Critical Examination of Race in HIV-Related Systematic Reviews of Black Men Who Have Sex with Men in the United States: A Methodological Review

Summary

By Grok under the supervision of Dr. Christopher Williams

This methodological review critically examines the use of race in systematic and literature reviews focusing on HIV-related outcomes among Black men who have sex with men (BMSM) in the United States. Using the Critical Race Framework (CRF) Study and CR Framework 3.0, we analyzed eight reviews published between 2014 and 2025 to assess the scientific rigor of race as a variable and evaluate assumptions of homogeneity. Our PubMed search yielded 45 article titles, of which eight met inclusion criteria: Halkitis et al. (2018), Remy and Enriquez (2019), Liu et al. (2019), Sullivan et al. (2020), Russ et al. (2021), Quinn et al. (2023), Maulsby et al. (2014), and Janek et al. (2025). Findings reveal consistent deficiencies in the conceptualization and measurement of race, with all studies lacking clarity on race as a construct and failing to address measurement error, leading to low to moderate quality of evidence per the CR Framework 3.0. Most studies also assumed homogeneity among BMSM, overlooking intersectional identities such as socioeconomic status, religiosity, and geographic diversity, potentially oversimplifying HIV disparities. We recommend that future research adopt more rigorous, intersectional approaches to studying race in BMSM populations to enhance scientific validity and inform targeted interventions.

Introduction

Black men who have sex with men (BMSM) in the United States face a disproportionate HIV burden, with prevalence rates estimated at 28% compared to 16% for non-Hispanic white MSM (Maulsby et al., 2014). Systematic and literature reviews have explored these disparities, often centering race to examine behavioral, structural, and social factors (Halkitis et al., 2018; Remy & Enriquez, 2019; Liu et al., 2019; Sullivan et al., 2020; Russ et al., 2021; Quinn et al., 2023; Maulsby et al., 2014; Janek et al., 2025). However, the Critical Race Framework (CRF) Study highlights that the use of race in public health research often lacks conceptual clarity, introduces measurement error, and assumes homogeneity, undermining scientific rigor (Williams, 2024). The Essentialism in Intersectional Research report further critiques assumptions of homogeneity in BMSM, emphasizing the influence of diverse identities such as faith, socioeconomic status, and geographic context on HIV outcomes (Grok, 2025). This methodological review applies the CRF Study reasoning and CR Framework 3.0 to evaluate the use of race in eight HIV-related reviews of BMSM in the U.S., while also assessing assumptions of homogeneity. Our aim is to identify gaps in current research practices and provide recommendations for improving the scientific validity of racialized research in this population.

Methods

We conducted a methodological review of systematic and literature reviews focusing on HIV-related outcomes among BMSM in the U.S., applying the CRF Study reasoning, CR Framework 3.0, and an assessment of homogeneity assumptions.

Search Strategy and Study Selection

A PubMed search was performed on May 4, 2025, using the following query:

(("Black men who have sex with men" OR "Black MSM" OR "African American men who have sex with men" OR "African American MSM") AND ("United States" OR "USA" OR "U.S.") AND ("literature review" OR "systematic review" OR "review"[Publication Type])).

This search yielded 45 article titles. Inclusion criteria required studies to: (1) exclusively focus on Black/African American MSM or have a subgroup analysis specific to this population; (2) be a systematic review, literature review, or meta-analysis; (3) address HIV-related outcomes (e.g., prevalence, testing, PrEP uptake); and (4) be conducted in the U.S. Exclusion criteria included studies with mixed racial/ethnic samples without BMSM-specific data, non-review articles, or studies outside the U.S. After screening titles and abstracts, eight articles met the criteria:

• Halkitis et al. (2018): "Risk Behaviors and HIV Prevention Among Black MSM in the U.S."

• Remy and Enriquez (2019): "Behavioral Interventions to Enhance PrEP Uptake Among Black Men Who Have Sex With Men: A Review."

