# Tarheel Health Portal/HIV/AIDS in African American MSM

Since its introduction to the West, HIV/AIDS has affected men who have sex with men (MSM) at greater rates than straight or heterosexual people. In recent years in the United States, HIV/AIDS has disproportionately affected men who have sex with men, especially African Americans. According to the CDC, In 2013 African American gay and bisexual men accounted for 39% of new infections, almost as many new HIV infections as white gay and bisexual men, despite the differences in population size of African Americans compared to whites. Increased risk is due to a combination of social and economic economic factors prohibiting access to healthcare, greater likelihood of being exposed to HIV, stigma, lack of awareness, and smaller sexual networks. Without the expansion of healthcare policies such as Medicaid, HIV-positive African-American MSM will lack access to care and the virus will continue to spread within this at-risk group, thus decreasing the effectiveness of education initiatives and prevention campaigns.

## History

While HIV/AIDS originated in Africa, its rampant spread in United States in the early 1980s first pushed the disease into the limelight. Gay men have been heavily impacted by HIV/AIDS since the beginning of the epidemic, with the virus first spreading like rapid-fire in the gay communities of San Francisco and New York. In 1983, 71 percent of the 3,064 reported AIDS cases were among gay and bisexual men. Due to prevalent prejudice surrounding the MSM communities, the HIV virus was widely politicized and feared. Even today, people infected with HIV are subjected to stigma from their communities. The virus often heavily affects communities of already highly marginalized populations often perceived as guilty of unnatural behavior. This stigma has impeded progress in health outcomes of MSM as well as healthcare and health insurance policies that would widely benefit those infected.

## Prevention Challenges

There are many challenges to preventing the spread of HIV/AIDS, and these challenges are only exacerbated by the history and current challenges facing the African-American MSM community.

### Sexual Networks

* There is already a relatively large percentage of HIV-infected men in the African-American MSM sexual networks, therefore increasing the rate of HIV transmission per sexual encounter.
* There is a higher rate of transmission of HIV with for anal sex.
* African-American MSM are likely to have more than one sexual partner, therefore increasing likelihood of transmission as well as facilitating the spread of the virus—with each sexual encounter, one takes on the risks of one's partner's sexual networks.
* Young African-American MSM are likely to have older sexual partners, who have likely had more sexual encounters and therefore are more likely to have contracted the virus.

### Lack of Education and Openness

* Homophobia, stigma, and discrimination increase the barriers to care.
* Many African-American communities are centered around the church. Many churches see homosexuality as a sin, therefore forcing MSM to be secretive about their sexual preferences, as well as discourages open dialogue about HIV-testing and safe sex.
* In order for prevention and HIV-education campaigns to be tailored to MSM, men must feel comfortable with acknowledging their homosexuality and subsequent risk for HIV.

### Testing

* African Americans are most likely to be unaware of their HIV-postive status.
* 20 percent of African American people living with HIV are still unaware of their status, and therefore cannot obtain treatment and take precautions to prevent the virus from spreading.
* Many African Americans live in rural areas, decreasing access to affordable testing and specialized clinics.
* Many African Americans, especially those in rural areas, are diagnosed late, increasing the risk of transmission.
* Due to stigma around HIV and homosexuality especially in rural, church-centric communities, many men will not seek out testing.
* Financial circumstances and a lack of health insurance can prevent African American MSM from seeking out testing.

### Adherence

* Once prescribed antiretroviral therapy (ART) treatment, less than 30 percent of African Americans living with HIV adhere to it, compared to 40 percent of people of other races. This may be due to a lack of financial resources, health insurance, personal reasons, or inconvenience.

## Important Policies

Health policy is especially important to improving the health outcomes of HIV-positive African-American MSM due to the stigma and lack of access to care that many infected people often face in their communities. When a disease targets certain populations and communities, it increases the likelihood of it spreading, as diseases spread more easily within close-knit communities, such as those of African-American MSM. Within communities with limited access to culturally competent health care providers, and convenient clinic locations, health insurance could prove instrumental in keeping them in care. Before real progress can be made in the United States, programs must be made available so that lower-income HIV-positive people living in America can have access to care. Unfortunately, political conflict often inhibits this sort of progress, as exemplified by the discord surrounding the Affordable Care Act.

