affordable Care communities—at national, state, and Act, as well as prioritized cultural local levels—should immediately Develop a national plan to end competence training for health care commit to hire a senior focal point AIDS among Black MSM. As workers to increase their ability to to oversee work to support a sound one of its highest priorities, provide appropriate care and treatment and effective AIDS response for Black Health and Human Services to Black MSM. MSM. These same organizations must should immediately spearhead m Support for initiatives to pledge to take specific steps to promote an inclusive process—involving increase Black MSM’s demand for Black MSM to leadership positions relevant federal agencies health services, including strong within their respective agencies. (e.g., CDC, HRSA, CMS, Office financing for targeted programs to m The Congressional Black Caucus of Minority Health, SAMHSA), build HIV science and treatment should ensure that Black MSM receive Black MSM, Black and LGBT literacy; community education efforts their fair share of HIV prevention and leaders, the philanthropic and to increase awareness of the availability treatment services funded under the private sectors, and state and of well-tolerated, easy-to-take HIV Minority AIDS Initiative. local health departments—to treatment regimens; and high-priority m Philanthropic organizations— develop a clear, results-driven efforts to roll out pre-exposure including those that focus on AIDS national plan to end the prophylaxis among Black MSM. issues, Black communities, and epidemic among Black MSM. m A nationwide campaign to the LGBT community, as well as This plan needs to include the dramatically reduce STDs among those that serve specific states or following elements: Black MSM, including intensive, localities—should immediately pledge targeted community awareness to substantially increase resources m A prioritized effort to ensure campaigns, as well as provider for efforts to end AIDS among Black universal knowledge of HIV serostatus education. MSM. Philanthropic and corporate among Black MSM, including support m Ensuring that HIV prevention funders should prioritize general for diverse, scaled-up testing strategies; programs for Black MSM address operating support for Black MSM intensified professional education for misconceptions about HIV organizations, as well as innovative health care and community-based transmission and increase awareness program models for health care personnel; targeted, state-of-the-art of risks to young men from having sex demand creation, HIV science and social marketing to position knowledge with older men. treatment literacy, and peer navigation. of HIV serostatus as a fundamental m Elimination of funding social norm; and assignment by the disparities in HIV prevention, Combat homophobia and U.S. Preventive Services Task Force treatment, care, and research that other social challenges faced of an A or B grade for risk-based HIV disadvantage Black MSM, including by Black MSM. Governmental testing. requiring all federal funders to track and non-governmental actors m A national effort to build robust, the share of resources dedicated to must join together with sustainable community capacity Black MSM. Black MSM to address the for Black MSM, with extensive m Concrete steps to ensure root causes of Black MSM’s support for the establishment of a Black MSM’s full and equal access vulnerability to HIV and the national network of health centers to appropriate and affordable mental factors that diminish health specifically designed by Black MSM; health and substance abuse services. care access. community skills-building, general operating support, and organizational Exert genuine, sustained m Congress should enact the development for Black MSM leadership in the fight against Employment Non-Discrimination Act, community organizations; and the AIDS among Black MSM. repeal the Defense of Marriage Act, establishment of durable linkages with Diverse non-governmental and ensure full and robust integration MSM-friendly health care settings. actors must recognize of LGBT service members in the m Intensified implementation both that AIDS remains a armed forces. research and support for adoption of severe and worsening crisis m Black organizations at the na- best practices to ensure timely health among Black MSM and that tional, state, and local levels should care linkage and retention for Black government alone cannot turn follow the lead of the NAACP and MSM. the tide against AIDS. formally endorse both non-discrimi- m Ensure Black MSM’s ready nation against LGBT people and legal access to affordable, high-quality, m Leading advocacy, civic, recognition of same-sex marriage.

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merica’s AIDS epidemic is phenomenon. Black MSM have Different Surveys, Different no longer featured on the been disproportionately affected by Numbers front page of newspapers HIV since the very beginning of the Why would one CDC-sponsored or highlighted on TV news epidemic. survey in 2004-2005 find 46% HIV A prevalence among Black MSM, channels. Yet for one population— What is startling, however, is the while a later survey determined Black men who have sex with men fact that the astonishingly high rates that 28% were infected? Have we (MSM)—AIDS hasn’t gone away. On of HIV infection, illness, and death actually succeeded in reducing the contrary, there is every sign that among Black MSM have elicited HIV prevalence among Black MSM the crisis is worsening. precious little response from those in recent years? Representing just 0.2% of the U.S. who ought to care—from our nation’s Far from it, according to CDC, 1 2 which reported in 2011 that HIV population , Black MSM accounted leaders, public health experts, the incidence among Black MSM has for nearly one in four (22.4%) new HIV national media, key opinion makers in actually increased. infections in the U.S. in 2009.3 And Black communities, and the lesbian, There are reasons why while medical breakthroughs have gay, bisexual, and transgender (LGBT) different surveys yield different made HIV a chronic and manageable community. estimates. First, the surveys were conducted in different settings. condition for some, Black MSM This report is dedicated to the The 2004-2005 survey, for continue to die in disproportionate passionate belief that this can—and example, focused on five of the numbers. According to researchers at must—change. most heavily affected jurisdictions the Centers for Disease Control and This report explores the facts about in the U.S.—Baltimore, Los Prevention (CDC), Black MSM are HIV among Black MSM: Angeles, Miami, New York, and m San Francisco. The later survey, by significantly less likely to be alive three How the disease affects Black contrast, encompassed 21 cities, years after being diagnosed with AIDS MSM unlike any other population including many where overall HIV than are white or Latino MSM.4 In in the developed world, sometimes prevalence is lower than in the five Florida, Black MSM living with HIV surpassing the epidemics in many high-prevalence cities surveyed are four times more likely to die than developing countries, in 2004-2005. In addition, 5 m different surveys use different white MSM. Why the epidemic’s impact is so methodologies for recruiting One can scour the world and have disproportionate among Black MSM, survey participants. Average age difficulty finding a single population and of participants often varies from more heavily affected by HIV than m The failure of most leaders to one survey to the next. Black MSM in the U.S. In an era in respond effectively to the health crisis Despite differences in HIV prevalence yielded by available which Americans seem to believe that among Black MSM. serosurveys, all available studies AIDS resides elsewhere, a genuine This report, though, also reflects agree on two key points. First, health crisis continues to burn here at considerable hope. Thanks to HIV prevalence among Black home. breakthroughs in biomedical research, MSM is higher than for any What is shocking is not that these we now have the tools to bring AIDS other population in the U.S. or throughout the developed world. disparities are occurring. The reality to an end—for all populations, in all And second, the percentage is that Black people from all walks of settings, including Black MSM here of Black MSM living with HIV is life experience more limited access in the U.S. Capturing the promise sharply higher—twice as high or to medical care and poorer health of these medical breakthroughs more—than among white MSM. outcomes than other Americans.6 7 constitutes the core of this report’s Nor are these figures striking recommendations on ways to because they reflect a new deliver the promise of an AIDS-Free

Back of the Line 15 1982 Scientists call new 1981 disease Gay-Related First official report of Immune Suppression 1982 AIDS concerns unusual (GRID) although AIDS CDC reports that cluster of immune (Acquired Immune male-male sex can suppression among Deficiency Syndrome) lead to AIDS gay men in Los is suggested and Angeles eventually endorsed by CDC

A Note on Terminology Key Messages No perfect term exists to refer No population in the entire developed world has been more heavily to Black men who have sex with affected by HIV/AIDS than Black MSM, who represent among the most men. Many Black MSM identify heavily affected group in the entire world. Moreover, this problem is as gay, reflected by such groups worsening. as the National Black Gay Men’s HIV represents a lifelong challenge for Black MSM, with a 40-year-old Advocacy Coalition or New York Black gay man facing roughly 60% odds of being HIV-infected. City’s Gay Men of African Descent. Black MSM do not engage in greater risk behaviors than other MSM. Others regard themselves as Rather, their disproportionate odds of becoming infected stem from bisexual, some prefer the term their poor access to essential health services, high background rates “same-gender loving,” while of sexually transmitted diseases, early sexual patterns (including early others who have sex with men sexual debut and the tendency of young Black MSM to have sex with consider themselves heterosexual. older MSM), and a confluence of multiple health, social, and economic Others refuse any kind of self- problems that increase vulnerability to HIV. identity based on sex or gender. Although the HIV crisis among Black MSM represents one of our A considerable number of Black country’s most serious health challenges, the national response remains MSM, like MSM of other races, wholly inadequate. Federal agencies do not monitor HIV expenditures also have sex with women. As this for Black MSM, state and local governments consistently under-prioritize report is designed to summarize services for Black MSM, Black and LGBT leaders have yet to respond the needs of all of these men, it effectively, and few philanthropic funders emphasize support for Black has adopted an inclusive term that MSM. focuses on behavior. Today, there is greater hope than ever for progress against AIDS, as antiretroviral therapy reduces the odds of HIV transmission by 96%. By reducing community viral load, we can sharply lower rates of new infections. Indeed, with recent biomedical breakthroughs, we now have the means to end the AIDS pandemic—for all populations and in all settings, including among Black MSM here in the U.S. Without a major change of direction, however, Black MSM will not benefit from recent research breakthroughs. Black MSM are more likely than other MSM to have undiagnosed infection, less likely to be linked to care once they test HIV-positive, less likely to receive antiretroviral therapy, and less likely to remain engaged in care. HIV-positive Black MSM are considerably more likely to die than other MSM living with HIV. A high-priority, multi-faceted, multi-stakeholder national plan is urgently needed to address the spiraling HIV crisis among Black MSM. This plan needs to ensure Black MSM’s full and equitable access to essential services, correct imbalances in resource allocation, and combat homophobia and other social and economic issues that increase vulnerability and reduce health care access. Such a plan can only succeed if dramatically greater leadership and commitment are demonstrated in the fight against AIDS among Black MSM.

16 Back of the Line The AIDS Alphabet Soup A Glossary of Acryonyms Here are a few of the abbreviations you’ll see in this report:

CDC Centers for Disease Control and Prevention

CMS Center for Medicare & Medicaid Services

FDA Food and Drug Administration

HAART Highly Active Antiretroviral Treatment

HRSA Health Resources and Services Administration

NBGMAC National Black Gay Men’s Advocacy Coalition

NIH National Institutes of Health

ONAP White House Office of National AIDS Policy

PrEP Pre-Exposure Antiretroviral Prophylaxis

SAMHSA Substance Abuse and Mental Health Services Administration

Generation—for Black MSM, as well as m Systems for the delivery of for all other people affected by HIV. high-quality, culturally relevant HIV “Business as usual” will not get medical care and other HIV services the job done. Black MSM may be at will need to be reconfigured to work the front of the line when it comes to for Black MSM, and risk for HIV, but they remain at the m Major new national initiatives back of the line for access to medical will be required to prevent and treat breakthroughs and other HIV services. sexually transmitted infections among To translate research breakthroughs Black MSM, to help Black MSM into concrete gains against HIV for navigate health and social service Black MSM: systems, to build robust and durable m Leaders across sectors— community infrastructure in Black government, community, scientific, gay communities, and to combat the and MSM themselves—will need related challenges of homophobia, to lead by squarely addressing HIV racism, and poverty. among Black MSM,

Back of the Line 17 18 Back of the Line Worse Than Any Other 5 More Heavily Affected by HIV Than Any Population in the Developed World

t is possible to analyze America’s HIV epidemic from multiple angles. Yet no matter how HIV in the U.S. Iis studied, the epidemic’s burden on Black MSM is striking: m Although Black people represent 13% of the U.S. population8 and an estimated 9% of all MSM9, Black MSM accounted for nearly 38% of new HIV diagnoses among MSM in the U.S. in 2010.10 Of all new HIV diagnoses among Black males in 2010, MSM accounted for 70%.11 m Representing one in 500 people in the U.S., Black MSM make up nearly one in six (15%) of all people living with a diagnosis of HIV.12 Extrapolating Black MSM’s share of diagnosed HIV infections across the total estimated population of people living with HIV13, it appears that MSM (21%).17 Subsequent studies time. From 2006 to 2009, the annual nearly 177,000 Black MSM were living have confirmed that Black MSM are number of Black MSM newly infected with HIV as of December 2008. substantially more likely than white with HIV rose by 20%.22 Among m In 2009 alone, 10,800 Black MSM to be infected with HIV.18 In young Black MSM (ages 13-29), new MSM were newly infected with HIV.14 New York City, for example, one study infections soared by 48% from 2006 to m Gay and bisexual men are 44 found that HIV prevalence was six 2009.23 times more likely to be diagnosed with times higher among young Black MSM HIV than other males15, and the odds than among young white MSM.19 A are considerably greater that Black national survey of MSM in 21 cities MSM will be newly infected than white detected HIV prevalence of 28% MSM. In New York City, Black MSM among Black men, nearly twice the are 488 times more likely than males level found among whites.20 generally—and 325 times more likely m While the health crisis than Black heterosexual males—to be among Black MSM is a nationwide diagnosed with HIV.16 phenomenon, the challenge is m Altogether, Black MSM especially acute in the South. In 2006, experience an unparalleled HIV for example, more new AIDS cases burden in the U.S. In 2004-2005, were diagnosed among Black MSM surveys of MSM in five cities found in the South than in all other regions that 46% of Black MSM surveyed combined.21 were living with HIV—a level more m Moreover, the impact of HIV than twice as high as among white on Black MSM is increasing over

Back of the Line 19 A Physician Speaks: 6 Health Care Barriers for Black MSM An Interview with Dr. David Malebranche

Dr. David Malebranche is an Associate before you get to issues of sexual ori- instituted a number of changes, Professor of Medicine at Emory entation. All of these issues form the including $2 co-pays for medication, University School of Medicine and lives of Black MSM before they become co-pays for provider visits, and other an HIV specialist at Grady Hospital’s sexual beings. things as well. Ponce de Leon Clinic in Atlanta. Fulton and Dekalb counties contribute funding to Grady. You live and work in Atlanta, Previously, a lot of surrounding As a clinician who treats which is sometimes regarded counties contributed funding to Grady large numbers of Black MSM as the capital of Black because their uninsured residents living with HIV, what have you America. What are some of relied on Grady for care. Over time, learned about how poverty the challenges you’ve seen though, these counties have cut their affects the ability of HIV- for Black men in Atlanta in contributions to Grady but have positive Black MSM to obtain dealing with the health care continued sending their residents to the services they need? system? us for medical services. As a result, Grady has instituted a rule that if you It has always been curious to me I can give you my perspective based are uninsured and impoverished, your how people somehow erase the notion on my experience at Grady Hospital. co-pay will be much less if you are a of Black gay men and Black MSM be- In recent years, we’ve had a reversal of resident of Fulton or DeKalb counties, ing part of a broader Black commu- white flight and the departure of more since these are the only two counties nity. The focus for a long time when affluent people from Atlanta. Inside contributing funding for services. it comes to Black MSM has been on the perimeter in Atlanta, we are seeing This actually makes sense from a fiscal sexual orientation, bullying, homopho- major changes. More affluent white point of view, but the reality is that bia, and such. But Black MSM emerge people are moving back in, and many the uninsured exist outside Fulton from Black communities and Black people who are not white and are less and Dekalb counties. And, of course, families, and to ignore that reality is affluent are being pushed out. This sexual networks cross these geographic a huge mistake. To understand the leads to physical and psychological boundaries. HIV-related challenges of Black MSM, trauma among people who are being Getting care at Grady isn’t easy. we need to understand how racism in- displaced. There are lots of hoops people need to tersects with poverty. Being in poverty Grady is a level one trauma center jump through to get that card. And influences your access to health care that gets most of its funding through you have to be prepared to wait for a and your ability to get information the State and local governments. long time to get a clinic visit or get care and education, and it also sometimes Georgia is a very conservative, Bible at the emergency room. puts you in desperate circumstances Belt state, and taking care of the in terms of situational sex or living in uninsured and the poor is not a high geographic areas under duress due to political priority. Over the last 10-15 What is the role of Medicaid economic distress, criminal behavior, years, funding for Grady has been and other third-party payers or substance abuse. All those issues flatlined. We’ve even seen reduced in supporting HIV care for have been linked to zip codes with funding for Grady in the last few years, Black gay men in Atlanta? high HIV rates. It’s no coincidence that even though the number of uninsured where you see high rates of HIV and is skyrocketing. We have had three or Clinic visits and labs may be cov- STDs you are also going to see high four different CEOs take the helm of ered by Medicaid, but there is very rates of poverty. And all of that is even Grady in the last 6-10 years. They’ve poor reimbursement for clinic visits.

