Download Black Men who Have Sex with Men and the HIV Epidemic: Next

 EDITORIALS 
seem to make risk reduction particularly problematic for a substantial fraction of MSM. They
include depression, persistent
problem drinking, high prevalence of recreational drug intake,
including polydrug use, and adult
sequelae of exposure to childhood sexual abuse.
The important new concept
suggested by Ron Stall and colleagues5 is that these conditions
often co-occur in the same individual and, in those circumstances, are synergistic in conditioning difficulties with the
adoption and consistent practice
of safer sex. Certainly, a just and
comprehensive concept of health
would identify these disparities
as important concerns in their
own right. Their association with
HIV makes the development,
evaluation, and dissemination of
effective diagnostic and treatment strategies all the more urgent a public health priority.
David Malebranche6 reminds us
that, as much as we may have
learned about predictors of transmission in predominantly White
MSM communities, our understanding of HIV among racial
and ethnic MSM subgroups remains primitive, desperate for innovative research and intervention approaches.
A rapid assessment methodology that characterizes microenvironments important for HIV
transmission, described by
Richard Needle and colleagues,7
is promising for pinpointing milieus in which risky behaviors
cluster, and also troubling. Interventions, such as they are—
furtive sex stalkers and drug
dealers temporarily scattered by
the beam of a patrol car searchlight—fail to keep pace with the
epiphenomena of transmission.
Now we better understand—who
doubted it?—that sex and drug
exchanges occur outside the daytime office hours kept by prevention project staff, and that risky
behaviors do not segregate
across the arbitrary turf carved
out by disparate public programs.
Heralding the threat of a
resurgent HIV epidemic, the
CDC noted 2 years ago that
MSM, especially young MSM
and MSM of color, were overrepresented among Americans
with HIV, yet underrepresented
in intervention research.8 As
elaborated in this month’s
“Going Public” feature,9 we need
new biomedical technologies as
well as rigorous assessment and
effective translation and dissemination of behavioral approaches
that never were adequately developed and implemented in the
first place to address the prevention needs of MSM. Perhaps
most important, somehow we
need to immunize prevention
science, programs, and policies
against stigma, political opportunism, and sanctimony.
Black Men who
Have Sex with
Men and the
HIV Epidemic:
Next Steps for
Public Health
Black men who have sex with
men (BMSM) are disproportionately affected by HIV/AIDS in
the United States. The Young
Men’s Survey estimates an HIV
incidence rate of 14.7% among
BMSM in 6 US cities, compared
with 2.5% and 3.5% among
White and Hispanic men who
have sex with men (MSM), respectively.1 Yet the disparity is
not explained by higher rates of
unprotected anal and oral sex.
There are 4 possible explanations,
which are not mutually exclusive:
(1) bias in assessment of risk behaviors, (2) increased prevalence
of HIV among sexual contacts,
(3) increased infectiousness
among sexual partners, and (4) increased physiological susceptibility to HIV. By exploring these
possibilities more deeply, we can
increase our understanding of the
apparent disparity between behavioral risks and outcomes while
at the same time improving the
design and implementation of
prevention programs that address
the specific needs of BMSM.
862 | Editorials
Michael Gross, PhD
About the Author
The author is the Journal’s associate editor
for HIV/AIDS and lesbian-gay-bisexualtransgender health.
Requests for reprints should be sent to
Michael Gross, PhD, 1601 18th St NW,
#716, Washington DC 20009 (e-mail:
[email protected]).
This editorial was accepted March 5,
2003.
References
1. Camus A. The Plague. Gilbert S,
trans. New York, NY: Random House;
1948.
2.
Ciccarone DH, Kanouse DE,
RISK ASSESSMENT AND
RISK REDUCTION
Methodological problems that
may lead to underreporting of
Collins RL, et al. Sex without disclosure
of HIV serostatus in a US probability
sample of persons receiving medical
care for HIV infection. Am J Public
Health. 2003;93:949–954.
3. Koblin BA, Chesney MA, Husnik
MA, et al. High-risk behaviors among
men who have sex with men in six
cities in the United States: baseline data
from the EXPLORE Study. Am J Public
Health. 2003;93:926—932.
4. Chesney MA, Koblin BA, Barresi P,
et al. An individualized intervention for
prevention of HIV infection: baseline
data from the EXPLORE Study. Am J
Public Health. 2003;93:933–938.