### The Affordable Care Act

The Affordable Care Act has the potential to greatly affect health outcomes of HIV-positive African American MSM. Currently, one in three HIV positive people lack health insurance. Without health insurance, a lower-income patient lacks the ability to stay healthy and prevent the spread of HIV. Adopting the Affordable Care Act will lead to increasing quick diagnosis, early treatment, and adherence to treatment, thus decreasing the rate of infection of HIV. The policy will achieve this by way of subsidizing the cost of testing and putting patients in a healthcare setting during testing, thus surrounding them with resources and increasing the likelihood of them engaging in ongoing treatment. Additionally, the Affordable Care Act's emphasis on educational initiatives, primary care, and community-based health clinics will directly affect the health outcomes of HIV-positive African-American MSM. A lack of health insurance disrupts the HIV care continuum, making it more difficult to achieve viral load suppression.

### The Expansion of Medicaid

Currently, 1 in 3 HIV-positive people lack healthcare. In order to improve the health outcomes of HIV-positive African-American MSM, states must expand Medicaid. While the Affordable Care Act requires states to create affordable and adequate health insurance programs for state residents, this power falls within in the parameters of states’ own jurisdictions. The federal government cannot force states to expand Medicaid. Until all states expand Medicaid eligibility, about 18 thousand HIV-positive people will remain ineligible for the benefits. A study done by the Kaiser Family Foundation estimates that there are between 50 and 70 thousand uninsured people with HIV currently receiving care, and 124,000 who currently are not in care, but would receive it with the expansion of Medicaid.
Before the introduction of the Affordable Care Act, HIV-positive people would not be able to get Medicaid support until the disease was so developed that they were disabled or impoverished by it. With the Affordable Care Act, people can qualify before they are desperate, thus increasing access to treatment and thereby preventing the spread of the virus.
HIV/AIDS medical treatment is expensive--the expansion of Medicaid will allow for more individuals to have access to the care they need as well as cut healthcare costs.

### Ryan White CARE Act

The Ryan White CARE Act was first enacted in 1990 in honor of, Ryan White a teenager who suffered stigma and prejudice in his community after being diagnosed with HIV/AIDS. This Federal program focuses on specifically on HIV/AIDS healthcare and aims to assist people living with HIV/AIDS who lack health insurance or the financial resources to pay for their medications. The Ryan White Care Act is a means of people getting treatment when all other funding options fall through. This policy has many implications for HIV-positive African-American MSM, as many lack health insurance and therefore have trouble getting the medications they need to treat their infection and prevent its spread. Today, about 43 percent of people with HIV live in states that are not expanding Medicaid.
The Ryan White Care Act currently serves more than 500 thousand people per year and allows for patients to obtain mental health services, as well as housing, transportation, and substance abuse programs. These benefits are very important to ensuring the overall health of patients, as these hurdles can prevent patients from adhering to medication. The Ryan White Care Act is necessary because it help ensure that HIV-positive people can receive the care they need to lead healthy lives and prevent transmission to others, regardless of their state's willingness to expand Medicaid. Until all states expand Medicaid eligibility, about 18 thousand HIV-positive will remain ineligible for benefits. 43 percent of people with HIV live in states that are not expanding medicaid, often in the more politically conservative Southern region of the United States. The Affordable Care Act does cover incarcerated people, one of the most at-risk groups of which 36% are African-American, disproportionate to the 12% of the United States population that is African-American. The Ryan White Care Act is unique in its multidisciplinary approach to HIV care and is necessary to ensure the health of HIV-positive African American MSM.

## Relevance to UNC

Many of the HIV-positive people who lack access to healthcare due to states' refusal to expand Medicaid live in the South. In North Carolina, HIV is on the rise in African-American MSM. As a major research university, UNC has a responsibility to engage in research, conversation, and activism around HIV.

### Current Centers and Research

* UNC Center for AIDS Research: The goal of the UNC Center for AIDS Research is to combat HIV/AIDS globally as well as domestically through activism and research.
* UNC Global HIV Prevention and Treatment Clinical Trials Unit aims to conduct research about HIV infection through a number of research groups as well as provide those at-risk or living with HIV resources to live healthy lives.
* Many UNC research teams have made tremendous breakthroughs and contributions to the study of the HIV virus, as well as the clinical and preventative sides of HIV. In 2011, Dr. Myron Cohen's research team showed that antiviral medications can prevent sexual transmission of the virus. This discovery was named "Breakthrough of the Year" by the journal Science.

### On-Campus Resources

* For free HIV/AIDS testing, visit UNC Campus Health Services.
* For more sustained primary and HIV-related care, visit the UNC School of Medicine Infectious Disease Clinic.

### Learn More and Get Involved

* Enroll in the UNC HIV/AIDS course to get a multidisciplinary perspective on HIV/AIDS.
* Get involved with the UNC GlobeMed chapter to engage in activism and conversation surrounding HIV/AIDS and other domestic and global health issues.