20 Back of the Line Dr. David Malebranche

Compensation for a clinic visit from to write lots of letters and sign prior bit about cultural competence Medicaid is $60, which is absolutely authorization forms. and its role in addressing the nothing. So people in private practice The AIDS Drug Assistance HIV care needs of Black MSM? aren’t going to take Medicaid. As a re- Program (ADAP) is a state- sult, everything is run through Grady’s administered program that provides When you look at medical system when it comes to taking care drugs for people living with HIV, but education and how cultural of low-income people living with HIV, the program has a waiting list here in competency is defined, the tacit and that system gets plugged up. Georgia. It can take a while for people assumption is there is going to be a There are a lot of problems in to get plugged into ADAP. white provider who is dealing with getting health care for someone on someone from another culture. Usually Medicaid who is diagnosed positive people think about patients who speak with HIV. Medicaid issues a lot of Finding a way to pay for your another language. denials of coverage. Medicaid has its medical care is, of course, only The cultural competence own drug formulary, and the program part of getting the treatment literature doesn’t focus much on class will change it at the drop of a dime and care you need if you are differences, race differences within and won’t tell providers the formulary HIV-positive. You also need the same country, sexual orientation has changed. It’s always about saving to find a qualified health care differences. Those issues get swept money. To make sure patients get provider with whom you are under the carpet and, unfortunately, the drugs they need, providers have comfortable. Can you talk a those are the components that often

Back of the Line 21 play into the lives of Black gay men. Unless we have a national health from the United States, and there were We did a study about eight or nine care system, we won’t make even the of lot of issues with adherence in the years ago looking at the health care remotest dent in racial and economic controlled environment of the study. experiences of Black gay men. We disparities. The current health care Have we really approached this in an asked these men whether it matters to system is based in capitalism, and intersectional way that integrates the them that the provider is white, Black, the business models just won’t work. biomedical with the behavioral? male, female, gay, or straight. The most I didn’t expect us to get to a national I do believe in ART as prevention. common response we got is that Black health care system overnight, so That should be our focus. Our focus gay men just want their provider to we need to see this as part of a long has to be on getting people who are be good. They wanted the person to process. But the sad fact is that so positive on treatment that is affordable, be able to communicate, not be racist many people are making a killing off reasonable, and of acceptable quality or homophobic, to take their needs the health care system at the cost of a so they can get their viral load seriously. lot of lives. down. We can’t achieve that without addressing the health care system. HIV isn’t in a compartmentalized box that How would you characterize What needs to happen to turn is unaffected by the broader system. the community-based the epidemic around among You have to have a provider that is able infrastructure for Black gay Black MSM? to communicate with the patient and men in Atlanta? follow up regularly. Here in Georgia, That’s a difficult question. we still see people who are being There are several community Personally, I’m not as excited about referred to us from rural areas and organizations to help people navigate PrEP and some of the other biomedical are on HIV regimens that don’t even the health care system. Some of these stuff as a lot of people are. We haven’t include three working medications! organizations have special services done anything about the social context One thing we need to do is get more for Black gay men, but a lot of these of this disease and what is going on medical students involved in HIV services are HIV-focused. If you are a with Black gay men. Thinking of care. But HIV care isn’t reimbursed community organization, you are not PrEP as a the main solution to AIDS well, and most medical students are going to get a lot of funding to address among Black gay men is trying to put leaving school with a debt of $200,000 the general life issues of Black gay men. a bow on something that is broken. or more. It’s no shock that most people There is still a huge question about want to go into a sub-specialty where who is going to pay for PrEP and they can make a lot more money. As a treating clinician, are who is going to benefit from it. We you hopeful that health care haven’t really talked much about the reform can help improve the possibility of developing resistance to ability of Black MSM to get the or of toxicities from PrEP. The study HIV services they need? results were not derived primarily

22 Back of the Line Back of the Line 23 24 Back of the Line At Risk No Matter the Age 7 A Lifetime Challenge

IV transmission patterns surge in new infections among Black HIV and Black MSM: differ among racial and MSM, the disparity in HIV diagnosis A Problem That Isn’t New ethnic groups. Whereas rates among Black and white males Hmore than two-thirds of new increased by 257% from 2005 to 2008.28 Black MSM have been at elevated risk infections among white MSM occur in But the challenge posed by since the beginning of the epidemic, men in their 30s and 40s, a majority HIV extends across the lifetime for although their disproportionate risk of newly infected Black MSM are ages Black MSM. According to modeling was obscured by the prevailing view 13-29.24 25 derived from CDC estimates of of AIDS as a “white gay disease” in Due to exceptionally high rates HIV incidence, Black MSM face the 1980s and through much of the of new infections among young startling, progressively serious risks of 1990s. From 1981-1985, when MSM Black MSM, many Black MSM enter contracting HIV as they age. represented three out of four reported adulthood already infected with HIV. The odds that a Black MSM will cases, Black people accounted for less Among 13-24-year-olds, Black men become infected with HIV increases than 12% of the U.S. population30 are nearly 14 times more likely to as he ages—rising from a 7.8% chance but for 25% of all AIDS cases.31 As be diagnosed with HIV than white of infection at 20 years old to a 59.3% early as 1986, the disproportionate men, with MSM accounting for more chance of infection by the time he HIV prevalence among Black MSM than 90% of new diagnoses among reaches 40 years old: was observed in the pages of the New young males.26 Although Black people By age 20, 7.8% England Journal of Medicine.32 In 1987, account for a mere 9% of all MSM By age 25, 24.9% researchers reported in the Journal of in the U.S., Blacks comprise more By age 30, 38.7% the American Medical Association that than 62% of new diagnoses among By age 35, 50% Black MSM appeared to experience young MSM in 2008.27 Due to a By age 40, 59.3%29 higher HIV prevalence and incidence than other groups of MSM.33 In 1988 in California, where Black people made Odds of HIV Infection Among Black MSM, Ages 20-40 up less than 8% of the population, Black people accounted for more than 13% of AIDS cases, with gay and bisexual men making up three out of four cases among Black Californians at the time.34 In short, the signs were plain from the epidemic’s early years that Black MSM confronted a severe and potentially unparalleled health crisis. Yet relatively few people noticed the above-average HIV rates among Black MSM in the epidemic’s early years— and even fewer responded. Yet Black MSM themselves took notice. In 1985, an AIDS Task Source: Running in Place: Implications of HIV Incidence Estimates Among Urban Men Who Have Sex with Men in the United States and Other Industrialized Countries. AIDS Behav 13:615-629. Force was created by the National Association of Black and White Men

Back of the Line 25 The AIDS Challenge In Black Together (NABWMT), eventually The National Response to the Transgender Communities becoming the National Task Force on Health Crisis Among Black An issue beyond the scope of AIDS Prevention, to focus specifically MSM: A Record of Failure this report—but one that warrants on the need for Black gay men to have a substantially stronger national access to HIV prevention services. Acknowledging that Black MSM effort—is HIV among transgender persons. Across the country, Black MSM joined are at disproportionate risk, the Due to the lack of routine together in an effort to address the National HIV/AIDS Strategy calls HIV surveillance among growing health crisis, alerting their for concerted efforts to reduce the transgender communities, a clear peers to the dangers associated with number of new HIV infections by understanding of the severity unprotected sex and working to care 25% by 2015 (from a 2010 baseline).38 and extent of the AIDS challenge is lacking. A 2011 study by for those who were living with HIV. In Development of a National HIV/AIDS researchers from the University New York City, for example, Gay Men Strategy represents a momentous step of California at Los Angeles found of African Descent was established forward in our national response and that 0.3% of the U.S. population in 1986, to provide a home for Black has served to reinvigorate domestic 1 qualifies as transgender. gay men and to address their health efforts to combat HIV/AIDS. As part According to a meta-analysis of HIV-related studies in transgender and social service needs. Similar of the implementation of the National communities, CDC researchers organizations sprung up in Chicago, HIV/AIDS Strategy, the Department report that Black transgender Dallas, Detroit, Houston, Seattle, St of Health and Human Services now people are at much greater risk Louis, and other cities. tracks use of federal HIV funding by of HIV, with an estimated 56% of As the years progressed, the race/ethnicity, gender, and exposure Black male-to-female transgender persons living with HIV.2 evidence would become overwhelming category—a major improvement that In New York City, 183 that Black MSM were being affected for the first time allows transparent transgender individuals were more severely than any other part reporting on the use of federal dollars diagnosed with HIV from 2006- of the LGBT community. In 1994, for HIV. 3 2010. Male-to-female transgender researchers conducting a serosurvey It is clear, though, that the goal individuals account for 94% of all transgender HIV cases in in San Francisco reported that HIV of cutting new infections by 25% New York during the five-year prevalence among young Black gay and is unlikely to be achieved without period, with Black and Latino bisexual men (21.2%) was more than reversing the epidemic among people accounting for more twice as high as for gay and bisexual Black MSM. What is equally clear, than 90% of such cases. Among men generally.35 According to results unfortunately, is that current efforts newly diagnosed transgender individuals, 28% report having from venue-based surveys in five U.S. are woefully short of what is needed been incarcerated, 11% have been cities in 1994-1998, young Black MSM to meet the AIDS challenge among homeless, 8% have engaged in sex were found to be more than six times Black MSM. Indeed, a review of how work, and 5% have been sexually more likely than young white MSM to available HIV resources are spent abused. be HIV-infeced.36 reflects our failure to take seriously the 39 Notes By the time that CDC reported HIV crisis among Black MSM. 1. Gates GJ, How many people are lesbian, gay, bisexual and transgender? 2011: http:// in 2005 that a five-city study had Although federal innovations in williamsinstitute.law.ucla.edu/wp-content/ found 46% of Black MSM surveyed tracking HIV expenditures represents uploads/Gates-How-Many-People-LGBT-Apr-2011. 37 pdf. to be living with HIV infection , important progress, resource tracking 2. Herbst JH et al., AIDS Behav 12:1-17. 3. New York City Department of Health and the evidence was irrefutable that is still not conducted in a manner Mental Hygiene, 2010: http://www.nyc.gov/html/ doh/html/dires/epi_surveillance.shtml. HIV among Black MSM was a that permits assessment of allocations genuine health crisis. With rates of specifically for Black MSM. In new infections among Black MSM 2009, when MSM of all races and now rising faster than in any other ethnicities accounted for 64% of population, no one can claim to have all new infections40, state and local been caught off guard. This news has health departments focused only long been there for all to see, although 27% of CDC-supplied risk-reduction it has yet to elicit a commensurate funding toward MSM.41 Allocation response. of dollars for HIV testing services at the state and local level was even more skewed, with MSM attracting only 10% of funding for targeted HIV testing programs.42 A recent survey found state and local health departments woefully unprepared to

26 Back of the Line undertake a meaningful strategy to reduce HIV incidence among Black 1983 MSM, with survey participants citing CDC reports gay and a lack of culturally competent staff and bisexual men represent a shortage of appropriate prevention 1983 overwhelming majority 43 French scientists of AIDS cases reported interventions for Black MSM. isolate HIV in 1981-1983 and that The state of Wisconsin, one of the Black people account recipients of CDC HIV prevention for 26% of all AIDS diagnoses funding, has shed further light on the mismatch between demonstrated need and HIV prevention programming. With the aim of assessing the fit between need and service access, Wisconsin undertook a careful Conspiracy Theories and HIV analysis of its prevention funding. There is little question that AIDS awareness is higher in Black In 2009, although MSM accounted America—perhaps higher than in any other segment of the American for 58% of all HIV diagnoses among population. According to a 2011 survey by the Henry J. Kaiser Family Black people in the state, Black MSM Foundation, Black people are more than twice as likely as whites to regard AIDS as a serious problem, and they want the government to do received only 19% of targeted HIV more to fight AIDS, with 63% of 18-29-year-old Black people believing tests in Wisconsin and represented a that too little money is being spent on AIDS. mere 11% of HIV prevention clients.44 But this high level of awareness about AIDS also co-exists with While Wisconsin deserves praise for conspiracy theories about AIDS among a sizable segment of the Black its leadership in tracking actual service population. According to a survey of HIV-positive Black people in rural Alabama, 31% said AIDS was a form of genocide against Black people, access among Black MSM, its findings while a majority (56%) believed the government was withholding a cure.1 underscore the urgent need for greater The persistence of conspiracy theories has potentially damaging accountability nationwide in how consequences for the fight against AIDS—both with respect to the limited prevention dollars are allocted. spread of HIV and for efforts to treat the disease. Black men who harbor The Health Resources and Service conspiracy beliefs about AIDS are notably more likely than those who disbelieve such theories to have unprotected sex.2 In a separate study Administration (HRSA) also fails to involving Black men, those who believed that recipients of antiretroviral track utilization of Ryan White CARE therapy were serving as guinea pigs for government experiments were funding by Black MSM.45 However, the less likely to adhere to HIV treatment than other patients.3 limited evidence that exists suggests Notes that Black MSM may be as under- 1. Zekeri AA et al. (2009) Psychol Rep 104:388-394. 2. Bogart LM et al. (2011) AIDS Behav 15:1180-1186. prioritized in care funding as they 3. Bogart LM et al. (2010) J Acquir Immune Defic Syndr 53:648-655. are with respect to HIV prevention resources. In New York City, for example—which accounts for roughly one-tenth of the U.S. epidemic and where MSM represent 34% of people living with HIV46—young MSM of color represented for only 0.6% of services supported through Ryan White Part A base funding in 2008- 2010, while LGBT clients of any race or ethnicity made up only about 9% of Ryan White clients.47 Although HRSA displayed important leadership in sponsoring a five-year project to identify best practices for engaging HIV-positive young MSM of color, no new resources have been allocated to implement the best practices generated by this important study. HIV intervention research is also failing Black MSM. After more than

Back of the Line 27 Profiles 8 Risk Among Black MSM Knows No Age Te e n

Teens: take sexual risks. “Being young, black, Christopher Barnhill and gay—when you add up all three components, that’s a lot to deal with,” Chris Barnhill was a newborn when he he says. “When you are young you’re was infected, although he didn’t learn trying to be accepted. The late-night he was infected until 2004, when he partying, the multiple partners, dating was 16 years old. somebody for two months and that’s it, “I was at a health fair,” he recalls. or random sex partners—I think that’s “And three people—three random an outlet to escape from day-to-day people—within a few minutes asked life. But I guess that’s not healthy. me to get an HIV test. I didn’t fit the “With gay people, mental health profile in my head of a person with is definitely important. I think what’s HIV—you know, like Tom Hanks in often missing is connection, and I Philadelphia. But, still, I believe in think sex is a connection for people— the power of three, and because three just to have two minutes of this, or 15 people asked me about getting testing, minutes of feeling love. Sometimes it’s I thought I might as well do that. So just that feeling of love, that need to I did. And 20 minutes later I received feel loved and cared for. I don’t want the result, and I was positive.” Washington group that engages young him to leave me, so I don’t mind not Barnhill recalls that the news that people on issues of HIV, pregnancy, protecting myself.” he was HIV-positive “confused the and other health concerns. In Barnhill’s view, building mess out of me.” He wasn’t a virgin He is also a youth minister at the community is an important strategy at age 16, but he quickly learned that Community Church in Washington, for improving the mental health of everyone he had had sex with was HIV- D.C. Although it is theoretically a gay men. “Building community makes negative. So he asked his grandmother “weekend job,” it occupies him seven me feel good,” he says. “I have friends and learned that he was born with days a week. “I think sometimes I have who do similar work. They may not be HIV. His aunt told him his deceased Saturdays off,” he jokes. engrossed in HIV, but they are doing mother had been diagnosed with HIV. Although he is only 25 years old, something that promotes a healthy This startling news changed his life. he has already lost two close friends to lifestyle for Black gay men. And, “We all have a gift to the world,” he says. AIDS. In one case, Barnhill spoke to because we do the same kind of work, “It wasn’t until I became positive that I his close hospitalized friend by phone. it builds community amongst us.” discovered why I was put on this earth. Thirty minutes later, his friend died. Barnhill is worried that HIV treat- I had thought the whole time that I was “The last day I spoke to him he told me ments have given people a false sense of put on this earth to make music or to not to come to the hospital because he invulnerability to HIV. “HIV is more be an actor. But it wasn’t until I learned was tired. That really affected me when than just a blue and an orange pill that my HIV status that I found that what he died, because it was 30 minutes you take and you’ll be fine,” he says. makes my soul dance is to talk publicly after I spoke to him. But I was blessed “I think that’s the perception of HIV and openly about being positive—in to have the opportunity to have one today. But that pill comes with a lot of any arena, in any setting that will give more conversation with him.” responsibility. That orange and blue pill me the voice to do so.” Barnhill believes the search for comes with hurt. That orange and blue Barnhill began working with an connection, for belonging, is what pill comes with discrimination and stig- organization called Metro TeenAIDS, a often prompts young Black gay men to ma. And it can come with death, too.”

28 Back of the Line into the hallway and said, ‘Look here girl, you gotta stop crying!’ I made her laugh and said, ‘You gotta suck this up!’” Two months after testing positive, Stallworth began taking HIV 20s medications. “I knew the only way to remain healthy was to be proactive in the fight and not sit around and be defeated,” he says. “I take three pills a day—once a day, every day. I try to eat as healthy as I can, always on the go. I exercise regularly, take my meds and Twenties: do what the doctors tell me to.” Lawrence Stallworth Stallworth says community awareness and education is key to At the age of 20, Lawrence Stallworth fighting AIDS among Black gay men. is only three years removed from “We need to be aware of what is really testing HIV-positive. “It only took going on,” he advises. “We need to one mistake for the virus to become a be read and be community-minded. personal reality for me,” he says. HIV affects all of us, and it needs to “I was sitting on the edge of the be something that isn’t dealt with bed, and the doctor told me I was individually. Community viral load positive. I was devastated. I had known comes down when you get people so much about taking the proper in treatment. If we can help people precautions, so when I found out that be safe, help keep them in care and I had HIV it was so shocking. No one consistent treatment, we help not only is ready to hear that kind of news. The ourselves but our entire community.” minute the doctor told me, I burst into Unfortunately, Stallworth says tears.” that too many Black gay men are After testing positive, Stallworth not effectively engaged in the AIDS had to navigate the complicated response, often because they don’t feelings of his friends and family. know about the availability of non- “The first I told was auntie,” he recalls. judgmental services. “Before I became “She’s actually a nurse in Cleveland infected, I didn’t even know there was where I’m from. She’s been my rock for a place that young Black gay people as long as I can remember, almost my could come and be free from ridicule surrogate mother. After I told her the and persecution,” he recalls. “I found news she rushed right over. an AIDS task force in Cleveland [after “My mom and dad were there, testing HIV-positive], and it really but not like I needed them. . . When opened my eyes. When I found out I my father found out, he went to the had HIV, I had two options—either to bathroom and closed the door. I had get involved or not to get involved, and just come out, so it was already a lot I chose the first one. It’s a collective for him to take in. My siblings took the fight to combat and prevent HIV/ news hard, but they saw my strength, AIDS.” so they were able to stay strong to a certain extent.” He lost a number of friends after testing HIV-positive, but he also learned who his true friends were. “[My best girlfriend and I] had just got off summer break, and we were in class together. I looked over at her, and she just started crying. I took her out

Back of the Line 29 Thirties: Cornelius Jones Jr.

