PERSPECTIVE: A Crisis, and a Riddle Too (Black youth disparities)

By: NATHAN RILEY, Gay City News (NYC)

05/01/2008


It's hard to explain, but black youth contract the AIDS virus more often than their white and Latino peers. Yet when we look at the sexual behavior of these young men, there seems to be little difference.

Gay City News reported that in New York City in recent years blacks accounted for 52 percent of the new cases among young gay and bisexual guys, and Latinos, 34 percent. Unhappily, this is a trend that has persisted for years - these percentages reflect 1,633 diagnoses in young men 13-24 between 2001 and 2006. Remarkably similar data for the same age range were recorded across the United States.

Explanations don't come easily. Blacks don't appear to disregard safe-sex messages any more than Hispanic or white youths; barebacking occurs in all groups.

A meta-study reviewing risk factors for HIV infection of black men bore this out: "Most studies published from the first decade of the epidemic through the present have found comparable, if not lower, self-reported rates of [unprotected anal intercourse] for Black [men who sex with men] relative to other MSM." The conclusion is that condomless sex occurs at roughly comparable rates among the three racial-ethnic blocs, but blacks sero-convert at higher rates.

Similar findings have been reported regarding drug use and the number of sexual partners, according to a June 2006 American Journal of Public Health (AJPH) article.

Even rates of incarceration don't provide an explanation. Black youth face prison at much higher rates than whites, but they also tend to have less sex behind bars, and when they get out they have more partners but use condoms more often. It must be acknowledged, however, that there are virtually no significant studies about the effect of imprisonment on HIV status. Is this ostrich posture how the US handles a bad conscience?

The bottom line is that the bad health outcomes do not appear attributable to riskier behavior. All groups have risk-takers, but the groups don't contract HIV or other STDs at the same rate.

Dr. Ron Stall, a University of Pittsburgh epidemiologist, points out that "sexual networks are bounded by race and class." He is one of the authors of the AJPH article "Greater Risk for HIV Infection of Black Men Who Have Sex With Men: A Critical Literature Review."

Black youth enter an "epidemiological context" that transmits HIV at a higher rate than the sexual networks frequented by young white or Latinos according to Stall.

The prevalence of HIV infection is not the key factor, the AJPH study found. Transmission occurs when an HIV-positive person has high levels of the virus in their bloodstream. Poz people who regularly take effective antiretroviral therapies should have a low viral count, which means they are unlikely to transmit the disease.

In contrast, individuals with the virus who go untested or untreated will often have a high count and be efficient transmitters of the disease. Stall's hypothesis is that young African Americans engage with sex partners with a high viral load more frequently than white or Latino youth do in their sexual networks.

Changing this reality is proving difficult - even though the higher infection rates may not be linked to riskier behavior, the answer can only come by lowering risk-taking even as society works to achieve better health care in people of color communities.

Dr. Monica Sweeney, assistant commissioner of the New York City Health Department, has led a campaign distributing free condoms with the colorful NYC logo. But she believes teenagers - straight and gay - should postpone sexual activity to prevent health risks and allow for a growth in emotional maturity. She would like to see the gay community create new norms about youthful sexual restraint, something that has proved a very tall order among youths generally.

Even in a prevention model based on changing community norms, black youth are at a disadvantage. According to the AJPH review, "Several studies overwhelmingly supported the assertion that Black MSM are less likely than White MSM to identify as gay and to join gay-related organizations."

Dr. Perry N. Halkitis, a professor of applied psychology at NYU who specializes in HIV/AIDS and drug abuse, rejects an exclusive focus on biological factors such as viral load. Twenty-five percent of the gay men in Chelsea are positive and yet the rate of new cases of HIV in that community is still lower than among gay and bi black youth citywide.

"AIDS is not the primary presenting problem for black youth," he said. "They are grappling with homelessness, poverty, and unemployment, and obstacles to education." In these circumstances, "discussions of HIV are not part of the norm."

There are access issues to medical care for black youth, as well. Once you start "layering" the challenges facing black youth, HIV becomes just one of the obstacles that must be negotiated. If the AJPH-Stall framework could be termed primarily biological, Halkitis' bottom line is that "these spikes in HIV are a social construction."

Surely there is overlap between the views Stall and Halkitis articulate, yet it is difficult to fully reconcile their perspectives.

Despite the evidence that risk-taking is relatively constant across racial and ethnic lines, Halkitis emphasizes that in Chelsea young gays are part of a community that supports safe-sex norms. Agencies providing services understand when a client or patient is gay and the young adult doesn't have the burden of declaring himself. According to the AJPH study, blacks are more likely to receive care at public health clinics and less likely to discuss HIV-related concerns with a doctor or nurse.

Of course fully sorting out the biological-social construction debate need not stand in the way of immediate steps.

Reversing the spike in HIV cases among African Americans will require continued growth in gay community-building, increased use of anti-retroviral therapies among all those living with HIV, and a better funded network of gay health services. There are as yet no solid estimates of the number of individuals who would need to begin treatment to reverse the current trajectory and see the number of new HIV cases decline.

The costs of these initiatives are substantial, but currently the largest expenditures on black youth are for prisons, courts, and cops. New priorities recognizing the importance of a healthy nation are required.