5. Stall R, Mills TC, Williamson J, et
al. Co-occurring psychosocial health
problems among urban men who have
sex with men are increasing vulnerability to the HIV/AIDS epidemic. Am J
Public Health. 2003;93:939–942.
6. Malebranche D. Black men who
have sex with men and the HIV epidemic: next steps for public health. Am
J Public Health. 2003;93:862–865.
7. Needle RH, Trotter RT, Singer M,
et al. Rapid assessment of the HIV/
AIDS crisis in racial and ethnic minority
communities: an approach for timely
community interventions. Am J Public
Health. 2003;93:970–979.
8. Wolitski RJ, Valdiserri RO, Denning PH, Levine WC. Are we headed
for a resurgence of the HIV epidemic
among men who have sex with men?
Am J Public Health. 2001;91:883–888.
9. Gross M. The second wave will
drown us. Am J Public Health. 2003;
93:872–881.
risk behaviors may also explain
why behavioral messages fail to
translate into safer sex among
BMSM: Measures, surveys, and
instruments may be culturally inappropriate for BMSM; interviewers may not be race- and
gender-concordant with or may
not be properly trained to interview BMSM; instruments may
use language or terminology that
does not resonate with BMSM;
research settings may not be
comfortable environments for
open discussion with and responses by BMSM.
Meanwhile, BMSM research
participants may (1) be unwilling
American Journal of Public Health | June 2003, Vol 93, No. 6
 EDITORIALS 
to use certain sexual orientation
labels on surveys for fear of discrimination, (2) distrust or fear
researchers, (3) fear that confidential information about their
sexual behavior will be disclosed,
or (4) report what they think researchers want to hear.
To solve these problems, researchers must conduct more
qualitative research with BMSM
in environments that provide a
more comfortable atmosphere in
which to talk openly about sensitive sexual issues. Such research
will ultimately guide the development of culturally appropriate
assessment techniques. Employing BMSM as research interviewers may lead to deeper exploration of the unique social
situation of being both Black and
homosexual through common
experiences shared by interviewer and subject.
Likewise, conducting such research away from clubs, bars,
parks, and other public or sexually identified venues may yield
more honest responses. Familiar
locations such as participants’
homes, cars, or other quiet settings chosen by the participants
themselves may equalize power
dynamics, establish trust, and
create a more relaxed environment that promotes honest discussion of intimate sexual behavior. HIV prevention initiatives
based on a more accurate reporting of sexual behavior will more
adequately reflect the life experiences of BMSM.
Additionally, interventions
should be offered in familiar and
empowering settings. For example, the African, American, Advocacy, Support-Services and Survival Institute, in Los Angeles,
Calif, designed the Critical Thinking and Cultural Affirmation
(CTCA) model, targeting BMSM
engaging in unsafe sex. CTCA is
a 6-month intervention that combines individual psychological
counseling with education on
Black history, critical thinking
methods, concepts of self-love
and respect, and an “HIV 101”
course.
Thirty-two Black men from
various socioeconomic backgrounds were surveyed before
and after participating in the
CTCA program. After completing the program, only 30% exhibited a willingness to put
themselves at risk for HIV, versus 70% before the program;
80% of the men responded that
they valued themselves as Black
men, had a positive self-concept,
and were willing to protect
themselves and their community
from HIV.2 The CTCA model
was community generated and
maintained, and approaches HIV
prevention and sexual responsibility by emphasizing the cultural affirmation of Black men,
regardless of income or sexual
identity. Despite the small sample size and lack of a comparison population, the outcome of
the CTCA program is encouraging for new approaches to HIV
prevention among BMSM.
Unfortunately, few programs
and evaluations consider the role
of the church and spirituality in
HIV prevention for BMSM. Numerous reports of homophobia
within Black churches obscure
the positive initiatives and contributions of some HIV/AIDS ministries. Organizations such as The
Balm in Gilead and Interfaith
HIV Network hold conferences,
provide capacity building to
churches and pastors, disseminate HIV educational materials,
and create a medium by which
issues of sexuality and HIV can
now be discussed in the Black
faith-based community. Despite
condemnation of homosexuality
June 2003, Vol 93, No. 6 | American Journal of Public Health
from many pulpits, church and
spirituality play a pivotal role in
the lives of many BMSM.