Cornelius Jones Jr. is a 34‑year‑old artist living in Los Angeles. Art not only led Jones to learn his HIV status, but he also sees art as a way to 30s transcend AIDS. “I was in college and . . . to make a long story short, there was this young lady there performing a performing art dance piece, and the piece was about her father dying of AIDS,” he recalls. “I decided it was time for me to get tested second or third date or conversation. It because a year prior to that I had heard is easier now than it used to be. rumors that someone I was involved “I thought at one point it would with was HIV-positive . . . [W]hen I be easier to date somebody who is saw this performance it was a spiritual positive, so I even attended poz dating calling to go and find out what’s going events and went to all poz-specific on with me.” groups and everything. And I found Jones believes art has a special that it’s really about the person, you power to communicate important know, it’s not necessarily about the messages. “I went to a comedy show person being negative.” here in LA not too long ago, and this He’s bothered by some of the woman was freaking hilarious the attitudes he encounters on online whole time. But right before she ended dating sites. “This thing of when you her set she spoke about some really make your profile and you write that, socially charged issues—about women ‘I am disease free, that I am clean,’ taking care of themselves, you know, that really bothers me. It’s as if you’re health and wellness, HIV and AIDS, saying that because you are HIV- relating to Black women. That was a negative you are clean, and because I powerful medium to get the socially It’s everyone’s responsibility to talk am positive, I am dirty.” important information across.” about this in some degree.” While he finds his 30s to be “a great Jones is open as an HIV-positive Being open about his HIV status place to be,” he admits to struggling gay man as a performer. “I speak to within his family is important. for a time after testing HIV-positive. specific experiences of me as a young “Within my family, who I don’t see In particular, he struggled with gay Black man growing up and being often, they are aware of my status, and depression, which stemmed he believed HIV-positive,” he says. “I am out in I am very adamant about having the from a combination of challenges—as my work to educate and help have this conversation with my nieces and my someone newly diagnosed with HIV, as conversation to erase the stigma, to nephews who are young . . . I know a Black gay man, and as a struggling, help have dialogue and conversation how it is back in Virginia. I was young young artist. around HIV and AIDS.” He was once, and your hormones are racing Health-wise, he feels fortunate. featured in a AIDS awareness public at an early age! I want my nieces and Because his CD4 and viral load service announcement that went nephews to know that, hey, this is your numbers have remained good, he national under the MTV logo. uncle’s life, this is what happened, this hasn’t had to initiate treatments. He “AIDS is a part of our culture in is how he is dealing with it. Do you sees his doctor regularly for follow-up Black America,” he believes. “Back have any questions? Do you need to and monitoring. in earlier days there was slavery, and know something? Talk to me.” there was jazz, R&B, those things that Jones finds disclosure sometimes made us, our soul food cooking—all of to be more challenging with potential that was part of Black culture. Now, it romantic partners than with is HIV/AIDS. That’s now a part of our family and professional colleagues. culture, and we need to embrace and “Sometimes I disclose right away at educate ourselves just like we did with the beginning of the relationship,” he slavery and with jazz, R&B, hip-hop. says. “Sometimes I need to wait for the

30 Back of the Line 40s

Forties: yet alone and hadn’t planned for the Chris Bland future,” he recalls. Today the outlook is not as bleak, but aging with HIV Chris Bland was 21 years old, in presents its own challenges. “Now I graduate school, and in the midst of have to worry about my cholesterol, getting two master’s degrees when diabetes, and cancer.” he tested HIV-positive in 1985. He Developing Black gay organizations thought his life was over and that he’d represents an important area of be dead before he was 25, but he’s still personal and professional interest here and is now 48 years old. for Bland. “I have provided technical “HIV hasn’t always been my life, assistance to many Black gay but it has definitely shaped and defined organizations and advocates around my life and career more than anything the U.S., and I’m concerned about else,” Bland said. “Even being Black has the shrinking numbers of those not impacted me as much.” organizations. We saw the white gay One of Bland’s degrees was in community organize and establish Public Health, and he has worked in institutions that are still here and the HIV/AIDS field for most of his on the forefront of the epidemic, professional career. He has experienced while in the Black gay community we balance is askew.” HIV/AIDS on a personal, professional, have regressed back to having only Moving forward, there is hope. and academic level. a few, underfunded organizations.” “We are a resilient people and it is Bland grew up in a small town in Bland feels that the fault for this is encouraging that through my ‘six Virginia and moved in the 1990s to shared across the board, including degrees of separation’ I am connected San Francisco. He missed out on the foundations, government agencies, to the White House and other horrifying and almost daily deaths of and the community itself. “We powerful structures.” But there is still friends and colleagues in the 1980s, but are the victims of homophobia, much work that needs to be done. he vividly remembers the week in 1997 institutionalized racism, and our own Organizations and individuals—Black, when the Bay Area Reporter, the main community culture of desire that white, gay, faith-based, must all be local gay newspaper, ran the headline would rather focus on creating Black held accountable and supported in “No Obits.” The first-ever absence gay circuit parties rather than saving addressing the needs of young black of obituaries since the epidemic’s the lives of young Black gay men.” gay men. HIV affects us as individuals beginning followed the approval of Bland is most alarmed by what is but the response must be a collective protease inhibitors, signaling a change happening to young Black gay men—a one.” in the epidemic for many, but not for pattern he refers to as “genocide.” all. “Young Black gay men are being Personally, Bland has been treated as disposable objects and not fortunate to avoid progressing to as the future of our movement and as AIDS, although the disease has our salvation. They are preyed upon definitely taken its toll spiritually and instead of praised, supported, and mentally. “Being HIV-positive caused nurtured. Part of the reason is that me to have a bit of a mid-life crisis we lost a generation of elders to the when I turned 40 and was still alive, epidemic, so the intergenerational

Back of the Line 31 50s

Fifties: from my employer,” he says. “I know Cornelius Baker the challenges of being in continuous care with a provider you can relate to, Cornelius Baker tested HIV-positive but on the whole I’ve had enormously in 1986. “In the early 80s there was the good care and good providers and perspective that everyone would die,” a wonderful relationship with my he said. physicians. But I’m also demanding Living with HIV and experiencing of them, and I think that’s a critical the epidemic’s extraordinary impact on piece. Proper care isn’t a gift that Black gay men has altered Baker’s life someone gives you; it has to be a gift in a number of ways. “Living in a time you give yourself. When we go to a of great challenge like this epidemic, physician there’s a tendency to just be and at an early age witnessing so many very passive and accept their direction, people die, it created a very different but it’s a service we’re paying for and perspective on life,” he said. “In some should be a partnership. One has to be ways a maturity of soberness and prepared to ask questions, prepared to impatience. You recognize that both get the best possible care, and to accept time and life are short. And you just that this is really about your life.” don’t really have a lot of patience for foolishness.” Baker’s impatience for change led him to AIDS advocacy. Baker formerly led the National Association of People with AIDS and the Whitman-Walker Clinic in Washington DC, is currently senior policy advisor for the National Black Gay Men’s Advocacy Coalition, and is a member of the Presidential Advisory Council on HIV/AIDS. Over more than two decades of work in AIDS, Baker has seen a lot of problems but also encountered considerable frustrations. “On the scientific side we’ve made a lot of progress,” he notes. “We have treatments for HIV . . . and we are making progress scientifically almost every day. Where we’ve not done so good a job is in implementing everything that we know.” “I’ve been very fortunate in that I’ve generally had very good health care

32 Back of the Line 60s

Sixties: believes, need spiritual, mental, and Ron Simmons emotional affirmation through group- and community-centered programs In 1989, at age 39, Ron Simmons was that enables men to address what diagnosed as HIV-positive. he calls “a lack of self-definition of When the doctor asked Simmons identity.” about his sexual behaviors, his “Black gay men are not white gay instinctive reply was authentic. HIV men with black faces,” he insists. “We was not going to stop him from living are different and need to embrace and an informed, holistic, and involved life. explore those aspects of us. ” “AZT [the most common When asked about his experience antiretroviral medication when he was running a service organization that diagnosed] gave you two more years caters to Black gay men, Simmons of life,” Simmons recalls. “I wanted cites two. The first involves finding the 30-40!” funding needed to support programs He decided to take more holistic for Black gay men. In particular, UHU methods of treatment, combining has struggled to obtain corporate mental, spiritual, and emotional sponsorship and hire the staff needed approaches with physical wellness. In to address the enormous needs of northern Virginia. 1991, Simmons joined a support group Black gay men in Washington, D.C. Simmons lives the principles for Black gay men that focused on the Second, navigating the culture of reflected in UHU’s programs, serving idea of “Living with the disease, not Black gay men is not always simple. As as a real-life example of human dying because of it”. This approach one would expect for a marginalized perseverance in the face of immense aligned with his own mindset about population that is itself highly diverse, challenges. “Do not be paralyzed by HIV, so he completed the 12-week ensuring cultural relevance to the fear,” he advises. “You are not alone. program. In 1992, he volunteered as many Black gay men in Washington is Get into care and know where you the organization’s executive director, a challenge. stand.” and in 2003 he became the President Seizing new opportunities and and Chief Executive Officer of what we meeting new challenges head-on are know today as Us Helping Us, People organizational attributes of UHU. In into Living Inc. (UHU). response to dramatic breakthroughs Simmons’ experience as an HIV- in new biomedical strategies for HIV positive Black gay man running prevention, UHU in 2012 was awarded a major service organization has a grant to increase public awareness given him insight about the many of biomedical HIV prevention and challenges faced by gay men of color. vaccine research among Black gay In particular, he emphasizes the need men, white gay men, and Black for Black gay men to pursue holistic heterosexuals. In conducting the health, in addition to taking life- project, UHU is collaborating with preserving medications. This holistic Heart to Hand, Inc. in Prince Georges approach, Simmons says, has to start County, Maryland, and the INOVA from within. Black gay men, Simmons program at Fairfax Hospital in

Back of the Line 33 two decades’ investment by U.S. 1985 taxpayers in the development of scores CDC reports that 1986 of evidence-based HIV prevention Black people (who A letter in the New programs, precious few interventions represent less than 12% England Journal of have been developed specifically for of the U.S. population Medicine notes the at the time) account disproportionately or validated for use among Black for 25% of AIDS cases high HIV prevalence MSM.48 49 Numerous studies tracking reported from among Black MSM 1981-1985 sexual behaviors of Black MSM have been undertaken, but extremely few focused research efforts have evaluated strategies to prevent new infections and improve health outcomes for Black MSM. Although NIH, like other arms Prisons, Sex, and HIV of the federal HIV response, does not Black MSM are more than twice as likely to have been incarcerated in track resource allocations for Black the previous year than white MSM.1 MSM, it is apparent from a review of The risks of HIV transmission in correctional settings is hotly the NIH research portfolio that Black debated. While CDC advises that there is little evidence that substantial MSM are badly under-prioritized. transmission occurs in prison settings—with most HIV-positive prisoners having been infected prior to becoming an inmate—the agency has This lack of research support for Black documented that transmission sometimes does occur.2 Others, though, MSM’s health needs is consistent are more skeptical of the supposed rarity of sexual transmission within with recent research indicating that prisons. Black investigators are 13% less likely What is apparent is that few prison settings take meaningful steps to to receive NIH research funding protect inmates from HIV. Federal prisons prohibit condom distribution, 50 and as of 2007 only two state systems and five municipal prisons compared to white investigators. systems made condoms available.3 Methadone maintenance or needle Apathy about the HIV crisis exchange is even scarcer. among Black MSM extends beyond Regardless of whether an individual contracts HIV within the prison the government and encompasses the walls, an HIV-positive man who has been incarcerated leaves prison with news media and community leaders. a mind-boggling array of handicaps that increases vulnerability for HIV- negative men and reduces the odds of health care access regardless Even after the release of CDC data of serostatus. A Black man released from prison is less likely than indicating that nearly one in two individuals without a criminal record to get a job, is less likely to obtain Black MSM surveyed may be living safe housing or get access to public benefits, and is often prevented with HIV and that young Black MSM from voting or otherwise participating as a full and equal citizen in the are the only population in the U.S. in life of his community. These disabilities are especially acute for Black men. According to an exhaustive study of incarceration in America, “The which new infections are significantly United States imprisons a larger percentage of its black population than increasing, very few major national South Africa did at the height of apartheid.”4 In Washington, D.C., our initiatives have emerged from the nation’s capital, three out of four Black men will serve time in prison leaders of Black America to confront sometime in their lives. this rapidly escalating crisis. Notes A similarly tepid response is 1. Millett GA et al. (2012) CROI Paper #1094. 2. CDC (2006) MMWR 55:421-426. evident from the organized LGBT 3. Okie S (2007) New Eng J Med 356:105-108. community. In large measure, the 4. Alexander M (2010) The New Jim Crow. LGBT community has moved on from AIDS, even as HIV infection rates and AIDS deaths among Black MSM have skyrocketed.51 Illustrative of this pattern is a landmark 2012 report by Human Rights Campaign that surveys the challenges confronting LGBT youth without mentioning that one in 12 Black gay men will be living with HIV by age 20.52 Although Black MSM are at the center of a major health crisis in the LGBT community, with the exception of Chicago’s Howard Brown Health Center, which is headed

34 Back of the Line 1987 1987 Researchers observe National Task Force in the Journal of the 1987 on AIDS Prevention is American Medical Blacks surpass formed with the goal Association that Black whites among new of improving Black MSM have higher HIV HIV infections in the MSM’s access to HIV prevalence and HIV U.S. prevention services incidence than other MSM

Black MSM Respond After CDC’s 2005 report found that nearly half of all Black MSM surveyed were HIV-infected, Black MSM petitioned CDC and demanded a plan of action. Following a CDC consultation in August 2005, the National Black Gay Men’s Advocacy Coalition was formed.

by Jamal Edwards, none of the nation’s leading gay health centers or AIDS service organizations are currently led by a Black gay man. The philanthropic sector is also indicative of this failure of leadership. At a moment when new infections among young Black MSM are rapidly rising, philanthropic funding for HIV activities of any kind in the U.S. declined by 10% in 2010.53 Today, only a handful of foundations remain engaged in supporting HIV-related programming. Notably missing from the list of the top funders for domestic AIDS activities in the U.S. are any foundations specifically grounded in Black America or expressly focused on addressing health or social issues the list of top funders, notwithstanding in Black communities. LGBT-focused the spiraling rates of HIV among Black foundations are similarly absent from MSM.

Back of the Line 35 1989 1990 1990 Americans With The Balm in Gilead Ryan White CARE Disabilities Act is is founded to engage Act enacted to passed, prohibiting Black churches in the support HIV care HIV-related fight against AIDS and treatment discrimination

The Limitations of Behavior Reasons for the and white MSM.61 Nor, according to Change Programs for Disproportionate Impact of the evidence, can differences in HIV Black MSM HIV Among Black MSM prevalence be tied to the somewhat Although sexual risk reduction lesser likelihood that Black MSM will will remain critical to long-term Over the years, various theories have self-identify as gay.62 efforts to reduce HIV infection been floated to explain why Black While available evidence has rates among Black MSM, there are several reasons why behavior MSM are at much higher risk of debunked a number of prior theories, change alone will not reverse the contracting HIV. It has been suggested accumulated research has identified epidemic in this population. Apart that Black MSM must engage in higher several factors that are consistently and from the fact that few validated levels of risk behavior to have such strongly associated with elevated HIV behavioral interventions have been disproportionate HIV risks, that Black risk among Black MSM: tested in Black MSM, it is difficult— and probably impossible—to bring males’ lower rates of circumcision in m Diminished health care access behavior change programs to comparison to whites increase the risk and health service utilization among sufficient scale, as only a small of transmission54, and that the fact that Black MSM, reflected in late diagnosis minority of MSM are reached by Black MSM are less likely than white of HIV, sub-optimal receipt of life- 1 behavioral interventions. It is MSM to identify as gay must somehow prolonging and prevention-promoting challenging, especially for small community-based organizations, explain disparities in rates of HIV antiretroviral treatment, and poorer to translate evidence-based infection. prognosis among those who are living behavioral interventions in the Over time, each of these theories w it h HIV. 63 real world; many interventions has been disproven. Studies m High background prevalence require psychologists or other consistently demonstrate that Black of other sexually transmitted diseases, trained staff, and most require participants to attend multiple MSM are no more likely to engage which increase by several orders of sessions (sometimes as many in HIV-related risk behaviors than magnitude the likelihood that HIV as 12). Staff turnover at small other MSM.55 56 57 Indeed, some will be transmitted or acquired during community organizations is studies even suggest that sexual risk sexual intercourse.64 65 often high, underscoring the behaviors are less frequent among m Sexual behavior patterns challenge of translating efficacious 58 interventions into effective Black MSM. For example, a CDC- among young Black MSM, including programs in the community.2 sponsored survey of MSM in 21 cities early sexual debut and a greater odds found that Black MSM were notably of having older (in some cases, even Notes 66 1. CDC (2006) MMWR 55:1-16. less likely than white or Latino MSM modestly older) sex partners , and 2. Stall R, The Evolving HIV/AIDS Epidemic m Among MSM, 2010. to have used cocaine, poppers, or A syndemic among Black MSM methamphetamine in the past 12 involving poverty, unemployment, months.59 A recent meta-analysis of violence, homelessness, experience more than 145 studies that collectively of childhood sexual abuse or enrolled nearly 155,000 Black MSM other trauma, experience of found that Black MSM were more hostile home environments and likely than other MSM to take steps associated disruption in education, to reduce their risk of HIV, but twice and disproportionate risk of as likely to become infected with the incarceration.67 68 virus.60 Differential circumcision rates What does available evidence tell also appear not to explain disparities us about how best to move forward in HIV prevalence between Black to reverse the epidemic among Black

36 Back of the Line 1994 Landmark study 1996 of gay/bisexual men Studies confirm in San Francisco finds 1995 that Highly Active 1998 Antiretroviral that Black MSM are FDA approves first Minority AIDS Therapy reduces more than twice as protease inhibitor Initiative created likely to be living with HIV-related HIV than whites sickness and or Latinos death

MSM? Two clear lessons emerge Treating HIV First, given the fact that differences How Things Have Changed in risks behaviors do not appear to be We are not in the same world as when AIDS first appeared in the driving the extraordinarily high HIV 1980s, or in comparison to the mid-1990s, when the first effective HIV rates among Black MSM, it is evident treatments became available. Today, most people newly diagnosed with HIV can be effectively treated with a once-a-day pill, experience few side that efforts to produce incremental effects, and expect to live a normal lifespan. changes in Black MSM’s risk behaviors The first drug approved for the treatment of HIV infection was AZT, are, on their own, unlikely to be an antiretroviral endorsed by the Food and Drug Administration (FDA) in sufficient. In communities where 1987. Although approval of AZT raised hopes, it soon became clear that a 40-year-old Black MSM has a the virus rapidly developed resistance to the drug. In 1993, results from a large multinational trial found that early initiation of AZT did not extend roughly 60% chance of being infected life. Subsequent approval of additional drugs similar to AZT allowed with HIV—and even a 25-year-old physicians to prescribe dual therapy, but this too achieved only limited Black MSM has a roughly one-in- clinical results. four chance—even extremely low In 1995, the FDA approved the first of a new class of antiretroviral levels of sexual risk behavior carry drugs, known as protease inhibitors. By combining at least three drugs from multiple classes, doctors for the first time were able to exceptionally grave risks of HIV stop HIV in its tracks in many patients. As a result, rates of HIV-related transmission. While HIV education hospitalization and mortality sharply fell beginning in the mid-1990s. and condom promotion will remain While combination antiretroviral therapy was a godsend for central to HIV prevention efforts hundreds of thousands of HIV-positive people here in the U.S., the early among Black MSM, much more will be combinations often had considerable side effects. As new drugs have been developed and new combination regimens devised, antiretroviral needed to reduce HIV incidence and drugs are now much easier to tolerate and associated with fewer side improve the health and well being of effects. The most popular regimen for newly diagnosed individuals is a Black MSM. single, once-a-day pill that combines three different antiretroviral drugs. Second, no strategy is likely to alter One thing that hasn’t changed over the years is that HIV drugs the HIV dynamic among Black MSM are extremely expensive here in the U.S., where drug prices are the highest in the world. Prices are especially high for the newer classes of unless it addresses the root causes of antiretroviral drugs, such as protease inhibitors, integrase inhibitors, and Black MSM’s disproportionate risk. fusion inhibitors.1 Today, it is estimated that lifetime treatment costs for a New approaches are urgently needed person living with HIV in the U.S. exceed $600,000. to eliminate health disparities for Notes Black MSM. In addition to policy and 1. NIH, http://www.aidsinfo.nih.gov/guidelines/html/1/adult-and-adolescent-treatment- program reforms to expand access guidelines/276/appendix-c—monthly-average-wholesale-price-of-antiretroviral-drugs. to care, considerable efforts are also needed to increase demand for and uptake of HIV treatment within Black MSM communities. It is also vital to dramatically lower rates of STDs, forge new sexual norms among Black MSM (with particular attention to the needs of young men), and combat the many economic, social, and health deficien- cies that combine to render Black MSM especially vulnerable to HIV.

