Cathy Maulsby

Employment status is a key social determinant of health, and many populations in the United States that are impacted by HIV have unequal access to education and employment opportunities which contributes to HIV-related disparities. Black men who have sex with men (BMSM) are one of the groups most heavily burdened by HIV. With improved health outcomes associated with advancements in HIV treatment, research suggests that more people living with HIV want to work. This study describes employment among BMSM living in Baltimore, assesses differences in employment by HIV status and assesses predictors of full-time employment among BMSM. The study found that BMSM have limited access to full-time employment and that this disparity is even more pronounced among BMSM living with HIV. Men living with HIV were less likely to be employed full-time compared to men not living with HIV controlling for education and social contextual factors (OR 0.40 95% CI (0.22–0.73)). HIV will most likely have important implications for employment patterns and trajectories of BMSM over the life course. Additional research is needed among BMSM living with HIV to understand work histories and experiences, facilitating factors, and the impact of various work experiences on the health and wellbeing.

Linkage to HIV medical care and on-going engagement in HIV medical care are vital for ending the HIV epidemic. However, little is known about the cost–utility of HIV linkage, re-engagement and retention (LRC) in care programs. This paper presents the cost–utility analysis of Access to Care, a national HIV LRC program. Using standard methods from the US Panel on Cost-Effectiveness in Health and Medicine, we calculated the cost–utility ratio. Seven Access to Care programs were cost-effective and two were cost-saving. This study adds to a small but growing body of evidence to support the cost-effectiveness of LRC programs.

Competing needs pose barriers to engagement in HIV medical care. Mixed methods were used to explore and describe the needs of participants enrolled in Access to Care, a national HIV linkage, retention and re-engagement in care (LRC) program that served people living with HIV who knew their status but were not engaged in care. When asked to prioritize their most urgent needs, participants reported housing or shelter (31%), HIV medical services (24%), and employment (8%). When we assessed the HIV continuum of care by needs status, we found no significant differences in linkage, retention, or viral suppression between participants with and without basic needs. Qualitative interviews with program staff contextualized the barriers to HIV medical care faced by participants and explored the strategies used by LRC programs to address participant needs. Study findings will be of use to future programs and have implications for HIV policy, in particular the implementation of the National HIV/AIDS Strategy (2015–2020).

Adequate engagement in HIV care is necessary for the achievement of optimal health outcomes and for the reduction of HIV transmission. Positive Charge (PC) was a national HIV linkage and re-engagement in care program implemented by AIDS United. This study describes three PC programs, the characteristics of their participants, and the continuum of engagement in care for their participants. Eighty-eight percent of participants were engaged in care post PC enrollment. Sixty-nine percent were retained in care, and 46 % were virally suppressed at follow-up. Older participants were more likely to be engaged, retained, and virally suppressed. Differences by race and gender in HIV care and treatment varied across PC programs, reflecting the diverse target populations, locations, and strategies employed by the PC grantees. There is an urgent need for programs that promote HIV care and treatment among vulnerable populations, including young people living with HIV. There is also an urgent need for additional research to test the effectiveness of promising linkage and retention in care strategies, such as peer navigation.

Black MSM continue to be the group most disproportionately impacted by HIV in the United States. This study assesses the relationship between partner-level and respondent-level characteristics and newly diagnosed HIV infection among a sample of MSM. Ego-centric data were gathered using venue-based time–space sampling on 335 men who reported on a total of 831 male anal sex partners. In multivariate analyses, age of partner, HIV status of partner, and respondent having had an STD in the past twelve months were associated with a newly diagnosed HIV infection among black MSM. Efforts for black MSM are needed that aim to increase HIV and STD testing, foster open communication between partners about HIV status, and address social determinants of health.

