Race and sexual identity can play a significant role in an individual’s health and healthcare experiences.1,2 Black gay, bisexual and other men who have sex with men (gbMSM) face challenges related to both race and sexual identity (among other identities with which they may self-identify) when navigating HIV prevention and care. Although there are no national HIV prevalence and incidence estimates in the Black community in Canada, it was estimated that 46.6% of all new HIV infections in Canada in 2020 were in gbMSM.3 An increased understanding of the social and structural context impacting Black gbMSM affected by HIV will help service providers better support them. This article summarizes the results of a scoping review that examined factors impacting HIV prevention and care for Black gbMSM in Canada.4
What kind of research did the scoping review include?
The review included 19 articles and reports published from 2004 to 2020. An article or report was included if it:
- involved self-identified Black gbMSM with or without HIV in Canada
- examined HIV prevention or care among Black gbMSM
- was published in English or French
The review included both published literature and grey literature. All the included published literature involved gbMSM in Ontario, except for one article with participants from Ontario and Nova Scotia and one article that compared gbMSM from Canada, the United States and the United Kingdom. As part of the grey literature search, the authors examined reports from HIV and health organizations that work with Black communities. The organizations included in the study were also primarily from Ontario.
What factors impact HIV prevention and care among Black gbMSM in Canada?
The results of the review were grouped into four themes:
- engagement with HIV prevention and care cascades
- healthcare experiences
- social determinants of health and HIV healthcare access
- Canadian HIV interventions
Engagement with HIV prevention and care cascades
Ten studies included findings on how Black gbMSM engage with steps in the HIV prevention and care cascades. The studies provided insight on HIV epidemiology, HIV testing and pre-exposure prophylaxis (PrEP) use among Black gbMSM.
HIV epidemiology
The review included studies that looked at HIV diagnosis rates among Black gbMSM compared with other populations. The review found that Black gbMSM have higher HIV diagnosis rates than white gbMSM. Compared with Black men who have sex with women, Black gbMSM had higher HIV and syphilis prevalence. Compared with other gbMSM, Black gbMSM had a higher prevalence of chlamydia, herpes simplex type 1 and type 2, and active hepatitis B infection.
HIV testing
The review found that HIV testing rates were lower among Black gbMSM than other ethnicities. Among Black gbMSM, age (being older than 21 years of age), engaging in condomless sex, past chlamydia infection, and having relatives or friends with HIV or who died of HIV were associated with having an HIV test. Factors associated with not getting an HIV test included low risk perception and use of safer sex strategies. Family doctors' offices were found to be the most likely place where Black gbMSM had an HIV test.
Factors associated with HIV diagnosis in Black gbMSM were the number of male partners (six or more), being older than 24 years of age and having a syphilis diagnosis.
Pre-exposure prophylaxis (PrEP) use
The review found that Black gbMSM accepted PrEP at higher rates than Black men who have sex with women but at similar rates to other gbMSM populations. Black gbMSM in younger age groups and gbMSM who were Canadian born were less likely to accept PrEP. The most common reasons for not accepting PrEP were concerns about side effects and low perception of risk for HIV transmission.
Healthcare experiences
Four studies included findings on the experiences of Black gbMSM accessing healthcare in Canada. The studies provided insight on experiences with discrimination, inadequate healthcare and missed opportunities for linkage to HIV prevention and care.
Discrimination
Black gbMSM reported discrimination when accessing HIV care and prevention interventions such as PrEP. Black gbMSM felt being Black created a barrier to accessing care, and they perceived neglect from healthcare staff, whom they observed favouring patients who were White. When engaged in care at Black-centred organizations, men reported feeling uncomfortable discussing their sexual practices.
Inadequate health care
When accessing care, Black gbMSM reported receiving low-quality and uncompassionate care, as well as depersonalized care during which healthcare providers demonstrated a lack of sincere interest in their sexual health. Black gbMSM also reported that their mental and emotional well-being was not considered during healthcare interactions, including when receiving an HIV diagnosis.