Back of the Line 37 38 Back of the Line The Best and Worst 9 U.S. Cities Ranked

IDS is a crisis for Black system that took into account Leadership on Gay Rights in MSM from coast to coast. 12 factors relevant to a sound Black America In a federal system of AIDS response for Black MSM. In May 2012, the board of government like ours, These factors generally addressed directors of the NAACP made A history when it endorsed same- however, states and municipalities comparative funding for HIV sex marriage, asserting that “civil have the leeway to pursue different prevention and treatment services, the marriage is a civil right and a approaches to public health challenges. comprehensiveness of the safety net matter of civil law.” The NAACP As a result, some settings are likely to for HIV prevention and treatment, and linked the fight for marriage have policies and programs in place legal protections for Black MSM. equality with the broader struggle that make them friendlier terrain for The Institute’s scoring system for civil rights in the U.S., with NAACP President and CEO Black MSM. used published data sources to Benjamin Todd Jealous stating, Ideally, all Black MSM will live in assign scores. However, the system “The NAACP’s support for a city in which they have equitable has limitations. Due to the lack of marriage equality is deeply rooted access to robust support for HIV city-specific information on some in the Fourteenth Amendment of prevention and treatment services. measures, for example, the Institute the United States Constitution and equal protection of all people.” Their rights ought to be recognized in several instances used statewide The NAACP’s endorsement of and protected and they should be data to assess criteria for individual same-sex marriage followed free from discrimination, state and cities. In addition, while the Institute’s President Obama’s own embrace local leaders should actively promote methodology took into account the of legal reform to permit couples knowledge of HIV status and magnitude of HIV-related funding of the same sex to be married. utilization of life-saving services, and available in different jurisdictions, it the health care safety net should be was unable to determine whether cities strong and comprehensive. made effective use of this funding to The Black AIDS Institute set out prioritize prevention and treatment to determine the degree to which programs for Black MSM. Black MSM living in different parts The Institute does not suggest that of the country have access to these its criteria reflect the optimal means prerequisites for a sound AIDS for ranking different cities. Due to the response. Using an objective scoring lack of available evidence, for example, system, the Institute ranked 25 the Institute’s scoring system cannot cities that were chosen on the basis assess the degree to which Black MSM of several considerations, including are integrated into broader Black or the presence of a substantial Black LGBT community institutions. Nor population, a heavy HIV burden do the Institute’s criteria address among Black residents, notable Black other cultural or quality-of-life issues political leadership in local affairs, a that affect Black MSM. Rather, the meaningful Black civil society (e.g., Institute offers its methodology as an civil rights organizations, churches, example of how key issues may affect Black radio stations), and engagement Black MSM and how the health and of Black community organizations in well-being of Black MSM are affected the delivery of HIV services. by policy and programmatic choices The Institute created a scoring made in different settings.

Back of the Line 39 Factors Taken Into Account in Ranking U.S. Cities

The Institute assigned scores for the following factors:

Total HIV Federal Grant collected by the Henry J. Kaiser Family in which either a state or local anti- Dollars Per Individual Living Foundation, the Institute ranked states discrimination law was in place with HIV from low to high based on average received additional points. The Institute relied on statewide ADAP spending. In large measure, data used by the Henry J. Kaiser ADAP spending represents state policy HIV Criminalization Family Foundation to rank states in choices, as states where legislative Cities in states with HIV-specific four categories, from low to high. leaders have made minimal financial statutes criminalizing HIV non- contributions to the program are most disclosure, exposure or transmission CDC Funding for HIV likely to have low per-client spending had points deducted. Somewhat fewer Prevention or waiting lists for ADAP services. points were deducted in states where The percentage of HIV prevention no HIV-specific criminal statute was in funding was compared to the ADAP Waiting List place but where prosecutions of people percentage of diagnosed HIV cases Any city in a state with an ADAP living with HIV have occurred based in each state, with points added or waiting list as of June 2012 had points on other laws (e.g., assault and battery). subtracted depending on whether deducted. States in which five or more such prevention funding exceeded or fell prosecutions have occurred in the past short of a state’s contribution to the Medicaid Spending two years had extra points deducted. national epidemic. Similar to the approach adopted with respect to ADAP, the Institute LGBT Relationships 12 Cities Initiative relied on data collected by the Henry Cities in states recognizing same- The federal government provides J. Kaiser Family Foundation to score sex marriages received additional focused support for HIV service states based on total Medicaid outlays points, with lesser additional points enhancement and coordination in per HIV-positive beneficiary. awarded in jurisdictions recognizing 12 cities that collectively account for same-sex civil unions but not gay nearly half of all reported HIV/AIDS Medicaid Exclusion marriages. Jurisdictions in states that cases. Each of the 12 cities received Most states do not allow single, have passed laws specifically outlawing additional points to take account childless adults to receive Medicaid, recognition of same-sex relationships of the additional federal support which serves as a major service barrier had points deducted. available. for many Black MSM. Any state with such an exclusion in place had points Testing Rate deducted. (The Affordable Care Act, as The scoring system used the four- originally drafted, would have resolved part categorization used by the Henry this gap by providing coverage for J. Kaiser Family Foundation based on income-eligible, single, childless the percentage of state residents tested adults, but the Supreme Court held in in the last 12 months. June 2012 that Congress overreached its authority by mandating that states Ryan White Part A Funding expand their Medicaid programs. It Additional points were provided for remains to be seen how many states all cities that receive Ryan White Part will expand Medicaid services to cover A funding, which is allocated based single, childless adults.) on service priorities agreed to by local community planning bodies. Anti-Discrimination Provisions The Institute consulted online ADAP Funding information regarding existing state The Institute assumed that total and local laws to determine whether ADAP spending per client reflects Black MSM in different cities were the strength and comprehensiveness protected from discrimination of state ADAP programs. Using data based on sexual orientation. Cities

40 Back of the Line The Three Best Cities for Black MSM

Based on the Institute’s scoring systems, three cities scored at the top:

1. New York City

Black gay New Yorkers benefit from living in a jurisdiction with among the highest per capita funding for HIV prevention and treatment. New York’s Medicaid program is among the country’s most expansive, offering comprehensive coverage for single, childless adults below 100% of the poverty line. Due to substantial state contributions, as well as allocations from Ryan White Part A, New York also has perhaps the most generous ADAP in the country. New York is one of the 12 cities receiving focused federal support for HIV service enhancement. New Yorkers are broadly protected from discrimination based on sexual orientation, and in 2011 state legislators formally recognized same-sex marriage. The state government complements federal funding with focused HIV prevention and treatment services, and the city’s Congressional delegation is politically active in supporting robust federal support for HIV services.

2. Washington, D.C.

Although the nation’s capital has garnered major headlines regarding the seriousness of its epidemic, it has also proven to be among the most energetic of jurisdictions in mounting an aggressive response. Like New York, Washington is one of federal government’s 12 focus cities for HIV service enhancement and has a generous ADAP, although its Medicaid spending per HIV-positive beneficiary is somewhat lower than in New York. Washington is also home to a vibrant community response among Black MSM, and its public health leaders have implemented innovative HIV programs, including the routine offer of HIV testing in many government offices, such as the motor vehicles department.

3. Los Angeles

Although HIV grant dollars are somewhat lower per capita in California than in New York and the District of Columbia, spending on Medicaid and ADAP per HIV-positive enrollee is among the highest in the country. Los Angeles scores behind New York and Washington, in part due to the fact that California’s Medicaid program (Medi-Cal) does not cover single, childless adults. The fact that prosecutions of people living with HIV have occurred under California law also lowered LA’s score. Other cities that had high scores were Chicago and Oakland. Chicago had generally impressive scores but missed making the top three primarily due to Medicaid’s failure in Illinois to provide coverage for single, childless adults. Oakland also had favorable scores but missed the top three primarily due to the fact that it is not one of the federal government’s 12 focus cities for HIV service enhancement.

Back of the Line 41 The Worst Cities for Black MSM

If some cities score better when it comes to addressing the HIV-related needs of Black MSM, it stands to reason that some do worse. Based on the Institute’s scoring method, three cities scored at the bottom:

1. Gary

Gary, Indiana, was the first city in the U.S. to elect a Black mayor, but today it qualifies as the worst city for Black MSM, according to the Institute’s scoring system. The city’s low score primarily stems from policy choices made at the state level. Indiana ranks in the very bottom category with respect to federal HIV grant dollars per person living with HIV, and the state’s ADAP program is also below average in spending per beneficiary. The state Medicaid program excludes single, childless adults, Indiana has enacted a law banning recognition of same-sex unions, and the state also has a record of prosecuting people living with HIV. Suffering from the loss of key industrial capacity and having an unemployment rate higher than the national average, Gary itself has limited ability to support a robust AIDS response for Black MSM, making it dependent on the state, which has proven itself unwilling to rise to the challenge.

2. Memphis

Memphis may have given birth to some of the greatest Black music in history, but it falls short when it comes to caring for the HIV-related needs of Black MSM. Tennessee is below average with respect to federal grant dollars per case of HIV infection, including CDC prevention funding. Single, childless adults are ineligible for Medicaid, which in any event provides funding for HIV care that is below the national average. The state is near the very bottom of per-beneficiary spending on ADAP. And the state legislature has enacted legislation prohibiting recognition of same-sex unions.

3. Richmond

Richmond shares many characteristics of Gary and Memphis—below-average access to federal HIV grants, below-average Medicaid spending for HIV, and exclusion of single, childless adults from Medicaid. HIV-positive Black MSM in Richmond are further disadvantaged by the state’s ADAP. As of June 21, 2012, nearly 600 people living with HIV in Virginia had been placed on a waiting list for ADAP services. Indeed, Virginia alone accounted for 28% of all people nationwide on ADAP waiting lists in June 2012. Several other cities vied for inclusion in the list of the worst cities for Black MSM, notably Jackson MS, Durham NC, and three cities in Ohio (Cincinnati, Cleveland, and Columbus). Indeed, Durham had the same score as Richmond, avoiding the bottom three solely by virtue of the fact that North Carolina’s ADAP waiting list is slightly less severe than Virginia’s.

42 Back of the Line What Do The Rankings Tell Us?

The Institute’s ranking of cities generates a number of important insights. The cities at the very top of the rankings are all urban powerhouses, in which the Black community is politically empowered Mobilizing to Make a Difference: and has long been mobilized to Us Helping Us in Washington fight for its rights. New York and Although Black MSM need and deserve the support of government, Washington are universally recognized the Black and LGBT communities, and private foundations, Black MSM as two of the political and cultural themselves will need to lead the fight if AIDS is to be reversed. While capitals of Black America, with a Black MSM experience multiple challenges in their efforts to overcome AIDS—homophobia, racism, social exclusion, and limited economic and history of Black political leadership educational opportunities—they also possess enormous reservoirs of at City Hall and (in the case of New resilience on which to build a durable and effective response. York) in its Congressional delegation. Us Helping Us (UHU) is an example of Black gay leadership in the Although the Black population fight against AIDS. Founded as a support group for HIV-positive Black is less prominent in Los Angeles, gay men in 1985, when no effective treatment existed for HIV infection, UHU focused on holistic health promotion and mutual support as means the city was the first of the most to promote Black gay men’s well being in the midst of a new epidemic populous metropolitan areas to elect that was spiraling out of control. a Black mayor, and its Congressional From its inception, UHU has understood the mind, body, and spirit delegation includes some of the as integral components of a holistic approach to health. Its early health country’s most visible AIDS promotion programs provided support and guidance to Black gay men on such issues as diet and nutrition, exercise, anger management, and a champions. dialogue between mind and body. Four of the five cities with the Over the more than 25 years that UHU has been in existence, the lowest ranking are south of the Mason- AIDS landscape has dramatically changed. While treatments now make Dixon line. This is cause for concern, it possible to live a long and healthy life with HIV, many Black gay men as cases among Black MSM are rising struggle finding culturally relevant health services. And the rate of new infections among Black gay men continues to escalate. the fastest in the South. Although Through all of these changes, UHU has formulated and implemented Southern states are hardly alone in model programs through a process of continuous innovation and skimping on support for health care adaptation. While its roots were in alternative therapies, today UHU safety nets—the major Ohio cities, for embraces advances in biomedical research and is a partner in the example, also rank near the bottom— National Institute of Allergy and Infectious Diseases (NIAID) Be the Generation Bridge Project (www.bethegeneration.nih.gov). Through this Southern states have generally adopted program UHU uses trainings, updates, social networks, and viral media much more restrictive Medicaid to disseminate biomedical prevention research information. According to policies than other states and are Ron Simmons, UHU’s executive director for more than 20 years, “Given disproportionately represented among the disproportionate rate of HIV infection among Black gay men, it is states with ADAP waiting lists. imperative for Black gay and same-gender-loving men to be aware of biomedical HIV prevention research, and become involved in clinical Significantly, the bottom five cities trials for biomedical prevention and vaccine research.” (Gary, Memphis, Richmond, Jackson, Another example of UHU’s impact on HIV/AIDS was a recent and Durham) are found in states in initiative to spark a national dialogue on the need for a “paradigm which urban interests have limited shift” in understanding and addressing HIV infection among black gay political clout. This pattern highlights men. Responding to studies indicating that Black gay men are more likely to use condoms and less likely to engage in risky sexual behavior an additional feature of importance than white or Latino men yet are at greater risk of HIV infection, UHU in the AIDS response for Black MSM. has worked to promote a public dialogue to increase awareness of While all Black MSM struggle to these patterns and to debunk notions that Black gay men engaged in obtain the services and support they riskier behaviors. This year-long collaboration with leading Black gay need, regardless of where they live, researchers and scholars worked to place the paradigm shift on the agenda of every major HIV/AIDS conference and to engage leading urban-dwelling men are often better government officials and funders on ways to reconceptualize HIV equipped to obtain community-based prevention for Black gay men. services or access to a spiritual home that is more accepting of diversity. By contrast, Black MSM residing in small towns and rural areas are most isolated and disenfranchised.

Back of the Line 43 44 Back of the Line New Hope, New Opportunities 10 But Will Black MSM Benefit?

he last two years have daily prophylactic regimen.72 HIV incidence as antiretroviral witnessed historic Whereas behavior change has therapy, it also represents a potentially breakthroughs in efforts traditionally been the centerpiece of important new tool to reduce the Tto develop more effective HIV prevention efforts, these study spread of infection among those who weapons with which to combat HIV/ results indicate that biomedical are at especially high risk. In the U.S., AIDS. Indeed, every sign suggests interventions are likely to be the no population warrants more intensive we have entered a new phase of most critical channel for stemming support for the implementation of our national response—one that the spread of HIV in future years. PrEP than Black MSM. potentially points toward the feasibility To translate the study results on While these and other prevention of bringing AIDS to an end. antiretroviral therapy as HIV breakthroughs have generated renewed Most significantly, study results in prevention to the real world, the goal hope and optimism, major steps will 2011 found that antiretroviral therapy is to achieve sharp reductions in be needed if they are to benefit Black reduces the odds that a person living community viral load, or the overall MSM. These new breakthrough tools with HIV will transmit the virus to an amount of virus circulating within will need to be delivered in health care uninfected sexual partner by 96%.69 any neighborhood, population, or settings, where Black MSM confront With the odds of HIV transmission sexual network. According to HIV substantial obstacles to timely, clearly correlated with the viral load surveillance data in San Francisco, a high-quality, non-judgmental, and (i.e., magnitude of virus circulating 40% reduction in community viral culturally competent care. in plasma) of the infected partner70, load in the previous decade was A legacy of discrimination in antiretroviral therapy helps reduce associated with a 45% decline in new health care settings against Black the risk of transmission by lowering infections.73 MSM, combined with an acute viral load (typically to undetectable While health care settings now take shortage of health care workers levels). The HPTN 052 results, which center stage in the effort to prevent who have been trained to provide confirmed observational studies in new infections, it is clear that health culturally appropriate care, deters several parts of the world, led Dr. care workers cannot on their own many Black MSM from routinely Anthony Fauci, leader of the federal accomplish all that needs to be done seeking the services they need.75 76 HIV research effort, to declare that to reverse the epidemic among Black Black MSM typically confront not the tools now exist to end the AIDS MSM. In addition to obtaining timely one, not two, but a host of factors epidemic.71 and ongoing access to health services, that impede their ability or desire to These findings followed earlier HIV-positive Black MSM must also access needed services. Socialized as study results demonstrating that the rigorously adhere to prescribed Black men, Black MSM confront the same antiretroviral drugs used to regimens in order to prevent treatment everyday reality of racism. They may treat HIV may also be taken by HIV- failure and related viral rebound. be ostracized from their families or uninfected individuals to reduce their Available evidence suggests that peer- communities of birth as a result of risk of acquiring the virus. According based interventions, as well as ready their same-sex attraction. Within to a multi-country study of MSM, access to supportive social services, are the mainstream LGBT community, pre-exposure prophylactic use of critical to ensuring strong treatment Black men often perceive themselves antiretrovirals reduced the odds of adherence and promoting the success as unwelcome; according to a large, HIV acquisition by 44%, with a more of clinical services.74 multi-ethnic survey of Black MSM than 90% reduction in new infections Although pre-exposure prophlyaxis in San Francisco, Black men were the among individuals confirmed by blood (PrEP) is unlikely to have the same least preferred sexual partners, less tests to have regularly adhered to the population-level potential to reduce likely to be considered friends, and

