Anyone who was following the HIV epidemic in 2001 found the news shocking: The US Centers for Disease Control and Prevention (CDC) reported that, in a massive study of young gay men in the United States, a whopping 32 percent of those who were black had HIV. This rate was on a par with those in sub-Saharan Africa, and more than four times higher than the rate among gay men overall. Most researchers were dumbfounded: Why, after some 15 years of widespread campaigns in gay communities urging condom use, was the HIV rate among black men so staggeringly high—and still rising?
Public health has been trying to answer these questions ever since. Even as the epidemic has slowed dramatically in other populations, new infections among black gay men spiked 22 percent between 2005 and 2014. Among black men under 24 years old, infections shot up 87 percent. Why?
That question has lots of complicated answers. But today, many researchers have shifted their attention to a major scientific breakthrough that, they hope, will simplify things considerably. In 2012, a groundbreaking study estimated that sexually active gay men who took a daily (or very close to daily) dose of Truvada, a medication initially developed to treat HIV infection, reduced their chances of getting the virus by 99 percent. The FDA approved Truvada’s use for preventive purposes—what’s called pre-exposure prophylaxis, or PrEP. More recent research has put PrEP’s effectiveness for people who take it faithfully at 100 percent. Finally, after more than 30 years of the epidemic, there is a prevention tool other than condoms.
But the effort to turn PrEP’s promise into a reality is providing insight that is valuable beyond HIV. The long, failing attempt to crack the riddle of black gay men’s higher HIV rate is a cautionary tale for any public-health system operating in a world with endemic inequity.
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If ever anyone was going to grow up to be an HIV-prevention researcher, it was Greg Millett, who was at the CDC when the 2001 study broke. Coming of age in 1980s Brooklyn, the son of a Panamanian microbiologist at St. Vincent’s in Greenwich Village—the hospital that became the epicenter of the AIDS epidemic in New York—Millett knew he was gay from an early age. At conservative Dartmouth College in New Hampshire, his coming-out (in the school paper, no less) prompted what he calls “a bit of a ruckus. Lots of people came up to me and said, ‘There’s no way you’re gay; you’re masculine and great at sports.’” He remembers being the only openly gay black person on campus, at a time when there were not more than 10 openly gay students at Dartmouth of any kind.
When he graduated and returned to New York in 1990, the AIDS epidemic was already raging. By the time he was 21, Millett had seen 18 of his friends die within the course of a single year. Aiming to overcome his personal fear of the disease, he volunteered at Gay Men’s Health Crisis, running HIV-prevention workshops for black and Latino men. But he wanted to delve deeper into the science, so he entered the prestigious public-health school at the University of North Carolina at Chapel Hill. “It was like the skies fell open for me,” Millett recalls. “I fell in love with being able to design studies and interpret statistics.” When he graduated, the CDC invited him to Atlanta to work on HIV prevention for young gay men. With no truly effective treatment for the disease discovered until 1996, it was the heyday of so-called behavioral interventions—programs that brought gay men together to talk about how to make safer sexual choices and reduce their risk.