Two steps forward, one step back fighting HIV in Chicago

Last week, one of my twitter followers called me to task for writing an entire column on HIV and AIDS without focusing on the huge disparities by race/ethnicity. She was certainly correct about the critical role of such disparities. Yesterday–again on twitter–Chicago commissioner of public health Bechara Choucair drew my attention to an especially pertinent report on such matters.

Little by little, Chicago is making progress in addressing rising HIV incidence, non-diagnosis, and late treatment among young men who have sex with men. Thing’s aren’t great, or even remotely acceptable. Epidemiological data from the Chicago component of the National HIV Behavioral Surveillance (NHBS) System indicate that HIV prevalence among men who have sex with men (MSM) continues to rise. At least a higher proportion of men know their status and are getting treatment.

In 2008, 67% of surveyed (and tested) Black MSM found to be HIV-positive were not aware of their infection. By 2011, only 33% were similarly unaware. These numbers remain far too high. (The comparable figures among non-Hispanic White MSM were 23% and 9% in the same years.) Yet awareness is moving in the right direction. MSM who tested positive in 2011 were also more likely to be receiving appropriate medications than was found in 2008. Among African-Americans, the percentage of HIV-positive MSM reporting being on HIV medications increased from 44 to 84 percent. Among HIV-positive Hispanic MSM, there was a similarly large increase from 50 to 82 percent. (Again–among surveyed non-Hispanic white MSM, the comparable figures were, um, 90 and 100 percent.) These data are hardly airtight; epidemiological data concerning stigmatized behaviors seldom are. The basic story here seems consistent with other sources.

If you are still wondering why there is such urgency concerning African-American MSM, read the accompanying report. In particular, compare the top two lines from Figure 2 (below the fold). Both the level and the disparity remain really concerning. So any sign of progress is especially heartening.

msm_fig2a

Author: Harold Pollack

Harold Pollack is Helen Ross Professor of Social Service Administration at the University of Chicago. He has served on three expert committees of the National Academies of Science. His recent research appears in such journals as Addiction, Journal of the American Medical Association, and American Journal of Public Health. He writes regularly on HIV prevention, crime and drug policy, health reform, and disability policy for American Prospect, tnr.com, and other news outlets. His essay, "Lessons from an Emergency Room Nightmare" was selected for the collection The Best American Medical Writing, 2009. He recently participated, with zero critical acclaim, in the University of Chicago's annual Latke-Hamentaschen debate.

13 thoughts on “Two steps forward, one step back fighting HIV in Chicago”

  1. Among MSM, we see the same familier and depressing ethnic breakdown in HIV infection rate that we see in nearly every social, economic, and physiological statistic: blacks doing the worst, followed by Hispanics, then whites, with Asians doing the best.

    I know the primary reasons why, namely racial differences in intelligence and impulsiveness, but they are depressing so I avoid the topic professionally.

    The authors here are not anonymous, so they are faced with the choice of saying something either true but extremely unpopular, or else engaging in the degrading act of knowingly lying and blaming all the troubles of blacks and Hispanics on white racism, which is the *only* socially acceptable explanation in the polite liberal circles they frequent.

    Thus I do not blame Pollack in the slightest for avoiding the issue initially, then just posting the bare statistics.

    Ironically, I think the drop-off in attention paid to HIV, though not the differential infection rates themselves, can be properly blamed in part on racism. Knowledge of safe sex practices has advanced to the point that middle and upper class white gay men now have other higher political priorities, while HIV continues to infect and kill black gay men at startlingly high rates, with the public increasingly indifferent even as they get warmer each year towards white middle class “model gays,” whom a majority now would permit to marry.

  2. I find this to be such a sadly misguided comment. Given race-ethnic differences in baseline HIV prevalence, the same risk-behaviors among young MSM would yield starkly different rates of new infections. I think anyone who has spent time with young people at risk–in Chicago or elsewhere–would strongly disagree with Igloo’s comment.

    Right outside my office door, one can see poverty, homeless, disparate access to medical and public health services, community rejection of same-sex relationships within many minority communities. All of these issues contribute to the disparities we see. There’s plenty of stupid and impulsive behavior to go around in most sexually active populations of human beings. Even White males have been known to run into trouble on occasion. We’re kindof designed that way.

  3. Harold, I agree that the factors you mentioned are also causes of the disparities, though as I noted the pressures of polite company mean you cannot make the same concession and acknowledge the genetic component I suggested.

    Further, the poverty and lack of access to health care you mention are themselves linked to the genetic differences between these groups. The large Chinese community in America is in many ways disadvantaged relative to native white Americans, but suffers from health and social dysfunction at much lower rates. It doesn’t hurt my feelings to admit this group is smarter and less impulsive on average than my own, but modern America doesn’t trust other groups to have the same detached and inquisitive reaction to frank discussions of their shortcomings.

  4. At least Igloo, by his own account, thinks Asians are superior in “intelligence and impulsiveness”, followed by Hispanics, then whites, so he’s not a standard-issue “person of bias”, since we’re trying to be polite here. His final paragraph is plausible.