Back of the Line 45 2000 CDC reports that 1999 surveys of MSM in 2002 five cities indicates FDA approves Black AIDS Institute that Black MSM are OraQuick rapid HIV founded six times more likely test than whites to be infected

less welcome in gay venues, and also than other MSM receiving HIV Leadership on HIV regarded as presenting the highest treatment. In 2008-2010, 70% of HIV- and Black MSM risks for HIV transmission.77 Black positive Black MSM on antiretroviral Although the overall picture MSM are also more likely than other treatment had viral suppression, of leadership on HIV and Black MSM to have been incarcerated in the compared to 84% of white MSM.88 MSM is rather dismal, there are 78 noteworthy bright spots. For past year , which in turn results in In addition to the deterrent example, CDC’s Act Against AIDS lifelong diminishment of employment effects of homophobia and racism on Leadership Initiative has supported opportunities, social acceptability, and health care utilization, Black MSM two Black MSM organizations. CDC ability to vote or otherwise participate also confront substantial systemic has also launched a nationwide fully in society.79 obstacles to timely and appropriate testing campaign for Black MSM, Testing Makes Us Stronger, which Altogether, these factors reduce care. Gay and bisexual men are less is focusing initially on six high- Black MSM’s trust in mainstream likely than heterosexual males to burden cities (Atlanta, Baltimore, service systems and slow uptake of have health insurance coverage89 90, Houston, New York, Oakland and essential health services. For example, and Black people generally are nearly Washington, D.C.). Black MSM are seven times more likely twice as likely as whites to lack health Greater Than AIDS—a 91 collaborative national campaign than other MSM to have undiagnosed insurance (20.8% vs. 11.7% in 2010). by the Henry J. Kaiser Family 80 HIV infection. In CDC’s 21-city Among more than 1,500 Black MSM Foundation, the Black AIDS survey of MSM, 59% of Black MSM enrolled in an ongoing NIH-supported Institute, and several other found to be HIV-positive were intervention trial, a majority are foundations—promotes HIV previously unaware of their infection, unemployed, lacking access to the awareness and combats HIV- 81 related stigma, with the aim of compared to only 26% of white MSM. typical route Americans use to obtain connecting the AIDS response to Once in care, Black patients living health coverage. Lack of insurance is Black America’s historic struggle with HIV are less likely than white associated with reduced likelihood against other challenges. Since its patients to receive antiretroviral of having ever been tested92 and with inception, Greater Than AIDS has therapy82—a pattern that holds lower utilization of needed health focused particular attention on 93 94 Black MSM, including developing for Black MSM as well as for Black services. a targeted campaign that 83 84 heterosexuals. Among MSM in In short, business as usual will specifically addresses Black MSM. care, Black MSM have fewer clinical ensure continued failure in the AIDS visits than other MSM and are also response for Black MSM. Even with less likely to adhere to prescribed potent new biomedical weapons treatment regimens.85 86 In the largest capable of breaking the epidemic’s cohort of young MSM of color ever back, Black MSM will fail to benefit studied, a five-year federally sponsored unless major changes are implemented project found that only half of to their ensure full and equitable treatment-eligible study participants access. In the absence of the concerted were receiving antiretroviral therapy.87 national action recommended in the Significantly, given the powerful National HIV/AIDS Strategy, Black potential of antiretroviral treatment MSM will remain at the front of the to slow the spread of infection by line with respect to need, but at the lowering viral load, Black MSM on back of line when it comes to access. antiretroviral therapy are significantly less likely to have viral suppression

46 Back of the Line Back of the Line 47 An HIV Prevention Leader Speaks: 11 Growing AIDS Crisis Among Black MSM An Interview with Dr. Kevin Fenton

Dr. Kevin Fenton is director of the discrimination, and poor access to serosorting and strategic positioning, National Center for HIV/AIDS, Viral health care. These factors are operating are becoming more prevalent within Hepatitis, STD and TB Prevention at at multiple levels and interacting with the community. At the individual level, the Centers for Disease Control and each other. we also know that sexually transmitted Prevention. With regard to individual-level diseases facilitate both acquiring and factors, we have seen increases in transmitting HIV. For MSM, with risk behavior across many MSM high background prevalence of STDs, Why are Black MSM so much communities. In part, these changes this can in turn increase the risk of more heavily affected by HIV are occurring because we are 30 years acquiring HIV. than other populations? into the epidemic, perhaps leading to Another factor is the high a certain complacency about HIV, a prevalence of disease among Black There are many reasons why we lack of urgency, a lack of fear about the MSM. High HIV incidence results are seeing the high rates of HIV seriousness of the disease, or ignorance in high HIV prevalence, especially among Black MSM. You have to about the epidemic and its impact. as people are living longer with the take into account individual-level These factors may be resulting in less disease. If there are more people factors, factors relating to the high vigilance at the individual level to in your community who are living background prevalence of disease practice safer sex. with HIV, the likelihood of coming within the community, and also We know that men are making into contact with the virus with each societal and broader community-level a lot of assumptions about their episode of unsafe sex is much higher. factors, such as stigma, homophobia, partners. Certain practices, such as Partnership issues also come into play. We know that most infections are occurring in the context of stable Dr. Kevin Fenton relationships. People may use a condom initially, but as they get to know one another other they stop using condoms without getting testing and ensuring that is a safe thing to do. This can result in transmission of HIV. Issues of disclosure, couples testing, and other partnership issues become incredibly important for all gay men, especially Black gay men. Societal factors also help explain why Black MSM are at much higher risk of HIV. Extensive research within minority communities has revealed a high prevalence of stigma and homophobia, which may have negative effects on the ability of gay men to disclose they are homosexually active. These issues are not unique to Black men, but they have to be taken into

48 Back of the Line account in understanding the problem We are doing a lot, but there is understanding of disease rates within in this community. always an opportunity for us to do the community. We want to use No discussion about Black MSM more. surveillance to better define what is would be complete without taking CDC’s efforts for gay and bisexual happening with Black gay men and faith communities into account. men focus on three key strategies. The to gather more real-time information When churches add their voices to an first is to scale up the most effective on how gay men are changing their effective response, it is truly powerful. prevention strategies, including HIV behaviors. But churches can also negatively testing, linkage to care, and screening Of course, we can’t do this alone, impact the lives of Black gay men by for STDs. We’re working with state and and it isn’t our intention to try to do reinforcing some of the societal factors local partners to integrate HIV across so. We are committed to working with I’ve mentioned. So we are working multiple services, to scale up viral other federal agencies, community- with faith communities to make sure hepatitis vaccination, and take other based organizations, and state and they can be even stronger partners in steps to improve the health of Black local health departments to better response to HIV. MSM. And we are working with other address the needs of Black gay men. In short, there is no one single federal agencies to help implement driver of the disproportionately high effective strategies. infection rates among Black MSM, and Second, we are working with a How do we make sure that there is no one single solution. range of partners to ensure that we Black MSM benefit from PrEP, are touching the lives of gay men in ART as prevention, and other new ways—whether this is through emerging prevention tools? If Black MSM don’t appear to directly funding community-based engage in higher levels of risk organizations to scale up effective The first thing we have to take behavior, is it reasonable to interventions, or working with federal account of is the reality of health expect behavior change alone partners like Health Resources inequities. The disparities we are to solve this crisis? and Services Administration and seeing for Black gay men pertain not the Substance Abuse and Mental only to HIV but to a range of health Studies consistently indicate that Health Services Administration to conditions that Black gay men have Black gay men are no more likely to engage Black gay and bisexual men to contend with. Given that, there have higher rates of partner change who are using Federally Qualified are some specific things that we can or unprotected sex than men of other Health Centers or other community and must do if we are committed races. What are other factors that may institutions. A key element of to addressing health inequities. The be putting individuals at risk? Higher our strategy is to ensure that the first is to use our data and strategic rates of STDs may partly explain the community is fully engaged in our information to better understand inequities. In addition, young Black efforts to address the needs of Black who is actually enrolled in care, who MSM are more likely to report having gay men. is maintaining care, who is getting partners that are older gay men. In Another part of our partnership antiretroviral treatment, and why an environment where incidence and strategy is to leverage the Act Against these things are or aren’t happening. prevalence are high, especially among AIDS Leadership Initiative partnership Second, we must raise providers’ older men, having older partners can and the Act Against AIDS campaign awareness of these health inequities increase young men’s risk of becoming to ensure stronger inclusion of and provide simple tools that can be infected. In other words, it isn’t just organizations that serve gay and implemented to improve performance. the kind of sex you are having but who bisexual gay men. We want to ensure And holding providers accountable you are having sex with and in what that social marketing campaigns for performing better will be a key environment. that target gay and bisexual men strategy for moving forward. Key Just as sexual networks may help are disseminated more widely and targets need to be set for improving explain HIV patterns among Black effectively. performance, and all of us must hold MSM, they can also be used to support Finally, we are strengthening ourselves accountable for making HIV prevention. We need more the use of our data and strategic improvements over time. We need to research on how best to use sexual information to ensure that have standardized indicators that can networks to enhance HIV prevention. policymakers have the information enable us to report how we are doing they need to target prevention dollars, at each step of the HIV spectrum, scale up interventions, and engage gay and then use the results to improve What is CDC doing to respond men. CDC is trying to obtain a clearer outcomes. to the AIDS crisis among Black sense of the population denominator Finally, we need to ensure that we MSM? of Black gay men so we have a better are supporting Black gay men, and

Back of the Line 49 indeed all gay men, to take control and for scaling up the most effective broader society about the problem. We of their care and engage with the interventions. For example, we need to have to work harder to re-engage the care system. We need to confront the look carefully to see if there are ways broader LGBT community on AIDS. challenges of economic disadvantage, that reimbursement for individual discrimination, and stigma. All of us, behavioral counseling and HIV including providers, need to be honest screening can be leveraged to help What is the role of Black that we are working in concert with community-based organizations leaders and institutions in Black gay men to address their needs. become more sustainable. reversing the AIDS crisis We need to think carefully about among Black MSM? what sustainability means for CBOs. You’ve mentioned that CDC We must find ways of ensuring We have come to a point where can’t do everything on its fiscal sustainability, and we also solutions to this issue have to begin own and that it needs to need to train and nurture the next within our community. That might engage effectively with Black generation of prevention workers. be within the LGBT community, gay men. But many Black How do we retool and expand and Black gay community, or the gay communities have weak engage prevention workers at the Black community as a whole. Each community infrastructures. community level? This question raises community has a role to play. What needs to be done to issues around training and capacity The Black community as a whole build stronger community building for community partners. We has many assets that can be brought institutions among Black gay need not only to train new workers to bear on this problem, whether men? in classic prevention approaches, but it is leveraging Black colleges and also ensure that they understand the universities, or Black businesses, or Communities responding to full prevention, treatment, and care the faith community, which serves HIV have been at the core of how spectrum. as a pillar of the Black community. we respond to HIV—both in the In short, the community response We should recognize that gay men U.S. and globally, in part because is critical to future progress in have always been a part of faith community-based organizations can preventing new infections among communities, and their lives have to actually engage and touch the lives Black MSM, but it is dynamic and be valued in a way that enables them to of gay men in ways the public sector is occurring within a dynamic achieve their full potential. The reality can’t. Community organizations also environment. is there are many churches that have provide culturally competent outreach been doing great work. We need to and prevention services. CDC is build on this. committed to supporting investments With HIV representing such Finally, the family is critically in indigenous organizations to do a serious crisis among Black important. Family has always played the very best we can in these tough MSM, why hasn’t there a critical role in the Black community. economic times to prevent new been more of an outcry for We need to engage fathers and mothers infections. intensified attention to this on issues relating to sexual orientation, We need to understand that for all problem? to help parents understand why not sectors that receive funding there is rejecting your gay and lesbian sons much greater accountability in today’s That is a difficult question to and daughters is so important. Having environment. As part of that increased answer. We all have to do some soul- open and honest conversations within emphasis on accountability, we must searching on what we are doing and the family about HIV and sex is critical ensure that dollars are being used for what we can do to make things better. to bringing this epidemic to an end. the most effective interventions. HIV For one thing, we need to do a better African-American athletes and has both social and structural drivers, job of using our data to tell compelling celebrities represent another pillar of as well as individual- and partnership stories that grab the attention of the the Black community. These influential level-drivers, and we need to ensure public and of policy-makers. figures have the ability not only to talk that finite resources are focused on the We also need to do much better in about the epidemic writ large, but also interventions that are most effective. engaging the LGBT community writ about issues relating to sexuality. We Community organizations large. A lot of people feel that effective already have great examples of Black need to look at opportunities that treatments are here, so the sense of celebrities who are taking on this fight, present themselves with health urgency about HIV prevention has and we need to build on that. system transformation. Changes in lessened. Accompanying that is an the health system may well bring increasing complacency, some have opportunities for greater sustainability argued, within the community and the

50 Back of the Line Back of the Line 51 52 Back of the Line Ending AIDS Among Black MSM 12 How Do We Move Forward?

ue to the grave weaknesses must be jettisoned, with resource Gay-Friendly Churches in in our national safety net allocations, service strategies Black Communities and to the poor HIV-related and research priorities brought In recent years, a growing policy and programmatic into alignment with documented number of churches have exhibited D non-judgmental openness to choices that have frequently been epidemiological patterns. gay and bisexual parishioners. made, our country has little chance Urgent efforts are needed to In some cases, these include of reversing the worsening epidemic address the root causes of Black MSM’s churches that specifically aim among Black MSM without a dramatic disproportionate vulnerability to to provide a welcoming spiritual change of course. Without a radical HIV. A multi-faceted, holistic agenda environment for Black LGBT change in direction, the promise that includes housing, employment, people. Leaders in pastoral efforts for LGBT individuals include the inherent in the National HIV/AIDS education, and psychosocial support Unity Fellowship and the United Strategy and recent prevention must be aggressively pursued for Church of Christ. In May 2012, breakthroughs will remain outside individuals and communities at risk. The New York Times profiled the reach of Black MSM, and the Through policy choices, increased Harlem’s Rivers at Rehoboth epidemic among Black MSM will funding opportunities and capacity- congregation, which has combined a ministry to LGBT people with continue to intensify. Unless a building support—including full worship traditions of Black change of direction is immediately implementation of the National HIV/ America. According to a 26-year- implemented, Black MSM will remain AIDS Strategy at federal, state, and old HIV-positive Black gay man at the head of the line when it comes to local levels—we must provide Black who attends church at Rivers at need but at the very back of the line in MSM the means to draw on their Rehoboth, “I believe it helped save my life.”1 accessing breakthrough treatment and considerable resiliency to turn back prevention tools. this health challenge and to sustain a Notes A combination of strategies will robust, effective response to AIDS. 1. The New York Times, May 28, 2012. be needed to alter the epidemic’s trajectory among Black MSM. Stronger, more consistent Demonstrate Leadership in leadership and commitment on AIDS the Fight Against AIDS for and other critical Black MSM issues Black MSM are absolutely vital to turn the tide against this health crisis. No longer AIDS will not be reversed without can we permit HIV infection, an strong and sustained leadership by eminently preventable problem, to diverse constituencies and institutions. flourish unabated, or remain hidden in Those who ought to care must stop the shadows of stigma and denial. hiding their heads in the sand. Every As the Affordable Care Act expands stakeholder in the AIDS response— access to insurance coverage, new including government leaders, Black approaches are needed to engage Black institutions, LGBT organizations, MSM in health services and to foster philanthropic agencies, the private and sustain Black MSM-identified sector, and the organized AIDS health clinics. establishment—must recognize the The legacy of under-prioritization fight against AIDS among Black MSM of the health needs of Black MSM as a central priority.

