Researcher: What Sex, Drugs, & Racism Have to Do With Black Gay Men & HIV

Neal D. Goldstein, PhD, MBI, (pictured above) an epidemiologist with Philadelphia’s Drexel University School of Public Health and Newark, Delaware’s Christiana Care Health System, examines sexual behaviors, drug use, and HIV. We spoke with Goldstein about why black gay men have higher rates of HIV than white gay men.

Why are the studies you do so important?
Health departments, when they allocate funds, they often rely on data that are obtained from population-based surveys.

So, what’s the problem with those results?
When you ask questions that are potentially stigmatizing, such as, “Do you engage in high-risk sexual behavior?” people will tend to under-report that. Someone may say that they are straight or heterosexual, but engage in anal intercourse with another man. We would call that some level of misclassification, where the reported data do not match reality. Just asking someone their sexual identity is not the best marker for high-risk intercourse that can lead to HIV. The better marker is just asking, “Have you had male partners in your lifetime?” But even that does not necessarily arrive at the risk because you could have had male partners and engaged entirely in oral sex and have a negligible risk for HIV.

How does this relate to racial disparities?
We know that there are huge racial disparities out there. Do these racial disparities in HIV risk somehow relate to how risk is assessed in these surveys? Again, just turning to the literature, you can see that if you are  black or African-American, you face more stigma in your community for disclosing that you are MSM [a man who has sex with men]. We thought, well maybe this is a prime reason why we see these divergent estimates in HIV risk. There’s a body of work out there mostly led by a researcher by the name of Greg Millett, who has done some really fascinating work about all these potential differences by race.

Do we see this increase in HIV risk among black MSM compared to white MSM because they are more promiscuous?

Well, no. In fact, based on the work by Greg Millett’s group, you see that black MSM have even fewer partners than white MSM. So, there is something else out there explaining the risk. In our second study, in addition to accounting for how risk is assessed, we also did a better job of establishing, Who is this risk being compared to? Because when someone says that black MSM have such and such increase in risk of HIV, it is important to capture who your comparison group is.

And you compared gay and bi black men to straight black men instead of comparing gay and bi white men to gay and bi black men?

Yes. We compare MSM to non-MSM. In our study, we do a better job of trying to assess things that are measured in these surveys that are some baseline risk characteristics of these groups. Baseline risk characteristics would just be other pathways to getting HIV, most notably for this population it’s either through sex or it’s through drug use.

Once we accounted for all these different factors and how they are measured in surveys, we begin to see these estimates between the racial groups converge. Originally, we thought, ... maybe we’ll see this racial disparity completely disappear, and then we have just an overall disparity to say that MSM have a high risk of HIV compared to non-MSM. We see that these HIV estimates converge in the direction we expect them to, but they don’t completely converge. 

Drexel Now wrote this about your recent study: "White MSM having such higher odds seems counterintuitive since the studies the Drexel team reviewed had historically suggested that black MSM are more likely to have HIV." Can you explain?

When we talk about HIV among MSM, we often talk of things in terms of relative risks. If we talk about MSM, we can make our reference group non-MSM, and so it makes it very clear when you do that that MSM has a much higher risk of being HIV positive.

It suggests that white MSM have a high risk, but in fact that’s just an artifact of the fact that when in comparison group among blacks for black MSM to black non-MSM, black non-MSM just have a higher overall prevalence of HIV.

It’s important when presenting results like this that you really give a lot of context. We want to be very clear that it’s important how you present these estimates because we don’t want to mislead people.

Okay, so the difference between straight black men and gay or bi black men is smaller than the difference between straight white men and gay or bi white men, because rates in the black community are higher overall. So what does this all have to do with dating?

We’ve accounted for all these underlying risk differences between the groups, and we arrive at this: that there really is something different between the racial groups here. We posit it is related to the concept of a social sexual network. If you are a black man, [race] may effect the size of the potential number of other men that you could have sex with. If your pool of men is smaller, then it’s a lot easier for HIV to move around. You may even be having less sex — [but] because you have a much smaller pool of available men to have sex with, it makes HIV a lot easier to [acquire]. We suspect it’s related to the social sexual networks, and unfortunately we just don’t have good data on those because that is very hard to ascertain. 

We need to do a better job of assessing the partnerships that form and not only just within the context of one specific racial group, but really across all groups out there. But] we don’t have good enough data to describe the sexual networks, and I think once we can get down that road, then we can do a much better job of really intervening. We can target public health funds specifically into these networks.

The Centers for Disease Control and Prevention predicts, if things don't change, that one in two black gay and bi men will become HIV-positive in their lifetime.
 It’s still a shocking statistic, even if you ignore the racial component of it, just the burden among gay men having HIV. We need to stop just saying, “Oh, it’s a behavioral difference.” We’re not saying that the racial difference is based on being more promiscuous or using more drugs. We’ve accounted for any differences in the number of sex partners and drug use in our analyses. 

Why do people — even within the community — continue to believe black gay men are more promiscuous? Despite studies showing that’s simply not true?
A lot of it is just to do with the media, in a way, and how the media positions messaging. If you just talk to the average straight person out there, their impression would be that gay men have exclusively anal sex every time they bump into each other, right? [But] anal sex probably happens only 20 percent of the time. It’s mostly oral sex, which confers a very negligible risk.

A 2016 study revealed 70 percent of straight people don’t think anal sex between men and women can transmit HIV.
Wow. This clearly demonstrates a gap in education and how people learn about sex. But when educators ignore reality, perhaps we should not be so shocked to hear statistics like these. Maybe it’ll be a generational thing and eventually those arcane ideas will die out.