Still Falling Behind

Recent studies underscore the fact that both HIV-positive African-Americans and transgender men are still being left behind other populations.

According to the Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report, only 40.8 percent of black people living with HIV in 2014 had sustained viral suppression, a percentage lower than that among Hispanics (50.1 percent) and whites (56.3 percent).

The 60.2 percent of black people who did not have viral suppression included 25.3 percent who were in care and 33.9 percent who had not had viral load testing in 2014. The latter is an indication that the person is not receiving adequate HIV care and therefore is unlikely to have a suppressed viral load.

Not reaching sustained viral suppression means their immune systems will continue being impacted by HIV, and they won’t see the benefits of being undetectable, which means they will still be able to transmit HIV to sexual partners.

Among people living with HIV who were in care, black people also experienced longer periods (six months out of a year) with viral loads over 1,500 copies/mL, which can also lead to poor health outcomes and higher risks of transmitting the virus. Although more black folks who received HIV care in 2013 were prescribed antiretroviral medication than in 2009, fewer received an ART prescription (92.9 percent) than did Hispanics (95.2 percent) or whites (95.2 percent).

The racial and ethnic differences in sustained viral suppression existed regardless of gender, age, or transmission categories, although the lowest rates of sustained viral suppression were found among black people aged 13 to 24 years old. Lower viral suppression, combined with the higher prevalence of HIV among black people, can lead to greater risks of transmission (thus causing the epidemic among African-Americans to intensify).

The study noted barriers contributing to the situation included a lack of health insurance (particularly in southern states that refused Medicare expansion), limited access to health services, stigma, lack of health literacy, and a lack of trust in providers. “Reducing health disparities,” the study suggests, will take “tailored strategies that address barriers to achieving and sustaining viral suppression among blacks, especially those aged 13–24 years.”

Transgender people also continue to face health disparities. Although research into HIV-positive transgender men is rare, the first national study of its kind suggests HIV-positive transgender men receiving medical care in the United States have unmet social and healthcare needs. Published in the American Journal of Public Health, the research showed that approximately half of poz trans men are living in poverty and only 60 percent have reached sustained viral suppression. Compare that to a 2016 study by the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention that showed men who have sex with men who were HIV-positive and 25 or older, had sustained viral suppression rates of 72 percent.

The report published in AJPH found that many transgender men receiving care for HIV experienced poor health outcomes and unmet needs, with 69 percent having at least one unmet support need and a quarter reporting they were currently living with depression. “To decrease disparities and achieve health equity among HIV-positive men, HIV care models could incorporate transgender-sensitive health care and mental health services and health insurance inclusive of sex reassignment procedures and physical sex-related care,” concluded the study.

Dr. Jessica Rongitsch, a primary care doctor at Capitol Hill Medical, an LGBT clinic in Seattle, Wash., who has been providing care for the trans community for over 15 years, argues that trans men have specific risks that are not being addressed. “Many of my trans masculine patients have condomless penetrative sex with penises so are at risk of HIV infection. Testosterone causes thinning and dryness of vaginal mucosa, which increases risk of bleeding and tearing during sex. While there aren’t studies specifically looking at this, I believe trans men may be at higher risk of contracting HIV if exposed to the virus, compared to cisgender women.”

The good news is that over the period of these studies (2009 to 2014), sustained viral suppression rates among all populations of people living with HIV have gone up. The bad news is that the current administration doesn’t have the same priorities, funding, or support of Obamacare that the previous one did — and that may increase disparities in the future.