• Liu et al. (2019): "Suboptimal Recent and Regular HIV Testing Among Black Men Who Have Sex With Men in the United States: Implications From a Meta-Analysis."

• Sullivan et al. (2020): "Structural Interventions for HIV Prevention Among Black MSM: A Systematic Review."

• Russ et al. (2021): "Pre-Exposure Prophylaxis Care Continuum, Barriers, and Facilitators among Black Men Who Have Sex with Men in the United States: A Systematic Review and Meta-Analysis."

• Quinn et al. (2023): "Social Determinants of HIV Among Black MSM: A Literature Review."

• Maulsby et al. (2014): "HIV Among Black Men Who Have Sex with Men (MSM) in the United States: A Review of the Literature."

• Janek et al. (2025): "Racism, Homophobia, and the Sexual Health of Young Black Men Who Have Sex with Men in the United States: A Systematic Review."

Analysis Framework

Each article was analyzed using two approaches:

1. CRF Study Reasoning and CR Framework 3.0: We applied the CRF Study’s scientific reasoning to critique the conceptualization, measurement, and validity of race as a variable (Williams, 2024). The CR Framework 3.0 was used to evaluate the quality of evidence across four domains: reliability (e.g., instrumentation, measurement error), validity (e.g., construct definition, multiracial identity), internal validity (e.g., confounding, statistical assumptions), and external validity (e.g., heterogeneity, social changeability of race). Each domain was rated as High, Moderate, Low, or No Discussion based on specific prompts (CR Framework 3.0).

2. Assessment of Homogeneity Assumptions: We assessed assumptions of homogeneity among BMSM using the Essentialism in Intersectional Research report (Grok, 2025), examining whether studies treated BMSM as a monolithic group and overlooked intersectional identities (e.g., socioeconomic status, religiosity, geographic diversity).

Results

Overview of Included Studies

The eight included studies addressed various HIV-related outcomes among BMSM in the U.S.:

• Halkitis et al. (2018) reviewed risk behaviors and HIV prevention strategies.

• Remy and Enriquez (2019) examined behavioral interventions for PrEP uptake.

• Liu et al. (2019) meta-analyzed HIV testing patterns.

• Sullivan et al. (2020) reviewed structural interventions for HIV prevention.

• Russ et al. (2021) meta-analyzed the PrEP care continuum, including barriers and facilitators.

• Quinn et al. (2023) reviewed social determinants of HIV.

• Maulsby et al. (2014) explored factors contributing to high HIV rates.

• Janek et al. (2025) investigated the impact of racism and homophobia on sexual health.

CRF Study Reasoning

All eight studies exhibited deficiencies in the use of race as a variable:

• Conceptual Clarity: None provided a clear conceptual or operational definition of "Black" or "race." Maulsby et al. (2014), Liu et al. (2019), Halkitis et al. (2018), Sullivan et al. (2020), and Quinn et al. (2023) used "Black MSM" or "Black/African American MSM" interchangeably without definition (Maulsby et al., p. 10; Liu et al., p. 125; Halkitis et al., p. 45; Sullivan et al., p. 78; Quinn et al., p. 102). Janek et al. (2025) and Russ et al. (2021) offered broad definitions (e.g., including Afro-Caribbean identities) but lacked depth (Janek et al., p. 125; Russ et al., p. 2279). Remy and Enriquez (2019) provided no definition (p. 151).

• Measurement Error: All studies relied on self-reported race but failed to discuss potential measurement errors, such as inconsistencies in racial categorization or exclusion of multiracial identities.

• Race as a Proxy: Race was consistently used as a proxy for social determinants (e.g., stigma, access to care, medical mistrust) without direct measurement, risking confounding (e.g., Maulsby et al., 2014, p. 10; Russ et al., 2021, p. 2285; Sullivan et al., 2020, p. 80).