    Some items in the linked report: “The overall HIV prevalence among White MSM under 40 nearly doubled from 7.8% to 14.6% between the two data collection cycles (p.05) …. White MSM reported more male sex partners in the past year (median:4) in 2011 than Black and Hispanic MSM (median: 3)”
    so the supposed differential black carelessness is very patchy.

  5. Let’s get a few things straight:

    (1) Intelligence tests are culturally biased, and generally are biased in favor of the majority cultural group.
    (2) Even with these biased tests, differences in measured intelligence across cultural groups reveal small differences in the population means.

    Attributing the differential infection rates to differences in intelligence is foolish and irresponsible. Differences in education and outreach in the subpopulations alone can explain the differences.

    The bottom line is appalling. We cannot expect to control an epidemic in a situation where so many people are unaware of ways to avoid infection and unaware of their own infection status.

  6. As an advocate for HIV/AIDS prevention, treatment and research in my professional life, igloo’s comment is profoundly depressing (and outrageous). The primary factors in these (and many other health disparities in the African American community are largely linked to the network of sexual partners within the African American community (e.g. Men and women generally have a smaller population in which they mix with a larger proportion of disease – potential partners are more likely to have HIV), less access to treatment and to some extent greater stigmatization that leads to less discussion of the issue. In general African American MSM actually have fewer partners than whites and actually engage in less risky behavior but are still more at risk than whites. This is well documented. One result of the lack of access to prevention and treatment services is that African Americans often are not tested and brought into care until late in their infection which also results in poor treatment outcomes. It also means that there is a longer period of time during which an individual may pass the infection to others. It’s a really vicious cycle and has nothing to do with intelligence or motivation or anything other than the mathematics of a spreading epidemic. I am hopeful that efforts to highlight the risk coupled with better access from implementation of health care reform will start to bring infection rates down in the community. So I’m sorry igloo but this is sheer ignorance on your part. I urge you to read the national HIV/AIDS strategy as a very early document to get educated on this topic.

    1. odd – I came up yesterday as capdcne instead of caphilldcne. anyway I wasn’t able to provide a link to information yesterday since I was commenting from a cellphone but the best (and most recent) study on this topic is HPTN 061 (specific to Black MSM so not necessarily correlatable to African American women but suggestive) released at this summer’s international AIDS Conference in Washington DC. Here is a link to the study: http://www.hptn.org/research_studies/HPTN061Results.asp. The one issue not specifically mentioned by the study is the issue of networking but Dr. Mermin’s comments (from the CDC) in the linked Washington Post article, touch on that particular issue. The issue of health care disparities among minorities in general and specifically related to HIV is a very serious issue and I’m really glad that this created a space to discuss it. Incidentally this epidemic has always had an African American component – at least one of the four cases described in the original MMWR first identifying symptoms of what eventually came to be called “HIV” was a gay African American man – already 25% of the cohort.

  7. For years, HIV advocates feared, with very good reason, that if AIDS every became a gay/Black/Haitian immigrant disease in the public’s eyes sympathy and funding would wane. One of the big AIDS/HIV decisions the Obama Administration made was to be more explicit in both description and funding regarding the fact that this is an epidemic that is concentrated in a few populations, not something that everyone is truly at great risk from. Our judgement was that the country had grown up enough to understand that fact yet continue to be compassionate toward their fellow beings. Despite what Igloo said, I think this was the correct assessment of American character.

      1. Well stated. In my travels around the UK this year to talk about addiction, I have noted repeatedly that the Duchess of Cambridge’s willingness to publicaly associate herself with people who have drug/alcohol problems is very much in the fine model Princess Diana followed with PWAs.

        1. Many people really stood up (and still are) and in general the international community has created strong efforts through the global fund (of which the U.S. is the largest contributor. Still not enough. Alas, the U.S.’s initial response was to try to sweep the disease under the rug due to its association with gay men. Comparison point – the all out effort to isolate and end Legionnaire’s Disease which emerged only a few years earlier than HIV vs. the very slow efforts to contain HIV. Interestingly I think we currently have the capability to reverse the course of the epidemic with the current prevention and treatment knowledge we have. Sadly I’m not at all sure we have the will to do so.

          1. In fairness, while there was resistance near the top of NIH, the people working on the disease directly did not stall the work. Also, a large factor in our inability to contain the virus came from the blood banks and the blood products industry. They were loathe to lose a subpopulation of reliable donors. When shown that Hep-B core antibody tests were a good proxy for high risk donors, they demurred from the added testing.

            Additionally, it was possible to reduce the risk of Legionella with some fairly simple changes in sanitation and air-handling practices. Reducing HIV risk is much more difficult, as you are aware.

  8. replying to Dennis:

    Good point. Certainly many of the folks at the CDC and even (after some strong prodding) NIH responded with appropriate vigor (and eventually the Surgeon General, C. Everett Koop) but top elected officials including Reagan directly impacted the response for the worse.

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