Back of the Line 53 Ironically, the U.S. government, Initiative, which aims to create a which has historically lacked national movement of young MSM, community advocates in leadership on with a particular focus on HIV. AIDS, is now in the vanguard when it comes to calling attention to the growing health crisis among Black Achieve Saturation HIV MSM. Those parts of society that Testing Among Black MSM would naturally be expected to exert leadership—such as AIDS advocates The HIV test is the gateway to care and service organizations, the LGBT and treatment for people who are community, and Black leaders—are living with HIV. Early diagnosis too often missing in action. enables clinicians to carefully monitor Churches offer both a challenge individual health and ensure timely Steadfast in the Fight Against and an opportunity to build leadership initiation of treatment, improving AIDS—An Example of LGBT in the fight against AIDS among health outcomes for the person living Leadership Black MSM. Many Black MSM are with HIV97 and reducing the odds of While many LGBT organizations in church on Sundays, and like further HIV transmission. According devote little attention and few other people, are in active search for to CDC researchers, people who are resources toward the AIDS spiritual sustenance and a sense of living with HIV but unaware of their response, at least one national LGBT organization continues to community in their lives. However, infection are 3.5 times more likely than prioritize the fight against AIDS, the spiritual homes where Black MSM those with an HIV diagnosis to pass with particular attention to the normally go as a sanctuary against the virus along to others.98 epidemic’s disproportionate racism may also effectively deepen Although Black MSM have effects on Black MSM. In 1983, internalized homophobia, as studies testing rates that are comparable Lambda Legal Defense and Education Fund brought and correlate a high degree of religiosity to, or sometimes higher than, won the nation’s first AIDS with disapproval of homosexuality and other subpopulations of MSM, discrimination case. Since then, opposition to same-sex marriage and disproportionately high background Lambda has been at the forefront other gay rights issues.95 96 prevalence of HIV among Black MSM in fighting for the civil rights, Black MSM also have a role to means that substantially higher rates health, and well being of all LGBT people, with a notable focus on play in catalyzing greater leadership of testing are needed to ensure prompt Black MSM. Lambda represented regarding this health crisis. Indeed, diagnosis. In the previously noted James Dorsey, an HIV-positive Black MSM have considerable sources five-city survey of MSM, 67% of Black Black gay man from Detroit, in his of resiliency with which to resist MSM who were HIV-positive had successful effort to overturn the social discrimination and to thrive previously unrecognized infection, U.S. Job Corps’ discriminatory 99 testing-and-exclusion policy in the midst of hardship—reflected compared to 18% of whites. for young vocational training in the Greater Than AIDS campaign, Over the years, CDC and state recipients. Lambda helped a collaborative undertaking of the and local health departments have convince the Supreme Court in Henry J. Kaiser Family Foundation expanded beyond stand-alone testing Lawrence v. Texas to overturn and the Black AIDS Institute that centers, investing in alternative testing state sodomy laws, with a Black gay man serving as one of the co- links the fight against AIDS among delivery approaches, such as rapid litigants in the case. Today, several Black MSM to the historic struggle testing through mobile services. AIDS discrimination cases are on for civil rights by Black people in this Studies suggest that these innovative Lambda’s docket, including one country. By confronting homophobia, methods have the potential to improve challenging the firing of an HIV- denial and apathy, Black MSM can program uptake and quality.100 CDC positive Atlanta policeman. help expedite the “moment of truth” has indicated it intends to de-prioritize among potential partners, demanding these alternative testing methods, an end to the inattention to worsening looking instead to mainstream health HIV rates. The National Black Gay care settings as the primary venue Men’s Advocacy Coalition (NBGMAC) for HIV testing. While this might is working to strengthen Black gay conceivably be prudent for some advocacy that is focused on research, populations, the considerable and policy, education, and training. As part well-documented barriers that Black of its efforts, NBGMAC is providing MSM face when it comes to accessing organizing space and support for the basic medical care argue in favor Young Black Gay Men’s Leadership of continued support for a range of

54 Back of the Line Black MSM is vital to increase testing uptake, as Black MSM remain less likely than other MSM to be tested for HIV and are consequently at higher risk for unrecognized infection.106 One important impediment to implementation of routine screening is the lack of comprehensive third- party coverage; routine screening is an optional benefit under Medicaid, and as of 2010 fewer than half the states provided for Medicaid coverage for routine HIV testing.107 Expanding health coverage—an issue addressed in greater detail in the following section—may have an important role in increasing testing rates among Black MSM. In a recent study involving Black MSM in San Francisco, lacking health coverage was significantly associated with unrecognized HIV infection.108 testing options to reach Black MSM. positive test results.101 Better aligning Even if Black MSM have the good However, America continues to targeted testing resources with actual fortune to have a physician with pursue a largely passive approach need would not only help close the whom they are open, they still may to testing, primarily relying on testing gap for Black MSM but also not be encouraged to have an HIV individuals themselves to obtain enhance the cost-effectiveness and test. A recent CDC study found that information and summon the public health impact of limited testing even when Black MSM disclosed their motivation to voluntarily seek testing dollars. sexual orientation to their providers, services. A much more proactive Although CDC has recommended these men were less likely to be tested approach is required. Substantially that HIV testing be routinely offered for HIV and more likely to have greater efforts are needed to market to patients in health care settings102, unrecognized HIV infection.109 These testing by positioning knowledge these recommendations have yet results may not improve even when of HIV serostatus as a fundamental to be fully embraced in health care Black MSM have Black physicians. community norm. Such efforts settings. A 2009 survey of general According to a 2011 survey by Janssen should draw from the extensive body internists identified broad awareness Therapeutics and the National Medical of evidence regarding factors that of the CDC guidelines, but only half Association, only one-third of patients facilitate and deter test-seeking, as well (52%) had increased testing, with of Black physicians were tested for as from state-of-the-art learning from only 2% of patients having been HIV in the past year. HIV stigma the marketing field. tested in the past month.103 Surveys appears to be the main reason Black Failure of state and local health of health care providers suggest they doctors avoid recommending the test, departments to prioritize Black MSM perceive themselves to be ill-prepared with 57% of the doctors surveyed for testing services also undermines to implement routine testing and saying they feared the suggestion efforts to ensure prompt diagnosis for require capacity-building support would be regarded as “accusatory or Black MSM. As previously described, from public health officials.104 Making judgmental” and 43% concerned that Black MSM are seriously under- HIV testing routine for all patients is their patients would be offended.110 prioritized with respect to targeted especially vital for Black MSM, who HIV testing services at state health are notably less likely than white MSM departments. This diminishes the to disclose their same-sex attraction Maximize the Therapeutic strategic value of taxpayer-supported to health care providers, rendering and Preventive Benefits of testing services. According to data risk-based targeting of testing Antiretroviral Therapy supplied by 29 health departments, recommendations substantially less white MSM accounted for the largest effective for Black MSM. 105 Improving To capture the prevention promise share of tests conducted, while Black the capacity of health providers to of antiretroviral therapy—and to MSM represented the largest share of deliver culturally competent care to promote the equally urgent aim of

Back of the Line 55 reducing HIV-related illness and death around the country found that early among Black MSM—the country linkage was more likely to occur if must do a much better job of closing the person providing the positive utilization gaps at each step of the HIV test result actually called to make the treatment continuum. People who test follow-up medical appointment.116 HIV-positive must be immediately Once linked to care, Black MSM, as linked to HIV primary care, treatment well as other people living with HIV, must be initiated in a timely manner, must be retained in continuous care to and patients must remain in care permit ongoing health monitoring. In and rigorously adhere to prescribed the above-noted HRSA study involving antiretroviral regimens. Because young MSM of color, Latino MSM of shortcomings at each step in the were significantly more likely to be treatment continuum, CDC estimates retained in care than Black MSM (96% HPTN 061: Testing a Multi- that only 28% of all people living with to 80%).117 Clinical experts recently Component Approach for HIV have achieved viral suppression.111 joined together to articulate evidence- Black MSM With Black MSM exhibiting poorer based guidelines to ensure prompt The NIH-supported trial HPTN results than other MSM at each stage linkage to care and retention in care 061 aims to assess the feasibility of of the treatment continuum, it is likely for people testing HIV-positive118; these implementing a multi-component that even fewer than 28% of HIV- need to be fully implemented. intervention for Black MSM, with an eye toward mounting a positive Black MSM have experienced Implementation of the Affordable community-level randomized treatment succss. Care Act will enhance access to HIV controlled trial to reduce HIV Nationally, nearly one in four primary care for Black MSM. The Act’s incidence in this population. The (23%) people newly diagnosed with Medicaid provisions will significantly multi-component program seeks HIV do not enter HIV care within extend coverage to many single, non- to increase condom use, decrease 112 community viral load, and prevent three months of diagnosis. Although disabled males who currently struggle STDs. national data are limited on racial/ to obtain Medicaid eligibility although Involving more than 2,400 ethnic and risk group comparisons the Supreme Court ruled in June 2012 Black MSM, interventions include with respect to linkage to care, that states may not be required to risk-reduction counseling, HIV evidence suggests that effective expand Medicaid coverage under the testing, and referral for STD testing and care. Participants linkage to care is less likely for newly new legislation. In addition, subsidies are screened for substance diagnosed Black MSM than for white to people with limited incomes will abuse, mental health issues, MSM. In New York City, for example, enable a greater number of people to partner violence, experience Black MSM are not only more likely obtain private health coverage. of homophobia, and provision than white MSM to be diagnosed with In the run-up to full of counseling and referral for care. Peer health navigators AIDS within one month of testing implementation of the Affordable are available to help Black MSM HIV-positive, but they are less likely Care Act in 2014, urgent efforts are enrollees receive the health and than their white counterparts to be required to ensure full and continuous social services they need. linked to care within three months funding for Ryan White-funded In addition to its primary of HIV diagnosis.113 Likewise, a study AIDS Drug Assistance Programs measures, the study also seeks to obtain HIV incidence data, in San Francisco found that Black (ADAPs). In a country where one in describe the social and sexual MSM confront severe challenges in six Americans lacks health coverage, networks of Black MSM, and being linked to appropriate treatment ADAP serves as a vital lifeline to improve understanding of Black and care after receiving an HIV antiretroviral medicines and other MSM’s attitudes toward other diagnosis.114 HIV-related drugs. Yet while federal prevention methods. As in the case of HIV testing, funding for ADAP has risen in recent which primarily depends on voluntary years, many states have flat-funded or utilization, the country’s approach cut ADAP, causing perilous funding to care linkage remains largely shortfalls. As of May 2012, more than passive. While testing sites are at least 2,500 people living with HIV were theoretically required to provide a on ADAP waiting lists in 10 states.119 referral to care, they are typically not These waiting lists have particularly under an obligation to verify that care pernicious effects for Black MSM, as linkage has actually occurred.115 A states with ADAP funding shortfalls recent HRSA-funded study involving are disproportionately found in the young MSM of color in eight sites South (six of 10 states) where epidemics

56 Back of the Line are heavily concentrated among Black MSM. Although some clients on the 2004 ADAP waiting list may be able to Candidates for vice obtain medicines from drug assistance president (Republican 2005 Dick Cheney and CDC reports that programs operated by pharmaceutical Democrat John Edwards) 46% of Black MSM companies, such a patchwork approach fumble when debate surveyed in five U.S. that requires patients to jump through moderator Gwin Ifill cities were HIV- asks them about AIDS positive multiple hoops to obtain essential in Black America drugs is inconsistent with a sound national effort to combat HIV/AIDS. However, ensuring a means of payment for medical services, while essential, will not be sufficient on its own to maximize service uptake. affect a patient’s ability to adhere A Vaccine and a Cure Policy reforms to expand health to prescribed regimens. Although A classic vaccine prevents coverage need to be coupled with ex- numerous studies have found peer- infection from ever taking hold. tensive investments in building the based and other approaches effective In the case of HIV, a preventive competence of health care providers in promoting treatment adherence123, vaccine would prevent an individual from becoming infected to effectively and sensitively address too few clinical settings prioritize such even after being exposed to the the needs of Black MSM.120 Typically, interventions or integrate peers as virus. Alternatively, some have cultural competency trainings in the part of multi-disciplinary care teams. suggested that a workable vaccine health field address racial, ethnic, or Targeted funding should be available might allow infection to occur language differences but often fail to to train and deploy a national network but would prevent the virus from progressing to active disease—a take account of homophobia, gender of Black MSM to provide peer-based somewhat less desirable result identity, or class-based biases. The adherence support and patient than achieved by a classic vaccine list of publications available through navigation services. but one that would nevertheless HRSA’s National Multicultural Center Engaging Black MSM in efforts have enormous public health is revealing; while guides are offered to promote treatment uptake is benefits. A cure would eradicate the for different racial or ethnic groups, no essential. Although extensive evidence virus from individuals who have single guide is available for LGBT care indicates that peer-driven treatment become infected. While current or specifically for Black MSM, the sole education and advocacy programs treatments dramatically slow the population in which new HIV infec- are highly effective in increasing rate of viral replication within the tions are significanty on the rise.121 treatment utilization and adherence124, body, they cannot reach certain reservoirs where viral replication Increasing the number of Black few such programs are based in continues. Although viral gay health care providers—or at minority communities and even fewer replication with treatment occurs the very least, the number of health specifically cater to Black MSM. at a much lower rate than without providers who leave medical, nursing, treatment, the fact that the virus and allied health schools having been hasn’t been eradicated means that the body will eventually trained in the delivery of culturally Dramatically Reduce STDs develop resistance to HIV drugs. competent care for Black MSM—is Among Black MSM To truly cure HIV and allow critically important to the long-term individuals to discontinue taking goal of maximizing the effectiveness of Untreated STDs increase the risk of antiretroviral drugs, it is believed biomedical HIV tools. The Affordable HIV acquisition by two to five times.125 that therapeutic options are needed to reach reservoirs that Care Act includes numerous provisions HIV-positive individuals who have an cannot be fully reached by existing and considerable new funding to train STD are also more likely to pass the medicines. and deploy primary care workers.122 virus to a sexual partner.126 Disappointing data regarding The background prevalence of other sub-optimal HIV adherence rates STDs is significantly higher among underscore the importance of an Black MSM, contributing to the spread open, trusting relationship between of HIV. According to surveillance HIV-positive Black MSM and their data, HIV-positive Black MSM were providers. To date, delivery of HIV more than four times more likely to care and treatment remains overly be diagnosed with an STD within one clinical in approach, failing to take year of testing HIV-positive than white account of the life issues that may MSM, while Black men overall were

Back of the Line 57 three times more likely than white men to have had an STD prior to their HIV diagnosis.127 According to surveillance 2005 data from 27 states, rates of syphilis Noah’s Arc, about 2006 four Black gay National Black Gay among Black MSM increased from friends, premiers Men’s Advocacy 2005 to 2008 at eight times the rate for on the Logo TV Coalition is formed white MSM.128 In New York City, Black network MSM are 495 times more likely than males generally—and 183 times more likely than other Black males—to be diagnosed with primary or secondary syphilis.129 Several steps are needed to lower Relationship Issues and HIV Risk Behavior STD rates among Black MSM.130 For Sexual HIV transmission is not a solitary act, but rather one that starters, health care providers must occurs through human relationships.1 Primary sex partners account for have a much higher index of suspi- more than two-thirds of incident HIV infections among MSM.2 cion when their male patients present Evidence indicates that many MSM are using various partnership with possible symptoms of an STD. In strategies in an effort to reduce their risk of contracting HIV. In particular, serosorting (or the selection of a partner with like HIV status) 2006-2007, a survey of Massachusetts has emerged as a common risk-reduction strategy for some MSM.3 Some MSM, 70% of whom had engaged in MSM also use seroadaptive behavior, also known as sexual positioning, unprotected receptive anal intercourse by engaging solely in insertive anal intercourse with unknown-status or and 50% of whom had been previously 4 HIV-positive partners. Men in long-term partnerships sometimes aim to diagnosed with an STD, found that “negotiate” safety by agreeing on collective risk-reduction strategies, although evidence suggests that some couples fail to adhere to agreed- while 98% had visited a health care on rules for negotiated safety.5 provider in the previous year, only 39% Whether as a result of skepticism regarding the safety of such had been screened for STDs.131 Physi- relational strategies or of less extensive understanding of the science of cians need to be comfortable soliciting HIV transmission, evidence suggests that Black MSM are less likely than and receiving information from their white MSM to use serosorting or sexual positioning as a risk-reduction strategy.6 patients regarding same-sex sexual Black MSM are 11 times more likely than other MSM to have sex with conduct. A clinician who undertakes a Black men.7 Although having sex with members of one’s own race or proper, comprehensive sexual history ethnicity is common, regardless of race/ethnicity or sexual orientation, of his or her patients should elicit any there is some evidence that racist attitudes within the broader gay information regarding anonymous community may actually increase the likelihood that Black men will choose other Black men as their sexual partners.8 Disturbingly, a recent sexual encounters. As many cases of survey found that a substantial share of Black MSM mistakenly believe STDs may be missed solely by exami- that having sex only with other Black men reduces their risk of becoming nation of the urethra, examining the infected, and these men were more likely to have undiagnosed HIV anus is especially critical. 8 infections. With gonococcal resistance on Notes the rise, proper treatment is essential, 1. Auerbach (2004), J Acquir Immune Defic Syndr 37:S122-S125. 2. Sullivan PS et al. (2009) AIDS 23:1153-1162. underscoring the need for clinicians 3. Bruce D et al (2012). AIDS Behav Feb. 15 (epub ahead of print). to be versed in state-of-the art 4. Wei C et al. (2011) AIDS Behav 15:22-29. 5. Davidovich U et al. (2000). AIDS 14:701-706. treatment of STDs. Where reasonable 6. Wei C et al. (2011); Eaton LA et al. (2010) Am J Pub Health 100:503-509. 7. Millett GA (2012) CROI Paper #1094. evidence exists that a patient may 8. Raymond & McFarland (2009). AIDS Behav 13:630-637. 9. Millett GA (2011) J Acquir Immune Defic Syndr 58:64-71. have an STD, clinicians should opt for presumptive treatment rather than waiting on laboratory confirmation. This approach is not only prudent from the standpoint of public health but also recognizes limitations of existing laboratory tests for MSM; the nucleic acid test is standard for confirmation of gonorrhea, although the FDA has not approved the NAT for anal or oral gonorrhea. Locating and treating partners of patients with

58 Back of the Line newly diagnosed STDs is vital in order Black MSM. The trial protocol is evidence indicates that Black MSM to prevent the STD from continuing to currently under development, with receive a share of prevention and circulate within sexual networks. expectations for enrolling 400-500 testing services that is sharply lower Community education plays a Black MSM. Operating under the than their proportion of new HIV central role in preventing STDs. assumption that ready access to infections. All agencies involved in Since the emergence of AIDS more essential services will be critical the fight against AIDS—CDC, HRSA, than three decades ago, community to Black MSM’s ability to benefit SAMHSA, state and local health concern about STDs has plummeted, from PrEP, the trial will assess the departments, and other stakeholders— with many MSM failing to recognize effectiveness of client-centered care need to ensure that limited prevention, the degree to which untreated STDs coordination in optimizing PrEP testing, linkage, treatment, and care increase the risk of HIV. In contrast outcomes for Black MSM. HPTN dollars are targeted to those with the to the 1970s and early 1980s, many 073 seeks to shed light on optimal greatest need. MSM today are wholly unaware of strategies to increase Black MSM’s As one sign of the lack of where to go for STD screening and acceptance uptake and adherence with accountability for ensuring that treatment. New initiatives are needed respect to PrEP. dollars go where they are most needed, to give MSM the facts about STDs Unfortunately, due to funding most HIV funders don’t even track and to drive home the importance of limitations, researchers have been the percentage of funds supporting prevention and treatment. forced to alter the trial design, services for Black MSM, in part reducing its scope. because they are not required to do PrEP currently resides in a common so as part of the implementation of Introduce Pre-Exposure “no man’s land” of newly validated the National HIV/AIDS Strategy, Prophylaxis health tools. While substantial which tracks allocations according to resources are often directed toward race/ethnicity, gender, and exposure PrEP offers a potentially powerful the evaluation of investigational new category. For example, in its fact new tool for individuals at substantial, health technologies, precious little sheets on CDC activities addressing ongoing risk for HIV, but much about funding is made available to learn Black MSM, the agency reports that this new strategy remains unknown. how best to use these tools in the real 44% of its prevention spending in Only about 50 Black MSM were en- world. With a potentially important Fiscal Year 2009 focused on MSM; rolled in the original iPrEX trial that new tool such as PrEP, federal agencies the fact sheet fails to note the racial found tenofovir-based oral PrEP to be responsible for health (including NIH or ethnic makeup of the MSM who effective in reducing the odds of HIV and CDC) must collaborate to develop received CDC prevention services that acquisition among MSM. The effects a well-funded, thoughtful plan to learn year, nor does it observe that MSM of long-term use of antiretrovirals as much as possible about PrEP roll- overall accounted for 64% of incident on HIV-negative MSM have not been out and program implementation. infections that year.134 All agencies determined, and there are concerns In light of the legacy of mistrust of involved in the HIV response—at that PrEP might increase the likeli- mainstream health systems in many federal, state, and local levels—need hood of drug resistance in men who Black communities, strong, consistent, to specifically track expenditures for seroconvert while using PrEP. It is also and respectful community engagement Black MSM to ensure that they receive unclear whether healthy, HIV-negative and leadership are essential to the their fair share of resources. men will carefully adhere to the daily success of HPTN 073 and to future In addition to correcting prophylactic regimen—an important uptake of PrEP.133 This is vital for all imbalances in the magnitude of consideration, given that the original Black MSM, but especially critical prevention services available to iPrEX study found that adherence for young Black MSM, who may be Black MSM, public health funders is critical to the protective effect of embarrassed to discuss HIV, know also need to take steps to sharpen prophylaxis. How best to deliver and little about the current state of HIV the content of prevention programs. pay for prophylaxis also remains un- research, and be concerned about In particular, prevention programs known, especially for vulnerable popu- issues of safety and side effects. targeting Black MSM need to correct lations such as young Black MSM.132 dangerous misperceptions (such These concerns and questions are not as the belief that having sex with insurmountable, but they must be an- Effectively Target Black MSM one’s own race or ethnicity protects swered expeditiously with the needs of with High-Impact Prevention against transmission—see text box). Black MSM foremost in mind. Prevention programs for Black MSM To obtain answers to these To maximize the impact of HIV should also emphasize the risks to questions, NIH is supporting HPTN prevention, services must be effectively young men of sex with older men. In 073, the first targeted PrEP trial for targeted. As previously noted, available Mississippi, young Black MSM who