SEXUAL NETWORKS AND
MASCULINITY
Evaluating whether BMSM select sexual partners who are
more likely to be HIV-infected
requires a more comprehensive
understanding of how sexual
partners are selected and behavioral risks are assessed. In the 6city study mentioned previously,
93% of the HIV-infected BMSM
did not know they were infected,
and many felt they were at low
risk for HIV.3
Having sex in certain settings—
such as gay-identified venues,
parks, and correctional facilities—
and engaging in “situational sex”
for drugs or money may increase
risk of HIV exposure and are relevant to this discussion. However, relationships between the
social construct of Black masculinity, sexual identification, and
sexual behavior decisionmaking
have not been adequately explored. BMSM are more likely to
identify as heterosexual or bisexual and less likely to identify as
gay than their White counterparts.4 Disclosing one’s homosexuality (“coming out”) has traditionally been associated with
improved mental health, more responsible sexual behavior, increased awareness of HIV risk,
and improved access to HIV prevention services.5,6 Yet BMSM
who disclose their sexual orientation have a higher HIV prevalence (24% vs 14%) and engage
in more unprotected anal sex
(41% vs 32%) than nondisclosers.7 So if disclosure of one’s
sexuality is not necessarily associated with safer sexual behavior
and decreased HIV risk for
BMSM, pressuring these men to
“come out of the closet” may be
counterproductive, particularly
with “down low” Black men
(men who secretly engage in homosexual behavior while living
“heterosexual” lives).
A deeper description of masculinity and gender roles among
BMSM is needed. Homosexual
desire, behavior, and identification are influenced by gender
roles and expectations predicated on one’s race, ethnicity, socioeconomic status, religious affiliation, and other factors. Black
masculinity is described as “fragmented” owing to denial of traditional opportunities for masculine affirmation (education,
employment, property ownership) by institutional and personal racism.8 In response, Black
men may adopt a “cool pose,”
exaggerating attributes of physical and heterosexual prowess to
compensate for disempowerment in other areas.9 Having female conquests, engaging in unprotected sex, and fathering
babies are important gender role
expectations that may influence
sexual behavior and HIV transmission among Black men, particularly BMSM.
Do race-specific gender role
and masculine expectations influence what sexual identity label
BMSM choose, whether they
continue to have sex with
women, their sexual roles (“top”
or “bottom”), their sexual behavior choices (oral, anal, protected,
unprotected), or the types of men
they allow in their sexual networks? One young Black man
described his sexual behavior decisionmaking process with
“trade”—a masculine-appearing
or -acting Black man: “A lot of
time whatever trade wants is
what trade gets. If that boy don’t
want—‘Oh, it don’t feel the same
with a condom on’—if he feel like
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 EDITORIALS 
that then a lot of time it’s like ‘ok
then,’ ‘all right then. And that
alone could be it [the reason to
have unprotected sex]’” (Fields
EL, Fullilove RE, and Fullilove
MT; unpublished data; 2001).
This young man abandoned
use of a condom, despite his
awareness of HIV risk, in pursuing an ideal of Black masculinity
in a sexual partner. Masculinity
as a concept influences sexual
identities ranging from “down
low” to transgendered; sexual
networks; perceived riskiness of
sexual partners; and choices to
engage in unprotected sex. Further exploration of these dynamics is needed to explain the gap
between HIV knowledge and
behavior.
INCREASED HIV
INFECTIVITY AND ACCESS
Concurrent ulcerative (syphilis,
herpes) or nonulcerative (chlamydia, gonorrhea) sexually transmitted infections (STIs) may facilitate HIV transmission.10,11 STI
prevalence has not been adequately evaluated in attempts to
understand HIV incidence disparities between BMSM and
MSM of other ethnicities.
Whether or not undiagnosed
or untreated STIs prove to be an
important variable, we do know
that BMSM are less likely than
other MSM to know their HIV
status. BMSM are therefore less
able to inform their sexual partners and perhaps more likely to
have acute infection or a higher
viral load than other MSM.
What social experiences affect
BMSM’s knowledge of their
HIV/STI status? In 8 focus
groups conducted in New York,
my colleagues and I asked 81
BMSM about their health care
experiences (Malebranche D,
Fullilove RE, Peterson JL, Stack-
864 | Editorials
house RW; unpublished data;
2001). Many participants—already struggling with displacement from both the gay White
community for being Black and
from the Black community for
being homosexual—said that
they had experienced additional
racism and sexual prejudice with
all levels of medical staff in
medical settings. This experience influenced their health
care utilization, communication,
and medication adherence behaviors. We concluded that access to and quality of health
care services received by BMSM
can be influenced by both the
internalization of their everyday
discriminatory experiences and
negative interactions with medical staff.