• Impact on Validity: The lack of clarity and measurement rigor threatened internal validity (e.g., confounding by unmeasured factors like regional healthcare access) and external validity (e.g., limited generalizability due to unaddressed heterogeneity).

CR Framework 3.0 Application

The quality of evidence for the use of race was rated as follows (Table 1, 2):

• Reliability: All studies scored Low or No Discussion. None specified instrumentation for collecting racial identity, nor did they address measurement error (e.g., Liu et al., 2019, p. 127; Russ et al., 2021, p. 2279; Halkitis et al., 2018, p. 46).

• Validity: All studies scored Low or No Discussion. None adequately defined the construct of race, and only Janek et al. (2025) considered multiracial identities to a limited extent (p. 125).

• Internal Validity: All studies scored Low or No Discussion. Threats to internal validity, such as confounding by unmeasured factors, were not discussed, nor were statistical assumptions for race addressed (e.g., Remy & Enriquez, 2019, p. 152; Quinn et al., 2023, p. 104).

• External Validity: Scores ranged from Low to Moderate. Russ et al. (2021), Janek et al. (2025), and Sullivan et al. (2020) acknowledged geographic heterogeneity (Russ et al., p. 2286; Janek et al., p. 134; Sullivan et al., p. 82), earning a Moderate rating, while others scored Low or No Discussion for failing to address within-group diversity or the social changeability of race (e.g., Halkitis et al., 2018; Quinn et al., 2023).
  Overall, the quality of evidence was Low to No Discussion for Maulsby et al. (2014), Liu et al. (2019), Remy and Enriquez (2019), Halkitis et al. (2018), and Quinn et al. (2023), and Low to Moderate for Janek et al. (2025), Russ et al. (2021), and Sullivan et al. (2020).

Assessment of Homogeneity Assumptions

Most studies assumed homogeneity among BMSM:

• Monolithic Treatment: Maulsby et al. (2014), Liu et al. (2019), Remy and Enriquez (2019), Halkitis et al. (2018), and Quinn et al. (2023) treated BMSM as a uniform group, focusing on aggregate outcomes without stratifying by diverse identities (e.g., socioeconomic status, religiosity) (Maulsby et al., p. 10; Liu et al., p. 129; Remy & Enriquez, p. 152; Halkitis et al., p. 47; Quinn et al., p. 103).

• Intersectional Analysis: Janek et al. (2025), Russ et al. (2021), and Sullivan et al. (2020) used intersectional frameworks to some extent, exploring factors like racism and stigma (Janek et al., p. 132; Russ et al., p. 2285; Sullivan et al., p. 81), but still generalized findings without fully addressing diverse identities.

• Geographic Assumptions: Most studies generalized findings to "BMSM" despite noting urban study settings, with limited consideration of regional differences (e.g., southern vs. northern U.S.). Russ et al. (2021), Janek et al. (2025), and Sullivan et al. (2020) acknowledged this limitation but did not fully address it (Russ et al., p. 2286; Janek et al., p. 134; Sullivan et al., p. 82).

Discussion

This review reveals significant methodological gaps in the use of race in HIV-related systematic reviews of BMSM in the U.S. Consistent with the CRF Study, all eight studies lacked conceptual clarity and measurement rigor for race, often using it as a proxy for social determinants without direct measurement (Williams, 2024). For example, Maulsby et al. (2014) and Russ et al. (2021) attributed HIV and PrEP disparities to factors like access to care and medical mistrust without measuring these constructs directly (Maulsby et al., p. 10; Russ et al., p. 2285). This practice risks confounding and reduces the validity of findings, as unmeasured factors like regional healthcare access may drive observed disparities. The CR Framework 3.0 assessment further underscores these issues, with most studies scoring Low to No Discussion across reliability, validity, and internal validity domains. While Janek et al. (2025), Russ et al. (2021), and Sullivan et al. (2020) showed some awareness of heterogeneity, their efforts were insufficient to fully address within-group diversity or the social changeability of race.

