Q&A: Improvements in HIV care for Black and white men who have sex with men

Katherine Rich, MD MPH, resident in the MGH Department of Medicine, is the first author of a recently published paper in JAMA Network Open, "Projected Life Expectancy Gains from Improvements in HIV Care in Black and White Men Who Have Sex With Men." Aima Ahonkhai, MD MPH and Emily Hyle, MD MSc, physician investigators in the Division of Infectious Diseases at Massachusetts General Hospital, are co-senior authors.

What question were you investigating?

Substantial inequities persist across the HIV care continuum in the US; Black people with HIV bear a disproportionate disease burden due, in part, to structural factors such as stigma, racism, and other social determinants of health.

Given existing inequities in the HIV care continuum, we asked: What are the differences in age at death between Black and white men who have sex with men (MSM) who acquire HIV, and what would be the outcome of achieving equity-centered goals vs. non-equity-centered goals?

Equity-centered HIV care goals promote the attainment of the highest level of health for all people and include strategies that increase HIV care levels to identical levels across subpopulations. Such interventions may call for additional investments for specific demographic subpopulations that have lower current-day care levels to address the very factors driving inequities in their care. In contrast, non-equity-centered goals may aim for equal improvements in care across subpopulations, rather than setting identical outcome goals, and thus may allow racial inequities to persist.

What methods did you use?

We used the Cost-Effectiveness of Preventing AIDS Complications (CEPAC) microsimulation model populated with 2021 race-specific data to simulate HIV care among Black MSM and white MSM in the US who acquire HIV.

The study first simulated status quo care using race-specific estimates for:

• Age at HIV infection
• Time to HIV diagnosis
• Receipt of HIV care
• Virologic suppression

We then projected the impact of attaining non-equity-centered vs. equity-centered HIV care goals by simulating strategies that would result in equal improvements-in-care goals; equity-centered goals; and an equitable care continuum that achieves annual HIV testing, 95% receiving care, and 95% virologic suppression in Black MSM and white MSM.

What did you find?

In this simulation modeling study, we found that the mean age at death would be 68.8y for Black MSM and 75.6y for white MSM given the current HIV care continuum ("Status Quo"). If HIV care is improved by equal increments for Black and white MSM, racial inequities would be the same or worsened (+0.5 life-years gained for Black MSM and +0.5-0.9 life-years gained for white MSM).

Achieving equity-centered HIV care goals would allow us to move towards achieving health parity between Black and white MSM (+0.5-1.7 life-years gained for Black MSM and +0.4-1.3 life-years gained for white MSM). With an Equitable Care Continuum compared with the nationally reported Status Quo, Black MSM and white MSM would gain 3.5 and 2.1 life-years, respectively.

What are the clinical implications?

Our results suggest that equity-centered approaches can help to improve HIV care for MSM with HIV. Allocating resources to develop and identify effective equity-centered, evidence-based interventions for Black MSM, and implementation strategies to deploy these interventions, will be essential to achieve health equity across the HIV care continuum.

What are the next steps?

Existing interventions for improving HIV care continuum outcomes in Black MSM primarily focus on individual-level factors, particularly medication adherence.

To comprehensively address the complex, multifaceted drivers of health disparities, it is imperative to implement structural and multilevel interventions.

Achieving an equitable care continuum requires strategic investment and prioritization of evidence-based interventions tailored to the diverse needs of Black MSM across various community contexts, while also accounting for local HIV epidemic dynamics.