BMSM’s reduced knowledge
of their serostatus and their
poorer treatment outcomes if
HIV-positive12 may be related
to negative experiences with
medical personnel that result in
fear of judgment and discrimination, which influences risk
behavior disclosure, willingness
to undergo HIV testing, and to
return for test results, and medication adherence if infected.
Delays in HIV diagnosis and
treatment can lead to more
rapid disease progression and
increased infectivity, ultimately
increasing risk among sexual
networks of BMSM.
These findings demonstrate
the need for a holistic approach
to addressing increased HIV infectivity among BMSM that
evaluates the complex relationship between possible biological
cofactors, (such as high STD
prevalence and high viremia)
and social variables, such as
racism, sexual prejudices, and
poverty, that can influence access to and adherence with medial care.
INCREASED
SUSCEPTIBILITY
Psychoneuroimmunology—the
study of interactions between
psychological factors and immune system function—has already identified associations between mental states and disease
progression. For example, for
HIV-seropositive gay men, traumatic events, such as the death
of a partner, or attributions of
negative experiences to self can
predict faster CD4 decline and
progression of disease.13,14 Exploring the relationship between
stress, mental health, and immune markers of susceptibility to
HIV is a plausible approach to
understanding the current disparity in HIV rates between BMSM
and other MSM.
While low self-esteem and the
internalization of racism and
sexual prejudice may influence
mental health and selection of
specific sexual partners and behaviors, immune system responses to these stressors may
also explain increased susceptibility to HIV infection among
BMSM.15 If so, future research
correlating mental health measures, immune markers, and HIV
prevalence—as well as interventions emphasizing specific coping
strategies to address the mental
health of BMSM (and other
MSM)—would be useful and
could lead to future areas for intervention to empower BMSM to
protect themselves from HIV,
emotionally, behaviorally, and
physiologically.
WHERE DO WE GO FROM
HERE?
Twenty-two years into the HIV
epidemic, we find ourselves at a
watershed. The next steps we
take with regard to BMSM will
shape the evolution of prevention
and intervention programs and
policies in the years to come. Robust research on and effective
outreach to BMSM requires the
identification of diverse recruitment venues to reach and serve
a population that is equally diverse in its sexual experiences
and identification. Additionally, it
requires methodologies that minimize biased self-reporting of sexual behaviors and research instruments that reflect culturally
specific variables influencing this
population.
Our assessment of risk behaviors and selection of sexual partners among BMSM needs to take
into account distinct meanings of
masculinity in relation to race
and culture. In particular, dynamics related to protective
norms among White MSM—such
as “coming out”—should not be
simplistically transferred to
BMSM. Our understanding of infectiousness and susceptibility
among BMSM must be informed
by considerations of the interactions between the immune system, psychology, culture, and social context, including the health
care setting—where racial and
sexual prejudice may impair delivery of services, helping to perpetuate rather than ameliorate
the HIV epidemic.
David J. Malebranche, MD, MPH
About the Author
Requests for reprints should be sent to
David J. Malebranche, MD, MPH, Division of Medicine, Emory University, 69
Jesse Hill Jr Dr, Atlanta, GA 30303
(e-mail: [email protected]).
This editorial was accepted February
26, 2003.
Acknowledgment
Thanks to Michael Gross, PhD, for his
valuable suggestions on revisions to this
editorial.
American Journal of Public Health | June 2003, Vol 93, No. 6
 EDITORIALS 
References
1. Centers for Disease Control and
Prevention. HIV incidence among
young men who have sex with men—
seven US cities, 1994–2000. MMWR
Morb Mortal Wkly Rep. 2001;50:
440–441.
2. Manago C. The Critical Thinking
and Cultural Affirmation Model—A Strategy for African American Health. Los Angeles, Calif: African, American, Advocacy Services-Support and Survival
Institute; 2002.
3. Centers for Disease Control and
Prevention. Unrecognized HIV infection, risk behaviors, and perceptions of
risk among young black men who
have sex with men—six US cities,
1994–1998. MMWR Morb Mortal
Wkly Rep. 2002; 51:733–736.
4.
Heckman TG, Kelly JA, Bogart LM,
Ruth Rice
Puffer
Kalichman SC, Rompa DJ. HIV risk differences between African-American and
white men who have sex with men.
J Natl Med Assoc. 1999;91:92–100.
5. Vincke J, Bolton R, Mak R, Blank
S. Coming out and AIDS-related high
risk sexual behavior. Arch Sex Behav.
1993;22:559–586.
