Gay, bisexual, and men who have sex with men (gbMSM) are the most affected by HIV, accounting for 69% of new HIV infections in the United States [1, 2]. Among this population, black gbMSM experience significantly higher rates of HIV infection compared to all other racial groups and are the least likely to initiate antiretroviral treatment. Black gbMSM are also disproportionately affected by HIV across the globe; a study found a similarly high prevalence of HIV for black gbMSM in lower- and middle-income countries, citing that public health systems have largely ignored the disparate health risks among this subpopulation . Examining race as it intersects with sexual orientation is vital to understanding how black gbMSM are disproportionately affected by HIV. Structural factors such as geographic location, interpersonal discrimination, and biases within the healthcare system perpetuate health care disparities in black gbMSM, which has led to high rates of HIV infection.
The effect of racism on health outcomes is no secret, as many black Americans have poorer health compared to their white counterparts . It is important to note that disparities related to race are further complicated by sexual orientation. This concept is known as intersectionality, which emphasizes that people with multiple social identities (such as race, gender, sexual orientation, or religious beliefs) have lived experiences that are distinct from any single group [5, 6]. By using this framework, we see that black gbMSM face many forms of social stigma, discrimination, and oppression; racism and homophobia from members in the community and health care providers can make it a daunting task for black gbMSM to feel comfortable seeking medical attention. Using the lens of intersectionality to understand structural barriers to access health care among black gbMSM has the potential to uncover key insights for effective prevention and intervention strategies.
Throughout the United States, geographic location and residential segregation have played major roles in perpetuating health disparities among black Americans. For black gbMSM, segregation is closely intertwined with socio-economic status as it relates to healthcare access. For example, black Americans in segregated communities have access to fewer doctors per capita, fewer hospitals, and less health care resources related to HIV testing and treatment [7-9]. This means that black gbMSM living in these segregated neighborhoods tend to have less access to health care resources, which then translates to fewer opportunities to detect and treat HIV. Less access to HIV prevention and treatment services in these neighbourhoods play a significant role in increased HIV risk among black gbMSM.
Experiences of interpersonal discrimination and stigma among black gbMSM Americans is another key source of health inequity in the United States. Researchers found that lifelong discrimination was significantly higher for black men compared to white men . Maltreatment, prejudice, verbal abuse, and isolation towards black and gay communities perpetuate stigma, shame, and internalized homophobia among black gbMSM. In turn, black gbMSM feel the need to hide their sexual identity, resulting in more short-term partners and not discussing HIV serostatus between partners, further increasing the risk of HIV infection .
Discrimination can also manifest through health care providers failing to deliver adequate health care to black gbMSM. Many black patients are not getting the health care they need as a result of health care providers’ negative perceptions and biases against black patients . This in turn has resulted in black patients often not trusting health care institutions, thereby foregoing necessary treatment. When health care in America is historically and socially contextualized, it becomes clear that blatant racism and discrimination towards black Americans have reduced access to health care resources and stirred feelings of mistrust among the community. Even in today’s context, this mistrust is exacerbated by stigma and discrimination from care providers related to race and sexual orientation . Consequently, black patients are more reluctant to seek and access medical care, thereby reducing opportunities for detecting and treating HIV.
While black men experience high levels of discrimination and prejudice within the healthcare system, being both black and gbMSM poses another barrier to health care access. Sexual minorities face many challenges to care as many of them fear the potential for discrimination from health care providers . Another study found that black gbMSM were less likely to discuss HIV-related concerns with health care providers, and as a result were significantly less likely to know their HIV status until later in the progression of disease compared to any other racial group . In the medical community, knowledge of HIV serostatus is closely linked to reducing HIV-related morbidity, mortality, and infectiousness . This means that interpersonal discrimination and the resulting social pressures contribute significantly to lifelong health inequities for the black gbMSM population. In the long-term, this means more individuals falling through the cracks of the healthcare system if these issues of discrimination and homophobia are not addressed.
The high HIV incidence among black gbMSM is the result of disproportionately lower access to health care resources for black gbMSM. Structural factors like segregation and interpersonal discrimination impede on how black gay men navigate the world, and the healthcare system is no exception. In the past decade, policy-based responses have been implemented in the United States to target these issues. Updated regulations of the Fair Housing Act (FHA) in 2015 were made to require jurisdictions to come up with meaningful approaches to combat segregation and Section 1557 of the Affordable Care Act prohibited medical professionals from discriminating against patients based on race, age, gender or sex, to name a few While these were seen as meaningful measures, the Trump administration has since suspended or removed parts of these protections, directly affecting black gbMSM [16, 17]. These seemingly non-health-related regulations have powerful implications for the health of black and gay Americans as they help lower barriers to access care that many black gbMSM desperately need. We must continue to investigate the ways – both directly and indirectly – that this group is affected and hold government agencies accountable for making these changes. This also means that efforts must be made by the community and policymakers alike to re-enact and improve laws that ensure black gbMSM are protected.
Taken together, stigma and discrimination rooted in America’s history of racism continue to affect black communities and create social conditions that contribute to increased risk of HIV among black gbMSM. Given their intersecting identities, black gbMSM are disproportionately impacted by the current HIV epidemic and face the highest risk of HIV infection in the United States. Circumventing these structural barriers underscores the necessity of addressing the social and structural determinants driving the disproportionate burden of HIV among black gbMSM.
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