Back of the Line 59 2008 2010 CDC estimates that HIV prevalence the number of new 2006 2009 among Black MSM infections among MSM CDC recommends 10,800 Black MSM found to be twice increased by about 50% routine HIV testing in are newly infected in as high as among from 1991 to 2006, with health care settings the U.S. white MSM in CDC- especially high rates sponsored 21- among young Black city survey MSM

Support from an Important report having older sex partners were administrative capacity, learn new Quarter found to be 5.5 times more likely to be skills, or undertake community Leaders at CDC are actively HIV-infected.135 education and outreach. urging the state and local health A central failing of current Among the indigenous Black departments that receive CDC prevention efforts for Black MSM is the gay organizations that currently ex- funding to increase their HIV prevention outlays for Black MSM. shortage of social marketing initiatives ist, many have been heavily oriented According to Dr. Kevin Fenton, to build awareness of prevention and toward delivery of CDC-certified Ef- director of the National Center treatment options and increase HIV fective Behavioral Interventions (also for HIV/AIDS, Viral Hepatitis, STD science and treatment literacy among known as DEBIs). Apart from the fact and TB Prevention, prevention Black MSM. This deficit is especially that few DEBIs have been specifically and research funding for Black MSM should at least be doubled. concerning in light of the growing developed for or validated for use with Fenton, who himself is a Black array of biomedical prevention tools. Black MSM, reliance on delivery of gay man, says homophobia plays Robust, targeted social marketing DEBIs serves as an exceedingly fragile a role in the under-prioritization campaigns should educate Black MSM reed on which to build a durable HIV of the HIV-related needs of Black that starting treatment as early as prevention infrastructure. With its MSM. “Our own stigma, our own homophobia, cascades down possible improves health outcomes, commitment to “High-Impact Pre- in our funding and allocations, that current therapies have few side vention,” CDC will be de-prioritizing intentionally or unintentionally effects, and that HIV can be treated DEBIs in the coming years, focusing resulting in underfunding of gay with a single pill a day. instead on prevention strategies that men’s work across the country,” offer a greater likelihood of success. Fenton told a community forum in Atlanta in March 2012.1 Yet relatively few AIDS Build Sustainable Community organizations in communities of Notes Infrastructure color—and even fewer Black gay 1. Bagby D (2012). GAVoice. Available at: http://www.thegavoice.com/news/national- organizations—have developed news/4374-cdc-leader-homophobia-impacts- funds-for-hiv-prevention. To be sustainable, the fight against extensive expertise in biomedical AIDS among Black MSM will demand prevention interventions or health a robust and effective community in- care delivery. Few, for example, have frastructure. Government alone is sim- strong working partnerships or formal ply incapable of reversing this health linkages with clinics, hospitals, or crisis and needs strong and reliable health centers. And few, if any, are community partners to be effective. prepared for the challenges and Unfortunately, the community opportunities potentially resulting infrastructure for Black MSM is from health care reform. weak and underdeveloped. Most of the organizations working to combat AIDS among Black MSM Develop New Prevention Tools are small and underfunded. While for Black MSM grant funds are often available to support implementation of specific At the same time that intensified programs, few funders provide efforts focus on bringing existing the general operating support that tools to scale, equally urgent attention small organizations need to build is needed to develop new prevention

60 Back of the Line tools to help Black MSM reduce Implement a National Plan to in New York City and Philadelphia, their risk of HIV transmission or Reduce the Vulnerability of recent experience of homophobia acquisition. With the goal of building Black MSM is associated with increased odds on earlier PrEP study results to achieve of engaging in unprotected anal even greater protection, researchers Gay and bisexual men of all races intercourse.151 are now testing other prophylactic and ethnicities experience numerous Although the confluence of regimens for use on their own or in health disparities, separate and apart economic, personal, and social combination with tenofovir.136 from the elevated rates of HIV.141 As disadvantages that disproportionately Another critical focus for one example, decades of research affect Black MSM presents a dense researchers is the development of have found that LGBT youth are at and complicated challenge, we are one or more safe and effective rectal heightened risk for suicide.42 not without tools with which to microbicides. These products are There is evidence that Black combat these ills. For example, legal gels or lubricants that can be used MSM suffer disproportionately reform to expand the rights and during anal intercourse to reduce the from economic hardship, social social acceptance of LGBT people risk of HIV or STD transmission. discrimination, and trauma. In one has been shown to have important A microbicide might arguably be study of HIV-positive MSM, Black health benefits. In the 12 months superior to PrEP, in that it could be MSM were found to be 80% more after approval of same-sex marriage used at the time of sex rather than on a likely than MSM generally to have in Massachusetts, for example, there daily basis. Moreover, a lubricant that experienced childhood sexual abuse.143 were significant declines in medical increases sexual pleasure might result Black MSM are more than twice as care visits, mental health care visits, in greater usage than a daily pill that likely as other MSM to be low-income and mental health costs among gay would need to be taken by a healthy, or to have been incarcerated in the and bisexual men compared to the HIV-negative peron. past year,144 and Black LGBT youth are 12 months prior to the change in Several rectal microbicide products more likely than white LGBT youth the law.152 A second study found are currently being evaluated in to attempt suicide.145 A startling 85% that state laws against hate crimes clinical studies—all but one of them of young MSM of color enrolled in a and employment discrimination on in early Phase I trials. The most five-year HRSA study reported having the basis of sexual orientation were advanced, which is expected to experienced bullying related to their associated with substantial declines begin Phase II testing in early 2013, sexuality, with 35% also reporting in psychiatric disorders, anxiety, and involves a reformulated version of a race-related bullying.146 In a study of post-traumatic stress disorder among tenofovir-based gel that was found to Black MSM in San Francisco, having LGBT people.153 be effective in reducing the risk of HIV HIV infection was significantly In addition, Black MSM need ready acquisition by women.137 The gel has associated with homelessness.147 access to services to mitigate the many been reformulated to reduce the risk of Studies demonstrate that multiple health challenges they confront. LGBT irritation. health and social challenges often people generally often have difficulty Ultimately, the development of a combine in synergistic ways to increase accessing appropriate, non-judgmental preventive vaccine will be needed to HIV risk and worsen health outcomes substance abuse and mental health bring the epidemic to a definitive end. for Black MSM.148 According to data services154, and Black MSM experience In 2009, for the first time, researchers from the Multicenter AIDS Cohort additional obstacles due to poverty reported that an experimental vaccine Study, a substantial share of HIV- and racism. Through the Ryan White offered partial protection against positive Black MSM study participants program, HRSA provides financial infection.138 Follow-up efforts aim suffer from multiple health problems, support for substance abuse, mental to build on this promising sign to such as depression, stress, substance health, and other supportive services improve the strength and durability of abuse, intimate partner violence, and for people living with HIV, but the protection against HIV infection.139 sexual compulsiveness. Significantly, agency does not track the degree to For those living with HIV, the Holy the study found strong relationships which these Ryan White programs Grail is a cure for the disease. NIH has between these conditions, with reach MSM of color. identified research toward a cure as independent evidence of individual one of its top priorities and is currently health problems strongly predicting pursuing a range of related research other health problems.149 Evidence efforts, including studies designed to suggests that many of these health shed light on strategies to eradicate and social problems either stem from, HIV from reservoirs within the body or are exacerbated by, internalized that current therapies are unable to homophobia.150 According to a recent reach.140 study involving 1,154 Black MSM

Back of the Line 61 Profiles 13 Gone Too Soon

Sylvester earned him a gold LP and two number one hits. Sylvester learned to sing in church. One of his number one hits, At the Palm Church of God and “You Make Me Feel (Mighty Real),” Christ in Los Angeles, Sylvester sang effectively became an anthem for Gay gospel, with a particular partiality to Liberation. an old standard performed by Aretha Sylvester was recording an album Franklin. According to an interview he in the mid-1980s when he was gave with the San Francisco Chronicle, diagnosed with AIDS. Although Sylvester was abused as a boy by an Sylvester was a star of the first order, evangelist at the church. his mounting medical bills threatened After singing gospel at conventions him with bankruptcy, prompting his across California, Sylvester began record company to release a “greatest performing with the Cockettes, a hits” collection to raise money. group of female impersonators. Their In 1988, Sylvester joined the People extravagant costumes and outlandish with AIDS group in the San Francisco performances garnered attention Gay Pride march, attending in a across the country. wheelchair. In illness, as in the rest Reggie Williams But it was disco that made Sylvester of his life, Sylvester was out loud and a star—one of the brightest stars in the proud. to combat racism within the gay firmament of popular music. Starting Sylvester died at age 42 on community. with his first solo album, Lights Out, December 1988 at his home in the Recognizing that HIV prevention which included the Pointer Sisters Castro district of San Francisco, his efforts were not reaching Black gay as backup singers, Sylvester released mother at his side. men, Reggie convened a meeting of the a series of blockbuster albums that AIDS Task Force of the local chapter of Black and White Men Together. Reggie Williams The work of that task force would eventually give rise to the National A child of Cincinnati, Reggie Williams Task Force on AIDS Prevention, which trained as an X-ray technician. Taking was founded in 1988 and played a the advice of the Village People to “go leading role in raising awareness of the west,” Reggie moved to Los Angeles to epidemic’s disproportionate burden work at Cedar-Sinai Hospital. While among Black gay men. at Cedar-Sinai, he began seeing cases As the head of the National Task of what was then called Gay-Related Force, Reggie became one of the most Immune Disease, or GRID. familiar faces and among the most Reggie moved to San Francisco at inspirational leaders of the early gay the time the epidemic was beginning response to AIDS. In 1989, Reggie led a to explode. He became executive protest in Washington D.C. to demand director of the AIDS program of more federal support for AIDS Sylvester National Association of Black and research and for nutrition, housing, White Men Together, which aimed and health care for people living with

62 Back of the Line HIV, many of whom had been made social justice and inclusion. After a “He was hardheaded until the very destitute as a result of their disease. special AIDS plenary session at the end,” Bellinger recalls with humor. “I Reggie demanded respect from American Public Health Association remember him smoking in his hospital those who ought to care—including annual meeting in Las Vegas in 1986 room! He would get excited about the broader Black community and the failed to include a single person of finding the right foundation to use to gay community. “My personal struggle color, Craig rushed the stage, took cover up his lesions.” with AIDS has forced me to demand the microphone away from then-San Craig Harris died in 1993 at the age respect and dignity from my people,” Francisco Health Commissioner of 34. he said. “Black gay men need to be able Merv Silverman, and announced to come home.” the formation of a new national In 1994, Reggie moved with his organization specifically dedicated to James Dorsey partner to Amsterdam. He died there addressing the HIV-related needs of of AIDS-related causes in 1999. people of color. James Dorsey was a teenager in 1986 People who were close to Craig when he traveled from his home in remember him as a devoted friend. Detroit to Kentucky to begin a new Craig Harris “He was gregarious, and he had life. James had just enrolled in the this ability to talk to people easily,” U.S. Job Corps, a vocational training Described by friends as a provocateur, recalls longtime AIDS activist George program for disadvantaged youth. Craig Harris combined his artistic Bellinger Jr., a close friend. “Men, The program—designed for people pursuits as a poet with an intense women, straight, gay. Craig was always between ages 15 and 21—takes commitment to activism. able to draw people to him. He did a young people away from their home After graduating from Vassar lot of multicultural stuff long before environment to provide intensive job College, Craig immediately threw people began talking about how training in secure residential settings. Unbeknownst to James, a routine medical exam upon his arrival at Craig Harris plants one the Kentucky Job Corps facility on Bert Hunter included an HIV test. Job Corps began mandatorily testing all program entrants in the 1980s under the Reagan administration and automatically ejecting those who tested HIV-positive. Having HIV-positive people living in dorms with uninfected Job Corp enrollees was simply too dangerous, the Reagan administration contended. James was told he was HIV-positive by a Job Corps staff member. Without receiving pre- or post-test counseling and without obtaining a medical referral, James was provided with one- way bus fare back to Detroit. James was devastated. Upon his return to Detroit, he fell into a deep depression. But then he got angry. And, finally, he decided to take action. himself into gay and AIDS activism. important it was.” He contacted the Lambda Legal He was former executive director of Craig suffered during his final Defense and Education Fund, which New York City’s Minority Task Force years. Still at work at GMHC, Craig brought a lawsuit against the Job Corps on AIDS, the first board chair of the navigated the agency’s staircases with in federal court in Washington. In National Minority AIDS Council difficulty. He continued to show up his lawsuit, James asserted that the (NMAC), and a staff member in the every day for work, but was aided federal government had violated his HIV prevention unit at Gay Men’s by his supervisor, Robert Penn, who constitutional rights. Health Crisis (GMHC). worked with Craig to incorporate When asked why he decided to file His role in the founding of NMAC flexible, shorter work hours. suit, James replied: “I thought about illustrates his fierce commitment to He also remained determined. Dr. King and everything he did for

Back of the Line 63 Black people. He stood up for our rights, and I thought I had no choice Marlon Riggs but to do the same.” As a result of the lawsuit, the Job Corps shelved its HIV policy in 1989. Thanks to James’ courage, HIV- positive young people have since had the right to obtain vocational training through the Job Corps. In the early 1990s, James died in Detroit.

Keith Cylar

Keith Cylar was full of anger and passion. But his friends—and the countless people he influenced—also remember his zest for life and his sense of humor. Keith lost his first lover to AIDS in 1988, the same year he graduated from Columbia University with a master’s degree in social work. He made his way to the activist group ACT UP, where he founded the group’s housing committee, which began protesting New York City’s failure to address the growing crisis of homelessness among people living with HIV. With his new life partner, Charles King, and AIDS attorney Virginia Shubert, Keith founded Housing Works. The organization was a new approach to AIDS services—one emphasizing housing as the linchpin of AIDS services and focused exclusively

on the most vulnerable, especially creation of tens of thousands of units those suffering from homelessness or of affordable housing for New Yorkers housing instability in the country’s living with HIV. From its outset, most precarious, congested, and Housing Works was deeply committed expensive housing market. to the empowerment of its clients, Together, Keith and Charles nur- involving them in all aspects of the tured Housing Works. Today, the or- agency’s operations. ganization is the largest AIDS service Keith died in 2004 at the age of 45 provider in New York City, with an an- of cardioarrythmia. nual budget exceeding $50 million. Housing Works was never your normal, staid AIDS service Marlon Riggs organization. Its militant tactics made enemies within the Giuliani Like many of his artistic and Keith Cylar administration, but they achieved intellectual peers in the Black gay extraordinary results, leading to the literary renaissance, Marlon Riggs

64 Back of the Line coupled his aesthetic innovation with advertisement during the 1988 courageous activism. election. And he also became a leading Born to a civilian military family activist in favor of the independence of in Texas, Marlon moved a lot in his public television. youth. While in junior high school in Marlon worked on his last film, Georgia, he felt “caught between these Black Is . . . Black Ain’t, even as his two worlds where the whites hated me body was rapidly deteriorating due to and the blacks disparaged me.” the effects of HIV. He died in 1994 at Graduating magna cum laude with age 37, leaving an extraordinary body an interest in history from Harvard of work as well as a host of questions University, Marlon focused his about what was lost—to Black gay men, intellectual pursuits on the history of and to the world at large—by the fact racism and homophobia. Ultimately, that such a brilliant life was cut so he made his way to film as his primary short. mode of expression. His films touched on a range of topics, including the penetration of racial stereotypes in Essex Hemphill American culture and the historic depiction of Black people on prime- Essex Hemphill was a leading poet, time television. essayist, and thinker in the Black gay His artistic courage inserted him renaissance of the 1980s and 1990s. Essex Hemphill into America’s culture wars. His But the nature and subject matter of second major film, Tongues Untied, his poetry—confronting profound role of family in the lives of Black gay created a firestorm of protest from homophobia and racism, and written men, the objectification of Black men the radical right when it appears on in an age when thousands upon in broader society, and the impact of the PBS series P.O.V. The film was a thousands of Black gay lives were being AIDS. personal and ferocious exploration cut short by AIDS—also made him a Essex achieved national attention of life as a Black gay man. Because profoundly influential activist. when his work was included in In Marlon had received $5,000 in support Born in Chicago, Essex was raised the Life, a breakthrough collection from a regional arm of the National in Southeast Washington, D.C. He of writing by Black gay men. The Endowment for the Arts, the film was began writing poetry at age 16. documentary films Tongues Untied used by critics to demand de-funding His writing cut to the heart and and Looking for Langston brought of PBS and the NEA. gave voice to the anguish, anger, his work to an even broader audience. Marlon’s activism extended beyond and frustrations of many. As one Essex edited Brother to Brother: New AIDS and gay rights. He authored commentator wrote after his death, Writings by Black Gay Men. a fierce op-ed commentary in the Essex’s poetry concerned “black and This leading light of the remarkable New York Times excoriating former gay men, faced with the prospect of flowering of Black gay writing and President George H.W. Bush for his death, [who] managed to love and live thought died in 1995 of AIDS-related use of the infamous Willie Horton fiercely.” His poetry addressed the complications.

