Alicia Sands Lurry, 404/616-6389, firstname.lastname@example.org
ATLANTA Why do black men who have sex with other men suffer a burden of HIV/AIDS that is up four times as great as those of whites and Hispanics? David J. Malebranche, MD, MPH, clinical instructor of medicine in the Division of General Medicine at the Emory University School of Medicine and internist at Grady Memorial Hospital, suggests there are four possible answers, but they all drive home the need for more research and heightened action by the public health establishment.
His views are set forth in an editorial in the June 2003 issue of American Journal of Public Health. It challenges HIV and AIDS public health professionals and researchers to take new steps toward resolving the dilemma of HIV/AIDS in the United States that disproportionately affects black men who have sex with men.
The term "black men who have sex with men" is used to include the many black men who engage in homosexual behavior but do not identify as "gay."
In the editorial, Dr. Malebranche says that black men who have sex with men (BMSM) are disproportionately affected by HIV/AIDS in the United States. He notes that the Young Men’s Survey estimates an HIV incidence rate of 14.7 percent among black men who have sex with men in six U.S. cities, compared with 2.5 percent and 3.5 percent among white and Hispanic men who have sex with men, respectively. Dr. Malebranche says the disparity, however, is not explained by higher rates of unprotected anal and oral sex. Rather, four possible explanations include bias in assessment of risk behaviors; increased prevalence of HIV among sexual contacts; increased infectiousness among sexual partners; and increased physiological susceptibility to HIV.
"From the studies so far that we’ve seen assessing risk behavior, there’s been really little difference in the amount of reported risk behavior between black, white, Latino and Asian men, yet black men are getting HIV at such a disproportionate rate than their other counterparts," says Dr. Malebranche, who treats HIV-infected patients and performs research on health disparities among African-American men. "This editorial explores how we can take the next steps forward to look at a public health agenda to address why that exists."
The need for more accurate risk assessment models and risk reduction are essential in addressing the specific needs of black men who have sex with men, Dr. Malebranche writes. In the editorial, Dr. Malebranche explains that measures, surveys and instruments may be culturally inappropriate for BMSM. He notes that 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; and research/medical settings may not be the most comfortable environments for the participants and may impede an open discussion with and responses by BMSM.
These factors, Dr. Malebranche hypothesizes, may lead to underreporting of risk behaviors and explain why behavioral messages fail to translate into safer sex among BMSM.
Dr. Malebranche also hypothesizes that BMSM research participants may be unwilling to use certain sexual orientation labels on surveys for fear of discrimination, distrust or fear of research, fear that confidential information about their sexual behavior will be disclosed, and may be reporting what they think researchers want to hear.
The key to alleviating distrust of researchers among BMSM, Dr. Malebranche explains, is for researchers to begin reconstructing surveys, redesigning assessment techniques, reconsidering those who conduct interviews, and changing locations, as a way of soliciting 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," Dr. Malebranche writes. "HIV prevention initiatives based on a more accurate reporting of sexual behavior will more adequately reflect the life experience of black men who have sex with men."
Dr. Malebranche also points to the Critical Thinking and Cultural Affirmation (CTCA) model, developed by the African-American Advocacy Support Services and Survival Institute in Los Angeles, Calif., which targets BMSM engaging in unsafe sex. CTCA is a six-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. Of the 32 surveyed men who completed the program, 30 percent reported a willingness to put themselves at risk for HIV, versus 70 percent before the program. Another 80 percent responded that they valued themselves as black men, had a positive self-concept, and were willing to protect themselves and their community from HIV.
The editorial also tackles the issue of sexual networks and masculinity and how sexual partners are selected and behavioral risks are assessed. In it, he explores the social construct of black masculinity, sexual identification, and sexual behavior decision-making. For example, Dr. Malebranche writes that 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. Black men who have sex with men, he writes, also are more likely to identify themselves as heterosexual or bisexual and less likely to identify as gay than their white counterparts.
And while "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 for white gay men, BMSM who disclose their sexual orientation have a higher HIV prevalence (24 percent versus 14 percent) and engage in more unprotected anal sex (41 percent versus 32 percent) than non-disclosers.
While not disclosing homosexual behavior is not necessarily associated with safer sexual behavior and decreased HIV risk for BMSM, Dr. Malebranche asserts that all black men (including BMSM) face institutional and personal racism. In response to societal expectations of what it means to be a black man, some BMSM resort to physical and heterosexual prowess, engage in unprotected sex, get married and father children to prove their manhood. Dr. Malebranche notes that these factors may influence sexual behavior and HIV transmission among black men, particularly BMSM.
"HIV has really been thoroughly explored as a medical disease, but there’s a lot more that we need to do, in terms of determining the how’s and why’s of why people chose to engage in certain behaviors at certain times and what specifically influences these men to either get in certain sexual networks or make behavioral decisions that may put them at more risk for HIV," he says.
Dr. Malebranche also writes that access to and quality of health care services received by BMSM can be influenced by both the internalization of racism and negative interactions with medical staff. This may result, he hypothesizes, 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.
"What you find is that black men who come into clinics come into care a lot of times and are diagnosed when they’re in stage AIDS or at a far level of HIV diagnosis," Dr. Malebranche says. "So if you have situations where people are scared for whatever reason to get tested earlier, then of course, by the time they get tested, they’re not only going to be diagnosed later in the stage of HIV, but they also will be more infectious to other black men and women they’re having sex with."
In conclusion, Dr. Malebranche asserts that social stressors such as racism, sexual prejudice and masculine expectations may actually depress the immune systems of BMSM more than their white counterparts, hence making them more susceptible to being infected with HIV during an exposure. He explains this by using the term psychoneuroimmunology the study of interactions between psychological factors and immune system function.
"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," Dr. Malebranche concludes.