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The Continuum of HIV Care in the Urban United States: Black Men Who Have Sex With Men (MSM) Are Less Likely Than White MSM to Receive Antiretroviral Therapy.

The US Centers for Disease Control and Prevention houses the Division of HIV/ AIDS Prevention within the National Center for HIV, Viral Hepatitis, STD, and TB Prevention, renamed in late 2016 to highlight hepatitis. Its National HIV Behavioral Surveillance (NHBS) study is a vital vehicle through which epidemiologists and behavioral scientists mine periodically collected NHBS data to track components of the continuum of human immunodeficiency virus (HIV) care. The NHBS was begun in 2003 by the Centers for Disease Control and Prevention “to conduct behavioral surveillance among persons at high risk for HIV infection” [1]. The surveillance is conducted yearly in 1 at-risk population (men who have sex with men [MSM], persons who inject drugs, or heterosexuals at increased risk for HIV infection); that is, 1 of the 3 populations is surveyed every year, such that each of the 3 populations is surveyed every 3 years and there is a single annual survey of 1 population. The NHBS permits tracking health system components that are needed to optimize both clinical care for persons living with HIV/AIDS and prevention of HIV transmission to others [2–4]. The continuum of care begins with testing and confirmatory diagnosis to identify infected persons [5]. After diagnosis, a person living with HIV must be linked to care, retained in care, promptly prescribed antiretroviral therapy (ART), and be highly adherent to the ART regimen [6]. The ultimate goal of this care cascade is viral suppression, to both slow HIV disease progression and minimize viral transmission to others. In this issue of The Journal of Infectious Diseases, Hoots and colleagues [7] from the NHBS Study Group team estimated 2 elements of the care continuum among HIV-infected MSM in the United States, the prevalence of linkage to care and ART coverage. In 2008, a total of 1144 men participated and were included in the linkage analysis, increasing to 1338 in 2011 and 1716 in 2014, with 2 fewer participating in each study year for the ART analysis, that is, 2 missing ART data for each of the years. From 2008 to 2014 surveys, 14% fewer white MSM participated and 13% more black MSM were included. There were no significant differences in education, income, or region across the time period, but insurance coverage rose steadily, from 7% in 2008 to 86% in 2014, and the median age of participants was younger in more recent surveys. Both linkage to care and ART coverage improved over time, consistent across all groups studied by Hoots et al [7]. However, a conspicuous health disparity was rediscovered, namely, that black MSM were less likely to secure ART in each of the 3 NHBS MSM study years of 2008, 2011, and 2014. This finding (a 9% coverage gap in 2014) persisted even after controlling for other predictors of lower access, namely, less education, lower income, and lack of health insurance. In this pithy report, other potential contributors to the racial differences were not addressed, including substance and alcohol use, mental health, disclosure of HIV status, whether sexual orientation was open or clandestine, incarceration experience, stigma and community attitudes, or social support and network phenomena. Hence, a more nuanced interpretation of why black men are less likely than white men to access ART must be sought elsewhere [8–36]. When racial or ethnic disparities in access to care are well documented, which programs can reduce such disparities? This remains a conspicuous priority for current research in the United States, whether focused primarily on care for persons living with HIV/AIDS or for prevention of HIV infection [37,38]. Innovative programs suggest that the gap may be bridged using community outreach and participation, community health workers and E D I T O R I A L C O M M E N T A R Y