Missed opportunities for linkage to HIV prevention and care
Studies found that healthcare providers did not provide Black gbMSM with information about HIV, including prevention and treatment interventions that would be of benefit to them. As a result, Black gbMSM felt they needed to self-advocate for their own care. Despite receiving regular HIV testing, Black gbMSM were unaware of PrEP or had inaccurate knowledge about PrEP.
Social determinants of health and HIV prevention and care
Ten studies included findings examining social factors impacting how Black gbMSM engage in HIV prevention and care. The studies provided insight on their experiences with stigma and homophobia; employment, income and housing; immigration; education; and mental health and emotional well-being.
Stigma and homophobia
Black gbMSM reported experiencing stigma and homophobia that impacted their use of HIV prevention services. For example, fear of ostracization from their community prevented them from having discussions about their sexual practices, and associations of HIV with a gay identity reduced the self-perceived risk for HIV of Black gbMSM who identified as heterosexual. Associations of PrEP with promiscuity also impacted Black gbMSM’s knowledge of PrEP.
Fear of HIV stigma and rejection impacted the likelihood that Black gbMSM with HIV would disclose their status to their sexual partners. Stigma also impacted the engagement of Black gbMSM with HIV in care, as Black gbMSM had concerns about privacy, confidentiality and judgment within healthcare organizations.
Employment, income and housing
Studies found unemployment and difficulties securing employment were concerns for Black gbMSM. In one study in Ontario, Black gbMSM had lower incomes than the average income of a sample of gbMSM. Lower income contributed to housing insecurity and poverty, and income disparities created barriers to HIV prevention. Concerns about their ability to afford PrEP limited Black gbMSM’s PrEP discussions with healthcare providers. Black gbMSM were also unaware of the programs available to assist with PrEP costs.
Immigration
Black gbMSM reported several barriers to HIV prevention and care related to migrant and immigrant experiences, such as language barriers, barriers associated with immigration law and immigration status, and experiences of racism and xenophobia within White gay communities. These barriers prevented Black gbMSM from accessing HIV medication and care and contributed to low HIV prevention and PrEP knowledge.
Education
Education was another factor impacting Black gbMSM’s knowledge of and ability to learn about HIV prevention methods. The review found that lower achievement in formal education, as well as low reading and writing skills, may limit Black gbMSM's ability to learn about HIV and sexual health. Black gbMSM also described experiences with heteronormative sexual education as a barrier to learning about HIV prevention methods relevant to their sexual practices.
Mental health and emotional well-being
The mental health of Black gbMSM was impacted by the stigma they experienced within their cultural communities related to their sexual practices. Feelings of isolation, alienation and internalized homophobia can lead to depression and psychological distress and impact the ability of Black gbMSM to access and engage in HIV prevention and care.
Canadian HIV interventions
The review included HIV interventions for Black gbMSM in Canada that the researchers identified in the course of their published and grey literature search. These were categorized as biomedical interventions, behavioural interventions and structural interventions. All of the specific interventions discussed below were conducted in Ontario.
Biomedical interventions
Condoms are the most accessible biomedical intervention for Black gbMSM. The Toronto-based organization Black CAP facilitated condom access at settings frequented by Black gbMSM, such as clubs, barbershops, bathhouses, Pride and other community events. Black CAP also developed a partnership with a local sexual health clinic to provide access to HIV and syphilis testing for Black gbMSM specifically.
Behavioural interventions
Behavioural interventions identified in the review included workshops and awareness campaigns that aimed to improve HIV risk perception and literacy, create awareness of HIV prevention services and change behaviours to reduce HIV transmission risk. For example, Black gbMSM reported “Keep It Alive” from the African and Caribbean Council on HIV/AIDS in Ontario (ACCHO) as an example of a campaign that had an impact on their HIV risk reduction behaviours. The campaign aimed to increase HIV literacy and knowledge in the Black community by using various forms of media (e.g., popular gay media) to promote testing and reduce stigma.
