HIV among Asian American and Pacific Islander MSM in the U.S.: A Small Enigma?

1. HIV among Asian American and Pacific Islander MSM in the U.S.: A Small Enigma? Frank Y. Wong, Ph.D. Georgetown University fyw@georgetown.edu Annual Meeting of the Council of State and Territorial Epidemiologists Atlantic City, NJ June 2006

2. Outlines • Background and Contexts • HIV among Asians in the U.S. • Men of Asia Testing for HIV (MATH) • Challenges

3. Background and Contexts • Who is an Asian? • Who is a Pacific Islander? • 15.4 million AAPIs in the U.S. (US Census, 2005) • 5.3% of total population • Diverse ethnic cultures (70 countries; 100 languages and dialects) • 61% are foreign-born • In 2000, 70% immigrants came from India, The Philippines, China, and Viet Nam (US Dept of Homeland Security, 2004) • Over 63% ages 5 and above speak an AAPI language at home • Coastal concentration

4. HIV/AIDS Data Sources • National AIDS surveillance (CDC) • 33 states with long-term confidential name-based HIV reporting (CDC) • Supplemental HIV/AIDS Surveillance or SHAS (CDC) • Other studies

5. HIV/AIDS Definitions • A diagnosis of HIV infection (not AIDS) • A diagnosis of HIV infection and a later diagnosis of AIDS • Concurrent diagnosis of HIV infection and AIDS

6. HIV among AAPIs: National Epidemiology • 1% cumulative AIDS cases • From the beginning of the epidemic through 2005, an estimated 7,739 AAPIs received a diagnosis of AIDS. • An estimated 3,383 AAPIs with AIDS died. • Those with a diagnosis of AIDS during 1997-2004, 81% AAPIs were alive 9 years after diagnosis, compared with 75% whites, 74% of Hispanics, 67% American Indians and Alaska Natives, and 66% blacks.

7. Of those given a diagnosis of AIDS 78% were men (2005).

8. Highest proportion of AIDS cases among men having sex with men (67%) • 4% are MSM IDU • From 1999 to 2003, AIDS cases increased by 35% among AAPIs compared to 8% in African Americans, 7% Latino, and 21% Native Americans. • Majority of AIDS cases among AAPIs are among the foreign-born.

9. HIV among AAPIs: HIV/STI Testing • Wong, Campsmith, Nakamura, Crepaz, & Begley (2004), AIDS Education and Prevention • Compared with whites, a higher percentage of AAPIs cited “illness” as the main reason for HIV testing. • Test was done as a hospital inpatient • Significantly lower percentage of AAPIs than whites were aware of their current CD4 counts.

10. Significantly lower awareness about a number of care-related services. • Among AAPIs, educational level was positively associated with awareness of these services.

11. HIV prevalence in AAPI MSM: 1.4% to 27.8% • Rates of sexual risk behaviors, rectal gonorrhea, syphilis surpassed those of white MSM in 2004 (McFarland et al.), AIDS Education and Prevention

12. Eckholdt & Chin (197), AIDS Education and Prevention • High rate of PCP as AIDS-defining illnesses • Do, Chen, McFarland et al. (2005), AIDS Education and Prevention • One quarter of AAPI MSM had never been tested • Older age, gay sexual orientation, history of STIs, higher lifetime number of sexual partners, and higher acculturation were associated with prior testing • Do, Hudes, Proctor, Han, & Choi (2006), AIDS Education and Prevention • Gay identity, comfort with sexual and AAPI identity, having a main partner, social support, and recent unprotected anal intercourse were associated with HIV testing

13. Issues affecting AAPIs: MSM • Cultural factors • Familial obligations • Saving face • Double jeopardy • Risk perception • Language • Structured factors • Availability of culturally sensitive testing (including langauge capacity) • Knowledge of testing • Travel and migration (?)

14. Men of Asia Testing for HIV(MATH) • To estimate the prevalence and incidence of HIV infection among AAPI MSM. • To describe the socio-cultural and individual-level correlates of HIV testing and knowledge of HIV infection status among AAPI MSM. • To examine the socio-cultural and individual-level of correlates of HIV risk among AAPI MSM. • To evaluate a consortium model framework for conducting scientific, community-based HIV research.

15. MATH Research Team • Scientific Research Team • Georgetown University • University of California at San Francisco • Consortium Team • Asian and Pacific Islander American Health Forum, San Francisco, CA • MATH Community Research Team • AIDS Services in Asia Communities, Philadelphia, PA • Asian American for Community Involvement, San Jose, CA • Asian Health Services, Oakland, CA • Asian & Pacific AIDS Intervention Team, Los Angeles, CA • Asian & Pacific Coalition for HIV/AIDS, New York, NY • Asian & Pacific Islander Wellness Center, San Francisco, CA • Massachusetts Asians and Pacific Islanders for Health, Boston, MA

16. Substance Use/ HIV Risk Behavior Impact Domain 1: Home Country Patterns Impact Domain 2: Migration Experience Impact Domain 3: US Experience Conceptual Model(Chng, Wong, Park, Edberg, & Lai, 2003)

17. What We Proposed to Do • Target Population • Self-identified MSM ages 18 and above (N = 2,400) • Ethnicity • Chinese • Filipino • Korean • Vietnamese • Self-identified as one of the AAPI groups • Language • English • In-language

18. Testing Technology • OraSure • Western Blot • Detuned ELISA • Behavioral Survey • Computerized • Recruitment • Venue-based • Respondent-driven sampling

19. What We Are Doing? • Target Population • Self-identified MSM ages 18 and above (N = 2,000) • Ethnicity • Chinese • Filipino • Japanese • South Asian (Indian) • Vietnamese • Self-identified as one of the AAPI groups

20. Testing Technology • OrasQuick • Behavioral Survey • Paper-and-pencil methodology

21. Some Preliminary Results: I • 106 participants enrolled to date • 13.9% recruited by referral • Mean age: 33 years old (SD = 11.2) • Ethnicity • 41.7% Filipino • 13.9% Chinese • 9.7% Japanese • 9.7% Vietnamese • 4.2% Indian • 30.5% Others • 20% reported English as primary language • 70% foreign-born

22. Some Preliminary Results: II • Sexual behavior • 30% reported lifetime bisexual behavior • Sexual identity • 76.4% gay • 8.3% bisexual • 4.2% straight • 2.8% queer • 8.3% other

23. Some Preliminary Results: III • Prior HIV testing: 73.6% • Mean time since last test: 1.6 years, SD 6.67 • Confirmed HIV-positive • 25 positive by EIA and WB • 22 already knew they were HIV-positive • 3 individuals newly diagnosed (12% of HIV-positive and 2.8% of total) • CD-4 cell count • Median 343 cells/mm3 (range 108-704) • 5 individuals’ viruses sequenced • 1 with NRTI resistance • 5 with 1≥ PI resistance mutations

24. Some Preliminary Results: IV • San Jose County awarded AACI testing capacity • Use MATH as a model

25. CHALLENGES • Challenges … challenges … more challenges …. • Programmatic • $$$$ • Laboratory and regulations • Community capacity • Institutional • Technology • Rapid changing environments

26. Acknowledgement • National Institute on Child Health and Development (RO1HD046354; GPO: Susan Newcomer) • MATH Core Scientific Research Team • Tri D. Do, M.D., M.P.H., UCSF • Vincent A. Crisostomo, Georgetown University • Christian Alvez, Asian and Pacific Islander American Health Forum • Daniel Bao, M.A., Oakland, CA • Brian D. Smith, M.A., Georgetown University • Darwin Young, Georgetown University