Back of the Line 65 66 Back of the Line Action Plan to End AIDS Among 14 Black MSM Priority Action Steps

Black MSM’s place in the line for HIV services and support must be commensurate with their share of the national epidemic. To effectively deploy the tools available to end AIDS among Black MSM, the Black AIDS Institute offers the following priority recommendations and urges their immediate adoption:

Develop a results-driven national plan to end AIDS among Black MSM

As one of its highest priorities, HHS of an A or B grade for risk-based HIV literacy; community education efforts should immediately spearhead an testing. to increase awareness of the availability inclusive process—involving relevant m A national effort to build robust, of well-tolerated, easy-to-take HIV federal agencies (e.g., CDC, HRSA, sustainable community capacity treatment regimens; peer-based patient CMS, Office of Minority Health, for Black MSM, with extensive support and navigation services in SAMHSA), Black MSM, Black and support for the establishment of a health care settings; and high-priority LGBT leaders, the philanthropic and national network of health centers efforts to roll out pre-exposure private sectors, and state and local specifically designed by Black MSM; prophylaxis among Black MSM. health departments—to develop a community skills-building, general m A nationwide campaign to dra- clear, results-driven national plan to operating support, and organizational matically reduce STDs among Black end the epidemic among Black MSM. development for Black MSM MSM, including intensive, targeted The plan should specifically identify community organizations; and the community awareness campaigns, as roles and responsibilities of all actors, establishment of durable linkages with well as provider education regarding specify timelines for results, and MSM-friendly health care settings. the conduct of patient sexual histories, set forth transparent accountability m Intensified implementation signs and symptoms of STDs among mechanisms and periodic reporting of research and support for adoption of MSM, proper treatment of STDs, and progress. The key aim of the national best practices to ensure timely health prompt partner-notification activities. plan should be to dramatically lower care linkage and retention for Black m Ensuring that HIV prevention community viral load among Black MSM. programs for Black MSM address MSM and thereby reduce the rate of m Ensure Black MSM’s ready ac- misconceptions about HIV new infections. This plan needs to cess to affordable, high-quality, cul- transmission and increase awareness include the following elements: turally appropriate health and social of risks to young men from having sex m A prioritized effort to ensure services, through full implementation with older men. universal knowledge of HIV serostatus of the Affordable Care Act, as well as m Elimination of funding dis- among Black MSM, including support prioritized cultural competence train- parities in HIV prevention, treatment, for diverse, scaled-up testing strategies; ing for health care workers to increase care, and research that disadvantage intensified professional education for their ability to provide appropriate Black MSM, including requiring all health care and community-based care and treatment to Black MSM. federal funders to track the share of re- personnel; targeted, state-of-the-art m Support for initiatives to sources dedicated to Black MSM. social marketing to position knowledge increase Black MSM’s demand for m Concrete steps to ensure of HIV serostatus as a fundamental health services, including strong Black MSM’s full and equal access social norm; and assignment by the financing for targeted programs to to appropriate and affordable mental U.S. Preventive Services Task Force build HIV science and treatment health and substance abuse services.

Back of the Line 67 2010 2010 2010 Multi-country study President Obama of MSM finds that pre- unveils first National MSM account for exposure antiretroviral HIV/AIDS Strategy, 70% of all new HIV prophylaxis reduces which calls for urgent diagnoses among the odds of HIV action to address Black males transmission by HIV/AIDS among 44% MSM

Exert genuine, sustained leadership in the fight against AIDS among Black MSM

Diverse non-governmental actors must Black MSM to leadership positions for efforts to end AIDS among recognize both that AIDS remains a within their respective agencies. Black MSM. Similarly, the private severe and worsening crisis among m The Congressional Black sector—especially the pharmaceutical Black MSM and that government alone Caucus should work to ensure that industry and companies that serve cannot turn the tide against AIDS. Black MSM receive their fair share of Black communities—must increase m Leading advocacy, civic, HIV prevention, treatment, and care philanthropic outlays to support and service organizations within funding through the Minority AIDS HIV-related programs and build the respective LGBT and Black Initiative. community capacity for Black MSM. communities—at national, state, and m Philanthropic organizations— Philanthropic and corporate funders local levels—should immediately including those that focus on AIDS should prioritize general operating commit to hire a senior focal point issues, Black communities, and support for Black MSM organizations, to oversee work to support a sound the LGBT community, as well as as well as innovative program models and effective AIDS response for Black those that serve specific states or for health care demand creation, HIV MSM. These same organizations must localities—should immediately pledge science and treatment literacy, and pledge to take specific steps to promote to substantially increase resources peer navigation.

Combat homophobia and other social challenges faced by Black MSM

Governmental and non-governmental in the armed forces. Until such time as discrimination against LGBT people actors must join together with Black Congress takes these steps, all states and legal recognition of same-sex MSM to address the root causes of and municipalities must ensure that marriage. Black organizations should Black MSM’s vulnerability to HIV and strong, enforceable laws are in place to actively recruit and promote Black the factors that diminish health care prohibit discrimination on the basis MSM as leaders. Black organizations access. of sexual orientation and to recognize should also actively lead community m Congress should enact the same-sex relationships. dialogues on the harmful effects of Employment Non-Discrimination m Black organizations at the anti-gay prejudice and childhood Act, repeal the Defense of Marriage national, state, and local levels sexual abuse. Act, and ensure full and robust should follow the lead of the NAACP integration of LGBT service members and formally endorse both non-

68 Back of the Line Back of the Line 69 15 Notes

1. Lieb S et al. (2011). Statewide 14. Prejean et al. (2011). 27. Hall HI et al. (2012). Estimation of Racial/Ethnic Populations of 15. CDC (2011). HIV and AIDS 28. Hall HI et al. (2012). men Who Have Sex with Men in the U.S. Among Gay and Bisexual Men: CDC Fact 29. Stall R et al. (2009). Running in Public Health Reports 126:60-72. Sheet. Available at: http://www.cdc.gov/ Place: Implications of HIV Incidence 2. U.S. Census Bureau (2012). nchhstp/newsroom/docs/fastfacts-msm- Estimates Among Urban Men Who Have Population (Table 1). Available at: http:// final508comp.pdf (“CDC Gay/Bisexual Sex with Men in the United States and www.census.gov/prod/2011pubs/12statab/ Fact Sheet”). Other Industrialized Countries. AIDS pop.pdf. 16. Pathela P et al. (2011). Men Who Behav 13:615-629. 3. Prejean J et al. (2011). Estimated HIV Have Sex With Men Have a 140-Fold 30. U.S. Census Bureau (1980). Incidence in the United States, 2006-2009. Higher Risk for Newly Diagnosed HIV and Population. Available at: http://www2. PLoS ONE 6:e17502. Syphilis Compared with Heterosexual Men census.gov/prod2/decennial/documents/19 4. Hall HI et al. (2007). Racial/Ethnic in New York City. J Acquir Immune Defic 80/1980censusofpopu8011u_bw.pdf. and Age Disparities in HIV Prevalence Syndr 58:408-416. 31. CDC (1985). Update: Acquired and Disease Progression Among Men Who 17. CDC (2005). HIV Prevalence, Immunodeficiency Syndrome—United Have Sex With Men in the United States. Unrecognized Infection, and HiV Testing States. MMWR 34:245-248. Am J Pub Health 97:1060-1066. Among Men Who Have Sex with Men— 32. Bakeman R et al. (1986). AIDS 5. Lieb S et al. (2010). Estimated HIV Five U.S. Cities, June 2004—April 2005. risk—group profiles in whites and Incidence, Prevalence, and Mortality Rates MMWR 54:597-601 (“CDC Five-City members of minority groups. New Eng J Among Racial/Ethnic Populations of Men Survey”). Med 315:191-192. Who Have Sex With Men, Florida. J Acquir 18. Schwarcz S et al. (2007). Prevalence 33. Samuel M, Winkelstein W (1987). Immune Defic Syndr 54:398-405. of HIV Infection and Predictors of High- Prevalence of human immunodeficiency 6. Mead H et al. (2007). Racial and Transmission Sexual Risk Behaviors virus infection in ethnic minority Ethnic Disparities in U.S. Health Care: A Among Men Who Have Sex With Men. homosexual/bisexual men. JAMA Chartbook. New York: Commonwealth Am J Pub Health 97:1067-1075. 257:1901-1902. Foundation. Available at: http://www.com- 19. Koblin BA et al. (2000). HIV 34. Wooten D (1989). Statistics Paint monwealthfund.org/~/media/Files/Publi- prevalence of HIV infection among young Grim Picture for Future of AIDS Cases cations/Chartbook/2008/Mar/Racial%20 men who have sex with men in New York Among African Americans in California. and%20Ethnic%20Disparities%20in%20 City. AIDS 14:1793-1800. BLK No. 5. U%20S%20%20Health%20Care%20%20 20. CDC (2010). Prevalence and 35. Lemp GF et al. (1994). A%20Chartbook/Mead_racialethnicdis- Awareness of HIV Infection Among Men Seroprevalence and HIV Risk Behaviors parities_chartbook_1111%20pdf.pdf. Who Have Sex With Men—21 Cities, Among Young Homosexual and Bisexual 7. Institute of Medicine (2003). Unequal United States, 2008. MMWR 59:1201-1207 Men: The San Francisco/Berkeley Young Treatment: Confronting Racial and Ethnic (“CDC 21-City Survey”). Men’s Survey. JAMA 272:449-454. Disparities in Health Care (Smedley BD 21. CDC (2009). HIV Infection Among 36. Valleroy LA et al. (2000). HIV et al., eds). Washington DC: National Young Black Men Who Have Sex With Prevalence and Associated Risks in Young Academies Press. Men—Jackson, Mississippi, 2006-2008. Men Who Have Sex With Men. JAMA 8. U.S. Census Bureau (2011). The MMWR 284:198-204. Black Population: 2010. Available at: http:// 22. Prejean et al. (2011). 37. CDC Five-City Survey (2005). www.census.gov/prod/cen2010/briefs/ 23. Prejean et al. (2011). 38. White House (2010). National c2010br-06.pdf. 24. CDC Gay/Bisexual Fact Sheet HIV/AIDS Strategy for the United States. 9. Lieb S et al. (2011). (2011). Available at: http://www.whitehouse.gov/ 10. CDC (2012). HIV Surveillance 25. CDC (2008). Subpopulation sites/default/files/uploads/NHAS.pdf. Report. Vol. 22. (“CDC 2010 Surveillance Estimates from the HIV Incidence 39. Millett G et al. (2005). Focusing Report”) Surveillance Systems—United States, 2006. “Down Low”: Bisexual Black Men, HIV 11. CDC 2012 Surveillance Report. MMWR 57:985-989. Risk and Heterosexual Transmission. J 12. CDC 2012 Surveillance Report. 26. Hall HI et al. (2012). Trends in Nat’l Med Assoc 97:52S-59S. 13. CDC (2011). HIV Surveillance— HIV Diagnoses and Testing Among U.S. 40. Prejean et al. (2011). United States, 1981-2008. MMWR 60:689- Adolescents and Young Adults. AIDS 41. CDC (2011). Funding Allocations 693. Behav 16:36-43. Distributed Under Program Announcement

70 Back of the Line (PA) 04012 by State and Local Health Risk for HIV Infection of Black Men Who Departments in 2008 and 2009 for CDC- Have Sex With Men: A Critical Literature Supported HIV Prevention Projects (“CDC Review. Am J Pub Health 96:1007-1019. Funding Analysis”). 57. Koblin BA et al. (2006). Risk factors 42. CDC Funding Analysis (2011). for HIV infection among men who have 43. Wilson PA, Moore TE (2009). sex with men. AIDS 20:731-739. Public Health Responses to the HIV 58. Millett GA et al. (2007). Explaining Epidemic Among Black Men Who Have Disparities in HIV Infection Among Black Sex With Men: A Qualitative Study of US and White Men Who Have Sex with Men: Health Departments and Communities. A Meta-Analysis of HIV Risk Behaviors. Am J Pub Health 99:1013-1022. AIDS 21:2083-2091. 44. Gasiorowicz M, Stodola J (2011). 59. CDC (2011). HIV Risk, Prevention HIV Prevalence Estimates and Alignment and Testing Behaviors Among Men Among Recent Diagnoses, Targeted Tests, Who Have Sex With Men—National and Prevention Services by Demographic HIV Behavioral Surveillance System, 21 and Racial/Ethnic Group in Wisconsin. U.S. Cities, United States, 2008. MMWR Whatever Happened to the AIDS Ed Prev 22(supp.):7-16. 60:SS12):1-34 (“CDC Extended 21-City 45 Report”). “Down Low” Phenomenon? 46. New York City Department of 60. Millett GA et al. (2012). A In 2004, the media became Health and Mental Hygiene (2011). New Meta-analysis of HIV Infection fixated on “men on the down York City HIV/AIDS Annual Statistics. Racial Disparities Among MSM: US. low”—a phrase meant to refer Available at: http://www.nyc.gov/html/ 19th Conference on Retroviruses and to non-gay-identified MSM who doh/downloads/pdf/ah/surveillance2010- Opportunistic Infections. Seattle,March kept their sex with other men a tables-all.pdf. 5-8. Paper #1094. secret. Major newspapers—such 47. Public Health Solutions (2011). 61. Millett GA et al. (2007). as the Los Angeles Times and the NYC Ryan White Part A Service Category Circumcision Status and HIV Infection New York Times—featured the Scorecards 2008-2010. Available at: Among Black and Latino Men Who Have phenomenon, and Oprah Winfrey http://www.healthsolutions.org/ Sexc With Men in 3 US Cities. J Acquir devoted a segment of her widely hivcare/documents/RW%20Service%20 Immune Defic Syndr 46:643-650. viewed talk show to the “DL Category%20Reportcard%202008- 62. Millett GA et al. (2007). issue.” It was suggested that the 2010%209-9-2011.pdf. 63. Millett GA et al. (2012). high rates of HIV infection among 48. Peterson JL, Jones KT (2009). HIV 64. Millett GA et al. (2006). Greater Black women might be explained, Prevention for Black Men Who Have Sex Risk for HIV Infection of Black Men Who in part, by large numbers of With Men in the Untied States. Am J Pub Have Sex With Men: A Critical Literature surreptitiously bisexual Black men Health 99:976-980. Review. Am J Pub Health 96:1007-1019. who were becoming infected 49. Johnson WD et al. (2005). HIV 65. Millett GA et al. (2012). during sex with other men and prevention research for men who have sex 66. Millett GA et al. (2012). then passing the virus to their with men: a seven-year update. AIDS Educ 67. Millett GA et al. (2012). female partners. Prev 17:568-589. 68. Fields SD et al. (2008). Childhood The phenomenon was titillating 50. Ginther DK et al. (2011). Race, Sexual Abuse in Black Men who have Sex and made for great newspaper Ethnicity and NIH Research Awards. with Men: Results from three Qualitative copy and sensational TV viewing. Science 33:1015-1019. Studies. Cultural Diversity & Ethnic The only problem is that there 51. Bardo S (2012). Shame = Death: Minority Psychology, 14 (4), 385-390. didn’t seem to be a lot of evidence HIV/AIDS Complacency in the Gay 69. Cohen MS et al (2011). Prevention to support the media hysteria. Community. Huffington Post. Available of HIV-1 Infection with Early While there are certainly Black at: http://www.huffingtonpost.com/ Antiretroviral Therapy. New Eng J Med MSM who also have sex with sal-bardo/hiv-aids-complacency-gay- 365:493-505. women—as there are in other community_b_1367583.html. 70. Quinn TC et al. (2000). Viral load racial or ethnic groups—extensive 52. Human Rights Campaign (2012). and heterosexual transmission of human research has failed to detect any connection between DL Growing Up LGBT in America: HRC Youth immunodeficiency virus type I. Rakai identification and unprotected Survey Report, Key Findings. Project Study Group. New Eng J Med anal or vaginal sex.1 53. Funders Concerned About AIDS 342:921-929. (2011). U.S. Support to Address HIV/AIDS 71. Fauci AS (2011). AIDS: Let Science Notes in 2010. Inform Policy. Science 333:13. 1. (Bond L et al. (2009) Am J Pub Health 54. Xu F et al. (2007). 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Back of the Line 71 2011 2011 Major study finds 2012 CDC reports that that antiretroviral President Obama new HIV infections treatment reduces and the NAACP among Black MSM the risk of HIV endorse same-sex rose by 48% from transmission among marriage 2006 to 2009 serodiscordant couples by 96%

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Back of the Line 73 16 About

Black AIDS Institute Black Gay Research Group National Black Gay Men’s www.blackaids.org www.thebgrg.org Advocacy Coalition www.nbgmac.org

The Black AIDS Institute, founded The Black Gay Research Group The National Black Gay Men’s in 1999, is the only national HIV/ (BGRG) is a diverse group of Black Advocacy Coalition (NBGMAC) is AIDS think tank in the United States gay men committed to creating a committed to improving the health and focused exclusively on Black people. platform for presenting, discussing, well-being of Black gay men through The Institute’s mission is to stop the and analyzing scholarly work being advocacy that is focused on research, AIDS pandemic in Black communities produced by and on Black gay men. policy, education and training. by engaging and mobilizing Black Inaugurated in the spring of 2001, the NBGMAC was founded in April leaders, institutions, and individuals BGRG has evolved from an informal 2006 following months of strategic in efforts to confront HIV. The discussion group to a structured organizing by Black gay activists Institute interprets and makes group of professional Black gay men concerned about the lack of response recommendations on public and who have accomplished a number of to data showing the disproportionate private sector HIV policies, conducts objectives: It hosted four Black Gay burden of HIV on Black gay men. trainings, builds capacity, disseminates Research Summits (2003, 2005, 2010, NBGMAC is principally a policy information, and provides advocacy and 2012); conceptualized a Black gay driven coalition of organizations and and mobilization from a uniquely and research think tank; and developed a members are committed to saving the unapologetically Black point of view. national Black gay research agenda. lives of Black Men.

BGRGThe Black Gay Research Group

74 Back of the Line Back of the Line 75 For more information or more copies of this report, contact: Black AIDS Institute 1833 West Eighth Street #200 Los Angeles, California 90057-4257 213-353-3610 n 213-989-0181 fax n [email protected]­ www.blackaids.org www.thebgrg.org www.nbgmac.org

BGRGThe Black Gay Research Group

76 Back of the Line