Black men who have sex with men (MSM) are disproportionately burdened by HIV/AIDS. Despite this burden there has been a shortage of research on HIV interventions for black MSM. This article provides a comprehensive review of the literature on interventions for black MSM to identify effective HIV prevention intervention strategies for black MSM. We searched 3 databases: Pubmed, Scopus, and Google Scholar to identify peer-reviewed articles and used the following search terms: African American or black; MSM or men who have sex with men and women (MSMW); HIV; program or intervention; and evaluation or intervention science or implementation research. We included research articles that assessed interventions for black men who have sex with men. We included studies that used an experimental, quasi-experimental, or pre-post test design as well as formative research studies. We also searched the CDC and NIH websites to identify planned and on-going intervention studies. We identified a total of 23 studies to include in the review. We identified 12 completed studies of interventions for black MSM. Eight of these 12 interventions aimed to reduce HIV risk behaviors and 5 found a significant reduction in HIV risk behavior over time. We identified 4 health service intervention studies for young black MSM. Behavior change interventions are effective at reducing HIV risk behaviors among black MSM. However, relying only on behavioral interventions that aim to reduce HIV risk behavior will most likely not have a population-level effect on HIV infection among black MSM. There is a compelling and urgent need to develop and test comprehensive HIV testing, linkage to care, retention in care and adherence interventions for black MSM.

In 2006, Millett published a seminal literature review that examined 12 hypotheses to explain the high rates of HIV among black MSM. This paper augments Millett’s article by reviewing the recent literature on behavioral, biomedical, structural, social contextual, psychosocial, and social network factors that affect HIV rates among black MSM. We searched three databases: PubMed, Scopus, and Google Scholar. First we searched all articles that included black or African American and MSM and HIV. We then searched the following terms for each area: behavioral (drug use during sex, crack cocaine use, and serosorting); biomedical (circumcision, STDs, and STIs); structural (access to care, HIV care, ART, HAART, patient-provider communication, HIV quality of care); social contextual (stigma, discrimination, internalized homophobia, internalized heterosexism, medical mistrust, social isolation, and incarceration); psychosocial (peer support and mental health); and social network (sexual mixing, partner characteristics, and social networks) factors. We identified 39 articles to include in this review. We found inconclusive evidence that incarceration, stigma, discrimination, social isolation, mental health disparities, or social networks explain the elevated rates of HIV among black MSM. We found evidence that the differences in rates of HIV between black and white MSM may be explained by differences in STIs, undiagnosed seropositivity, access to care and treatment services, and use of HAART. There is an overwhelming need for HIV testing, linkage to care, retention in care, and adherence programs for black MSM.

Men who have sex with men and women (MSMW) are at high risk for HIV. However, the majority of research on populations of men who have sex with men (MSM) combines MSMW and men who have sex with men only (MSMO) samples, which limits our understanding of HIV risk behaviors and factors associated with HIV risk among MSMW populations. We used the BESURE-MSM2, a venue-based cross-sectional study of HIV risk behaviors among MSM in Baltimore, MD, to examine HIV risk among MSMW. MSMW were less likely to report unprotected receptive anal intercourse than MSMO (6.8% vs. 19.6%, p = .0024). Among MSMW, 43.0% reported unprotected sex with a woman in the past year, but only 19.4% reported unprotected sex with both men and women, representing only 5.0% of the total MSM sample. In multivariate analyses, we found that among MSMW having unprotected sex with women in the past year, disclosing same sex behavior and having a main female partner were associated with unprotected anal intercourse with male partners. HIV prevention programs for MSMW are needed that address the complex partnerships of MSMW and the social contextual factors within which relationships and behaviors are embedded.

The study examined differences in HIV testing between men who have sex with men only (MSMO) (n=300) and men who have sex with men and women (MSMW) (n=105) and assessed associations with HIV testing among MSMW. A venue-based cross-sectional HIV surveillance study in 2008 (BESURE-MSM2) was examined. Prevalence of HIV testing was similar for MSMO and MSMW. One-on-one counseling (excluding counseling that is part of HIV testing) and having seen a health care provider in the past twelve months were associated with HIV testing in the past six months among MSMW in multivariate analyses. One-on-one counseling interventions may increase rates of HIV testing among MSMW.