6. Kennamer JD, Honnold J, Bradford
J, Hendricks M. Differences in disclosure
of sexuality among African American
and white gay/bisexual men: implications for HIV/AIDS prevention. AIDS
Educ Prev. 2000;12:519–531.
issues in theory and research related to
black masculinity. West J Black Stud.
1986;10(4):161–166.
9. Bush LV. Am I a man?: a literature
review engaging the sociohistorical dynamics of black manhood in the United
States. West J Black Stud. 1999;23(1):
49–57.
10. Bentwich Z, Maartens G, Torten D,
Lal AA, Lal RB. Concurrent infections
and HIV pathogenesis. AIDS. 2000;14:
2071–2081.
7. Centers for Disease Control and
Prevention. HIV/STD risks in young
men who have sex with men who do
not disclose their sexual orientation—six
US cities, 1994–2000. 2003;52:
81–86.
11. Anzala AO, Simonsen JN, Kimani J,
et al. Acute Sexually transmitted infections increase himan immunodeficiency
virus type 1 plasma viremia, increase
plasma type 2 cytokines, and decrease
CD4 cell counts. J Infect Dis. 2000;182:
459–466.
8.
12. Blair JM, Fleming PL, Karon, JM.
Franklin C. Conceptual and logical
On September 2, 2002, at the
age of 95, Ruth Rice Puffer died.
I met Dr Puffer in March
1962, when she came to the
School of Public Health at the
University of São Paulo to discuss
the operational aspects of the
Inter-American Investigation of
Mortality in Adults. This was an
international collaborative project including 10 large cities in
Latin America (among them São
Paulo), 1 city in England, and 1
city in the United States. The
purpose was to get the most
complete and comparable data
on the deaths of adults between
15 and 74 years of age, and one
of the major objectives was to
find out whether the differences
in mortality patterns in published
statistics were real or a result of
poor-quality data.
I had just completed my internship and started to work at
the University Hospital at the
University of São Paulo when I
was invited to participate on the
team in São Paulo responsible for
the investigation. My job was to
carefully read the interviews with
the families and physicians, the
hospital records, and the necropsy reports of every case in-
June 2003, Vol 93, No. 6 | American Journal of Public Health
cluded in the sample and to report the underlying cause of
death, complications, and terminal cause. On the basis of this information I was to create a new
death certificate. I had never participated in such an important investigation, and I knew very little
about mortality statistics or even
about epidemiology.
DEDICATION TO QUALITY
Dr Puffer frequently visited
the investigation areas and I attended her meetings when she
was in São Paulo. She was almost
obsessive about the project development. She reviewed the
drawing of death certificate sample cases, read several questionnaires to assess the accuracy of
responses, and many times she
requested a new visit to the family to have another interview because in her opinion the questionnaire had not been filled in
accurately. All this to improve
the quality of data collection.
Another important contribution was her instruction to check
the existence of death cases that
had not been registered and
therefore would not be included
Trends in AIDS incidence and survival
among racial/ethnic minority men who
have sex with men, United States,
1990-1999. J Acquir Immune Defic
Syndr. 2002;31:339–347.
13. Segerstrom SC, Taylor SE, Kemeny
ME, Reed GM, Visscher BR. Causal attributions predict rate of immune decline in HIV-seropositive gay men.
Health Psychol. 1996;15:485–493.
14. Kemeny ME, Weiner H, Duran R,
Taylor SE, Visscher B, Fahey JL. Immune system changes after the death of
a partner in HIV-positive gay men. Psychosom Med. 1995;57:547–554.
15. Stokes JP, Peterson JL. Homophobia, self-esteem, and risk for HIV
among African American men who
have sex with men. AIDS Educ Prev.
1998;10:278–292.
in the study. She showed how
this had happened in other
areas, in her international experience and even in the United
States when she was director of
statistical services in the Department of Public Health for the
state of Tennessee. She would
also discuss and compare the
causes of death reported by physicians in the original death certificates with the causes entered
in the new certificates issued
after the investigation. She
strongly suggested that educational materials on this subject
be distributed to physicians and
students and that lectures be
given in medical associations,
hospitals, clinics, and other
places. This was done, and on 2
occasions when she was visiting
São Paulo, she participated in
these meetings. She was not a
physician and barely spoke Portuguese, but she was always talking with doctors and was always
able to convince them of the importance and the uses of mortality statistics, which should be, as
she used to say, “complete and
of quality.”
In 1967 the book with the investigation results was published
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