1. It's Not Just Black and White: Determining Within Group Differences for HIV Infection among African-American Gay and Bisexual Men Matthew R. Beymer, MPH, Robert K. Bolan, MD and Risa P. Flynn Los Angeles LGBT Center Research Institute BackgroundMethods Results Discussion References Funding Source: All research was funded by the Los Angeles LGBT Center. Conflicts of Interest: None declared Men who have sex with men (MSM) account for only 2% of the US population but 70% of all HIV infections (CDC 2014). Furthermore, African-Americans (AAs) make up 12% of the population but 44% of all HIV infections (Figures 1 and 2; USCB, 2014). In the MSM community, AAs make up nearly 39% of all HIV infections. Data were analyzed for all individuals who identified as 1) African-American, 2) gay, bisexual or reported sex with a man in the past year 3) and tested for HIV at the Los Angeles LGBT Center between January 2011 and September 2014 (n = 1,784). Simple Cox proportional hazards (PH) analyses were used to determine differences between AA MSM who seroconverted and those who remained HIV negative. Following these analyses, multivariable PH analyses with backward elimination were used to determine differences between these groups at baseline, controlling for age and education. A total of 135 AA MSM eventually tested HIV- positive out of 1,784 testers for a seropositivity rate of approximately 7.6% (Table 1). In simple PH analyses, gonorrhea, chlamydia and syphilis diagnosis, meth use, condom use during receptive sex, race of last partner and intimate partner violence (IPV) were statistically significant in predicting HIV infection. 1.Centers for Disease Control and Prevention, “HIV Among African American Gay and Bisexual Men.” Accessed 23 May 2014 - http://www.cdc.gov/hiv/risk/racialethnic/bmsm/facts/ http://www.cdc.gov/hiv/risk/racialethnic/bmsm/facts/ 2.United States Census Bureau, “2010 Census Shows America’s Diversity.” Accessed 29 May 2014 - http://www.census.gov/2010census/news/releases/operations/cb1 1-cn125.html http://www.census.gov/2010census/news/releases/operations/cb1 1-cn125.html 3.Henry J. Kaiser Family Foundation, “The HIV/AIDS Epidemic in the United States.” Accessed 29 May 2014 - http://kff.org/hivaids/fact-sheet/the-hivaids-epidemic-in-the-united- states/ http://kff.org/hivaids/fact-sheet/the-hivaids-epidemic-in-the-united- states/ 4.Millett GA, Peterson JL, Wolitski RJ, Stall R. Greater risk for HIV infection of black men who have sex with men: A critical literature review. American Journal of Public Health 2006;96:1007-19. 5.Singer M. AIDS and the Health Crisis of the United-States Urban- Poor - The Perspective of Critical Medical Anthropology. Social Science & Medicine 1994;39:931-48. 6.Halkitis PN. Reframing HIV Prevention for Gay Men in the United States. American Psychologist 2010;65:752-63. 7.Halkitis PN, Kapadia F, Siconolfi DE, et al. Individual, Psychosocial, and Social Correlates of Unprotected Anal Intercourse in a New Generation of Young Men Who Have Sex With Men in New York City. American Journal of Public Health 2013;103:889-95. Study Objective Predictorp-valueHR (CI) Age Group (REF = 40+) <25 25-29 30-39 0.9 0.56 0.54 0.95 (0.45-2.02) 1.25 (0.59-2.65) 1.28 (0.59-2.8) Education Level (REF = Post-Grad) High School or Less College 0.1 0.15 5.61 (0.74-42.7) 4.28 (0.59-31.1) Gonorrhea Infection (REF = Negative)0.011.88 (1.14-3.12) Chlamydia Infection (REF = Negative)<0.00012.79 (1.73-4.49) Syphilis Infection (REF = Negative)<0.00015.76 (2.8-11.9) Intimate Partner Violence (REF = Not Experienced)0.0082.33 (1.25-4.34) Race of Last Partner (REF = Heterophilous)0.0051.92 (1.22-3.01) Figure 3 – Syndemics Theory (Halkitis 2013) Results (Continued) Most notably, history of any STI (gonorrhea, chlamydia, syphilis or HIV), testing frequency for HIV, age of last partner, drug use other than meth and number of partners in the last 30 days and last 3 months were not significantly different between groups in simple PH analyses. In multivariable PH analyses, the final model contained gonorrhea diagnosis (p = 0.01), chlamydia diagnosis (p < 0.0001), syphilis diagnosis (p < 0.0001), intimate partner violence (p = 0.0008), and racially homophilous last partner (p = 0.01), controlling for age group and education (Table 2). The model also met the proportional hazards assumption (p = 0.99). This study showed strong support for Syndemics Theory in analyzing differences in HIV infection among AA MSM. STI diagnosis, IPV and racially homophilous partnerships were significantly different between AA MSM who seroconverted and AA MSM who remained seronegative. Previous studies have shown that comorbidities with an STI partially explain the HIV infection disparities between AA and White MSM. However, the present study shows that IPV and race of last partner are unique contributors to HIV infection among AA MSM. These results highlight the heterogeneity among different groups of MSM and call for more precise attention to racially-specific risk factors. By identifying specific risks within racial sub-groups, public health interventions may be more effective at addressing HIV health disparities. While numerous studies have analyzed HIV incidence disparities between White and AA MSM (Millett 2006), few studies have looked at the differences in risk factors between AA MSM who seroconvert (i.e., test HIV-positive) and AA MSM who remain HIV negative. Furthermore, even fewer studies have applied Syndemics Theory (Singer 1994, Halkitis 2010) in appraising these differences (Figure 3). The present analysis uses Syndemics Theory to holistically assess within group differences in HIV infection among AA MSM. Table 2 – Multivariable Proportional Hazards Analysis PredictorHIV Positive N % HIV Negative N % Age Group <24 25-29 30-39 40+ 48 39 34 14 35.6 28.9 25.2 10.3 510 433 378 328 30.9 26.3 22.9 19.9 Education HS or Less College Advanced Degree 36 89 2 28.3 70.1 1.6 286 1208 110 17.8 75.3 6.9 Gonorrhea Infection Positive Negative 28 82 25.5 74.5 218 1241 14.9 85.1 Chlamydia Infection Positive Negative 38 72 34.5 65.5 184 1270 12.6 87.4 Syphilis Infection Positive Negative 12 75 13.8 86.2 16 1341 1.2 98.8 Intimate Partner Violence Experienced Not Experienced 18 111 13.9 86.1 105 1511 6.5 93.5 Race of Last Partner Homophilous Heterophilous 66 64 50.8 49.2 468 1088 30.1 69.9 Determine the significant risk factors for HIV infection between AA MSM who seroconvert and those who remain HIV negative using a Syndemics Theory framework at a large LGBT-focused organization Table 1 – Demographics of Unique AA MSM