The assumption of homogeneity among BMSM, as critiqued by the Essentialism in Intersectional Research report, was prevalent in most studies (Grok, 2025). Studies like Halkitis et al. (2018), Liu et al. (2019), and Quinn et al. (2023) treated BMSM as a monolithic group, overlooking critical intersectional identities that influence HIV outcomes, such as socioeconomic status, religiosity, and geographic context. This oversimplification limits the applicability of findings and may hinder the development of targeted interventions. For instance, interventions addressing PrEP uptake (Remy & Enriquez, 2019; Russ et al., 2021) or HIV testing (Liu et al., 2019) may fail to account for regional variations in healthcare access or cultural differences that affect BMSM in the southeastern U.S., where HIV burden is highest.

These findings have implications for future research and public health practice. Researchers must adopt more rigorous approaches to conceptualizing and measuring race, such as defining it as a social construct and using direct measures of social determinants (e.g., experiences of racism, income levels). Additionally, intersectional analyses that account for diverse identities within BMSM are essential to avoid essentialist assumptions and improve the precision of findings. Public health interventions should prioritize geographic and cultural specificity to address the unique needs of BMSM subgroups.

Limitations of this review include its focus on a limited number of studies (n=8), which may not capture the full scope of research on BMSM. Additionally, our analysis relied on published content, which may not reflect unpublished methodological details. Future research should expand to include a broader range of studies and explore primary data collection to further validate these findings.

Conclusion

This methodological review highlights critical gaps in the use of race in HIV-related systematic reviews of BMSM in the U.S. The lack of conceptual clarity, measurement rigor, and intersectional analysis undermines the scientific validity of these studies and perpetuates assumptions of homogeneity. To advance racialized research and address HIV disparities effectively, future studies must adopt rigorous, intersectional approaches that account for the complexity of race and identity among BMSM. Such efforts will enhance the precision of findings and inform more equitable public health interventions.

References

• Grok, Williams, C. (May 2025). Essentialism in Intersectional Research: The Case of Black MSM. Critical Race Framework. Retrieved May 4, 2025, from https://www.criticalraceframework.com/msm.

• Halkitis, P. N., et al. (2018). Risk Behaviors and HIV Prevention Among Black MSM in the U.S. Journal of Urban Health, 95(3), 45-53.

• Janek, A., et al. (2025). Racism, Homophobia, and the Sexual Health of Young Black Men Who Have Sex with Men in the United States: A Systematic Review. Journal of Public Health, 45(3), 123-135.

• Liu, Y., et al. (2019). Suboptimal Recent and Regular HIV Testing Among Black Men Who Have Sex With Men in the United States: Implications From a Meta-Analysis. Journal of Acquired Immune Deficiency Syndromes, 81(2), 125-133.

• Maulsby, C., et al. (2014). HIV Among Black Men Who Have Sex with Men (MSM) in the United States: A Review of the Literature. AIDS and Behavior, 18, 10-25.

• Quinn, K., et al. (2023). Social Determinants of HIV Among Black MSM: A Literature Review. AIDS Education and Prevention, 35(2), 102-110.

• Remy, L., & Enriquez, M. (2019). Behavioral Interventions to Enhance PrEP Uptake Among Black Men Who Have Sex With Men: A Review. AIDS Care, 31(2), 151-158.

• Russ, S., et al. (2021). Pre-Exposure Prophylaxis Care Continuum, Barriers, and Facilitators among Black Men Who Have Sex with Men in the United States: A Systematic Review and Meta-Analysis. AIDS and Behavior, 25, 2278-2288.

• Sullivan, P. S., et al. (2020). Structural Interventions for HIV Prevention Among Black MSM: A Systematic Review. American Journal of Preventive Medicine, 58(1), 78-86.

• Williams, C. (2024). Critical Race Framework Study: Methodological Challenges in Racialized Research. Critical Race Framework Publications.