Black HIV activists have been saying it for decades, but now a study published in the Journal of the International AIDS Society confirms it: Lower rates of undetectable HIV viral load among same-gender-loving Black men has almost nothing to do with individual behavior and almost everything to do with structural factors such as poverty and homelessness.

Indeed, the racialized gap between Black and white people affected by HIV has been the engine driving the epidemic for years, especially in the South. But disparities in viral suppression between Black and white people living with HIV persist in every pocket of the United States, from New York City to San Francisco and Oakland. It’s so persistent that recently The Lancet called for a reckoning on systemic racism and universal health care. 

In the EngageMENt study, Patrick Sullivan, PhD, of Emory University, and colleagues wanted to pinpoint exactly what was driving the gaps in Atlanta. They recruited 398 men who have sex with men living in Atlanta between June 2016 and June 2017. All the men were on HIV treatment.

All participants were followed for two years. The researchers gathered viral load data at baseline, at one year and at the end of the study. The participants received cash incentives, including $60 for attending the baseline and one-year check-ins and $75 for completing the 24-month visit. The men also filled out surveys at 3, 6 and 18 months for $40 each.

Just over half of the participants (206) were Black men; the rest were white. The cohorts were not matched for age, income or other factors. In fact, the disparities were stark: Black men were younger than their white peers—a mean of 37 years compared with 44 for white men—and made less money. Nearly two thirds of participants who earned less than $20,000 a year were Black, though the employment rate was similar (49% for Black men, compared to 51% for white men). Two thirds of the students in the study were Black men. And while homelessness was low in the study overall (2%), Black men accounted for 78% of those experiencing homelessness. Likewise, one in 10 participants in the study overall (11%) had been incarcerated, but 68% of those involved in the criminal justice system were Black. All participants identified as gay or bisexual, but Black men made up the majority of those who identified as bisexual or some other orientation.

There were disparities in HIV care too. While 95% of white participants had antiretroviral prescriptions to treat HIV, only 85% of Black participants did. White participants were more likely to have private insurance (81% versus 62%), which may explain why Black participants were more likely to receive care through the Ryan White Care program, use AIDS Drug Assistance Programs and use drug company assistance programs. And while participants overall received the majority of their care at a doctor’s office, Black participants were more likely to receive care at a public health clinic.

When it came to viral suppression, 74% of the overall group had an undetectable viral load at baseline, but again, this split between white participants and their Black counterparts: 79% of white men had undetectable viral loads compared with 67% of Black men.

But interestingly, it wasn’t race itself that was associated with viral suppression or lack thereof. Neither was employment, relationship status, binge drinking, cocaine use or hepatitis C. In fact, viral suppression was associated with other factors, like younger age, lower income, unstable or no housing, lack of insurance, symptoms of anxiety and depression and cigarette, pot or meth use.

In order to learn exactly which factors were associated with a detectable viral load, the researchers looked at each of these factors one at a time against the finding for race, to see what stood out.

After adjusting for age and race, the odds of Black participants having an undetectable viral load went up if they made more money, had stable homes, had insurance coverage for HIV meds or if they used less marijuana. If Black participants had all these factors, their odds of having an undetectable viral load increased by 21%.

The results led Sullivan and colleagues to call for immediate and full Medicaid expansion in Georgia, more and better public-private partnerships to improve housing for people living with HIV and programs directed specifically toward same-gender-loving Black men. As for addressing the one factor that was up to the men in the study—marijuana use—the authors said it’s unclear whether using lots of marijuana was associated with memory and planning impairment that impacted the men’s HIV med schedule or whether lack of viral suppression and the health conditions associated with it might have led to marijuana use to manage symptoms.

“Health inequities arise from societal inequities, and structural racism is at the core of policies that perpetuate them,” wrote Sullivan and colleagues. “There is still more to understand about the mechanisms of achieving and sustaining viral suppression for Black and white MSM. Similar prospective analyses are needed to describe the factors associated with losing viral suppression to document whether rates of loss of viral suppression are also higher for Black MSM living with HIV in this cohort who have achieved viral suppression.”

Click here to read the full study.