The proportion of
newly diagnosed HIV-positive men who have sex with men (MSM) in the United
States who were promptly linked to care and started antiretroviral therapy
(ART) increased substantially between 2008 and 2014, investigators report in
the online edition of the Journal of
Infectious Diseases
. But the research also revealed racial disparities in
ART initiation rates, which in 2014 were 9% lower among black compared to white

“Blacks continue
to be less likely to be prescribed ARV [antiretroviral] treatment,” comment the
authors. An editorial notes that the differences in ART use “persisted even
after controlling for other predictors of lower access, namely, less education,
lower income and lack of health insurance.” Its author calls for further research
to identify the reasons for this persisting difference.

MSM remain the
group most affected by HIV in the United States. The National HIV/AIDS Strategy
(NHAS), which was originally published in 2010 and updated in 2015, prioritised
prevention and care for MSM, especially
those in the Southern states.

The national
strategy set two important targets: that 85% of people should be linked to
HIV care within three months of diagnosis (one month in the 2015 update) and
that the proportion of people starting ART should also increase.

wanted to see if NHAS targets were being achieved among MSM. They therefore
monitored changes in rates of three-month linkage to care and ART initiation
between 2008 and 2014.

The study
population consisted of 1144 adult MSM in 2008, increasing to 1228 in 2011 and
1716 in 2014. Participants were recruited at treatment centres in 20 cities
across the United States. Data were obtained on predictors of engagement with
care, including age, level of education, health insurance, region and race.

The proportion of
white MSM decreased by 14% between 2008 and 2014 whereas the proportion of
black MSM increased by 13%. The proportion of people with health insurance
increased from 75% to 86%.

Overall, the
proportion of people linked to care within three months of diagnosis
increased from 79% in 2008 to 87% in 2014 (prevalence ratio [PR] = 1.05; 95%
CI, 1.03-1.07). The proportion of people linked to care increased by
approximately 5% each three-year period, and the rate of increase was similar
across subgroups. However, linkage to care was more likely among people with
higher levels of education and health insurance.

The proportion of
people linked to care within one month of diagnosis also increased, from 75%
in 2008 to 78% in 2014 (PR = 1.04; 95% CI, 1.02-1.07). 

Overall prevalence
of ART increased from 69% in 2008 to 88% in 2014 (PR = 1.15; 95% CI,
1.12-1.18), a percentage change of 15% per three years.

In all years,
higher rates of ART use were observed among white people, older age groups, better
educated MSM and those with insurance. There were also regional disparities,
with people in Southern states having the lowest level of ART use. But the
association with region and poor ART uptake disappeared when the investigators
took into account race. In 2014, black MSM were 9% less likely to be on ART
compared to white MSM (83% vs 92%).

Although the proportion of uninsured men on ART has increased from 50% in 2008 to 70% in 2014, men with current health insurance remain more likely to be on ART. In 2014 90% of the currently insured were on ART. The authors note that men who live in the South are less likely to be insured because fewer Southern states have expanded Medicaid coverage under the Affordable Care Act.

“Our analysis
demonstrated increases in linkage to care and ARV treatment among HIV-positive
MSM,” conclude the authors. “Despite these increases, a large disparity in ARV
provision between white and black MSM remains, particularly in the South, where
the population density of black MSM is greater.”

The editorial
offers several possible reasons for this enduring racial disparity, including
substance and alcohol use, education, lower income, mental health, clandestine
sexual orientation, stigma and community attitudes and lack of social support
and networks.

Understanding the
racial differences in ART use should be a research priority, says the author.
Experience thus far suggests that the gap can be bridged using innovate
programmes such as community outreach, peer educators and use of incentives.

“The issues
involved are often as much societal as medical, as with access to housing and
education, employment and adequate income, substance use and mental health
services, and other social determinants of health,” concludes the author. “How
health systems can be improved and linked to communities of need without
addressing these overarching issues remains a massive challenge for
investigators and implementers alike.”