by Myla Lyons, TASHI T32 Fellow
Edited by Derek T. Dangerfield II, PhD, Associate Professor
As we continue to celebrate Pride Month, we must keep in mind that some members of the LGBTQ+ community continue to experience disproportionate health outcomes compared to others. Specifically, unrefuted data suggest that Black gay and bisexual men have an estimated 50% lifetime risk of HIV and the worst outcomes along the HIV prevention and treatment cascade. For example, Black men are the least virally suppressed and be retained in HIV care compared to others. Despite the increased access to pre-exposure prophylaxis (PrEP) and antiretroviral therapy for HIV prevention and treatment, the CDC acknowledged that no progress was made to reduce disparities in HIV incidence for this part of our community between 2015-2019. There is no biological basis for race-based differences in disease susceptibility among Black gay and bisexual men. Moreover, more than a decade of research has shown that Black gay and bisexual men’s increased vulnerability is not because they engage in greater risk behaviors than other gay and bisexual men. Studies have consistently shown that Black gay men are actually more likely to report using condoms, having fewer partners, and using drugs less than others.
Key public health questions remain: Why are Black sexual minority men so vulnerable to negative HIV outcomes, and what risk factors are mutable to change?
Increased attention is being given to the vulnerabilities of Black gay and bisexual men at multiple levels of society. For example, the Ryan White HIV/AIDS Program saw a nearly 20% increase in viral suppression among Black patients over the past 14 years partly due to comprehensive HIV care and treatment including case management, housing, and other socioeconomic support systems. This provides hope that with attention to more holistic aspects of health, including the social determinants, we can improve outcomes for some of our most marginalized community members. In order to rectify these inequities for Black sexual minority men in HIV specifically, we still need to address the surrounding issues particular to their lives: mental health, employment, housing, and health literacy, so that these aspects support rather than inhibit engagement in HIV care, prevention, and prevention research participation.
Intersectionality is an approach to studying problems in society that analyzes the role of power in society (in which Black sexual minority men have been very underrepresented in formal positions of power, such as in the healthcare industry and government). This distribution of power influences who has the ability, and ease, to access the services and resources to maintain good health. The minority stress model is another widely used framework that focuses on how stigmatized groups of people are affected by larger, structural processes such as discriminatory policies and social norms. It highlights that the health outcomes we see are happening because of the additional stressors you live through as a minority in society. Taken together, these frameworks are useful to help us think about how Black sexual minority men experience the “normal stressors” associated with daily life, in addition to the minority stress from racist, heteronormative ideas that permeate U.S. society, which increases their disease vulnerability and risk for poor outcomes. HIV is one of these outcomes, which studies show is impacted by intersectional, Black sexual minority men’s minority stress experiences.
Health is strongly affected by the environment in which individuals live, work, and play. If we want to improve the persistent low rates of HIV prevention and treatment outcomes for Black sexual minority men, we need to address how power in society (including in families, schools, and healthcare settings) favors those in the majority and increases vulnerability for individuals with multiple identities of vulnerability, such as Black gay men. To do so, we must turn our attention to the policies and practices regarding inclusive sexual health education, nondiscriminatory employment, and affordable housing, to name a few. We must also begin to target mental health issues in the community, given that exacerbated stress is considered a normal part of the lives of Black sexual minority men’s intersectional experience. Addressing these vulnerabilities could be key to improving access to prevention and treatment and reducing the lasting effects of known structural barriers in the community. Until these are addressed, Black sexual minority men will continue to experience disparities and inequities in HIV outcomes.