Structural interventions
Interventions that aim to reduce social inequalities were identified. Black CAP provided interventions that included linking Black gbMSM to support services that address food insecurity, housing, income and immigration issues, as well as programs that focus on employment.
What are the implications of the review for service providers?
The review identified factors that impact HIV prevention and care among Black gbMSM in Canada. A wide array of social and structural barriers and facilitators were found in the literature; addressing the barriers and recognizing the facilitators can help service providers deliver more effective HIV prevention and care for Black gbMSM. Key considerations for service providers include:
- Anti-Black racism, stigma and homophobia were concerns underlying many of the barriers to services and care experienced by Black gbMSM. Service providers should remain mindful of these issues and incorporate into their programming ways to help Black gbMSM address them in their lives. Service providers should also be mindful of their own attitudes and biases as well as the biases that may be present in their programs and policies to ensure equitable, non-judgmental care for all Black gbMSM regardless of their HIV status.
- The review authors stressed the importance of programs and services that address the intersections between race, gender and sexuality in HIV prevention and care for Black gbMSM. Culturally responsive programs that deal with multiple system-level, provider-level and patient-level barriers and social determinants of health are needed, not just approaches that address barriers in isolation.
- The review did not find examples of Canadian PrEP programs targeted to Black gbMSM despite the importance of PrEP as an HIV prevention strategy. Black gbMSM in Canada would benefit from tailored programs that facilitate and promote PrEP use and address the barriers limiting their knowledge of and access to PrEP.
- The review also did not find examples of Canadian interventions promoting linkage to and engagement in care for Black gbMSM with HIV. Future work in this area is needed to help Black gbMSM with HIV receive the care they seek.
When considering this scoping review, it is important to remember that much of the evidence found in the review was about the experience of and programs for Black gbMSM in Ontario. Understanding the factors impacting Black gbMSM in other provinces and territories will enhance our ability to develop HIV prevention and care programs to support them. Discovering and documenting unpublished programs from other regions in Canada will also add to the number of program models service providers can draw from in their work.
What is a scoping review?
Scoping reviews use a rigorous process to identify all the studies related to a specific, often emerging, topic. Relevant studies can then be used to understand the scope, volume and characteristics of research available on the topic, as well as identify where there may be gaps in the literature.
References
- Public Health Agency of Canada. Social determinants and inequities in health for Black Canadians: A snapshot. Ottawa: PHAC; 2020. Available from: https://www.canada.ca/en/public-health/services/health-promotion/population-health/what-determines-health
/social-determinants-inequities-black-canadians-snapshot.html - Rainbow Health Ontario. Health in focus: Racialized 2SLGBTQ health. Toronto: Sherbourne Health; 2022. Available from: https://www.rainbowhealthontario.ca/wp-content/uploads/2022/03/Health-in-Focus-Racialized-2SLGBTQ-Health-1.pdf
- Public Health Agency of Canada. Estimates of HIV incidence, prevalence and Canada’s progress on meeting the 90-90-90 HIV targets, 2020. Ottawa: PHAC; 2022. Available from: https://www.canada.ca/en/public-health/services/publications/diseases-conditions/
estimates-hiv-incidence-prevalence-canada-meeting-90-90-90-targets-2020.html - Demeke J, Djiadeu P, Yusuf A et al. HIV prevention and treatment interventions for Black men who have sex with men in Canada: Scoping systematic review. JMIR Public Health and Surveillance. 2024;10:e40493. Available from: https://publichealth.jmir.org/2024/1/e40493
Externally reviewed by: Jemal Demeke
About the author(s)
Erica Lee is CATIE’s manager of website content and evaluation. Since earning her master of information studies, Erica has worked in the health library field, supporting the information needs of frontline service providers and service users. Before joining CATIE, Erica worked as the Librarian at the AIDS Committee of Toronto (ACT).