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Substance abusers

What Are Substance Abusers’ HIV Prevention Needs?

Are Substance Abusers Who Don’t Inject At High Risk Of Infection?

Yes. Although sharing used needles is a high risk for HIV transmission, substance abuse and HIV goes beyond the issue of needles. People who abuse alcohol, speed, crack cocaine, poppers or other non-injected drugs are more likely than non-substance users to be HIV positive and to become seropositive. People with a history of non-injection substance abuse are also more likely to engage in high-risk sexual activities.1 Many injection drug users (IDUs) use other non-injected drugs primarily. When an IDU is HIV-positive, needle sharing may be the primary risk factor, but other non-injected drug use may have a great effect on risk behaviors. For example, a study of high risk clients in a methadone treatment program found that those at highest risk for HIV infection were also crack cocaine users.2 A survey of heterosexuals in alcohol treatment programs in San Francisco, CA, found HIV infection rates of 3% for men who were not homosexually active or IDUs and 4% for women who were not IDUs. This was considerably higher than rates of 0.5% for men and 0.2% for women found in a similar population survey.3 In Boston, MA, a study of gay men found a strong relationship between use of nitrite inhalants or “poppers” and HIV infection. Men who always used poppers while engaging in unprotected anal sex were 4.2 times more likely to be HIV positive than men who never used poppers and engaged in unprotected anal sex.4 Crack cocaine use has been shown to be strongly associated with the transmission of HIV. A study of young adults in three inner-city neighborhoods who smoked crack and had never injected drugs found a 15.7% HIV rate. Women who had recently had unprotected sex in exchange for money or drugs, and men who had anal sex with other men were most likely to be infected.5

Why Are They At Higher Risk?

There are probably a lot of reasons why substance abusers are at higher risk for HIV. The reasons most likely vary by drug and social context-crack abusers may have different risks than alcohol abusers, for example. For non-injecting substance abusers, HIV infection is not caused by drug use but by unsafe sexual behavior. Recently, observers have found an association between HIV infection, heavy crack use and unprotected fellatio among prostitutes. This may be due to poor oral hygiene and oral damage from crack pipes, high frequency of fellatio, and inconsistent condom use.6 Gay male substance abusers in San Francisco, CA, identified a number of factors that made safe sex difficult for them, including: perceived disinhibiting effect of alcohol and other drugs, learned patterns of association between substance use and sex (especially methamphetamine use and anal sex), low self-esteem, lack of assertiveness, and perceived powerlessness.7 Post Traumatic Stress Disorder (PTSD) may account for high sexual risk-taking activities among female crack users in the South Bronx, NY. In one study, 59% of women interviewed were diagnosed with PTSD due to violent traumas such as assault, rape or witness to murder, and non-violent traumas such as homelessness, loss of children or serious accident.9 It is often believed that having unprotected sex while under the influence of drugs or alcohol accounts for substance abusers’ HIV risk. However, sexual networks and sexual mixing might better explain risk.9 Many people who are in treatment or using drugs or alcohol are primarily selecting sexual partners from similar networks. They might include people who have used needles, have traded sex for money or drugs, have been victims of trauma, or have been incarcerated. All of these populations may have higher rates of HIV infection, making transmission more likely.

What Are Obstacles To Prevention?

In American social culture, drug use and sex have become hopelessly linked. For many people, straight or gay, bars are the main method for meeting people. Ads and commercials portray alcohol as seductive. Honest conversations about sexuality, including homosexuality, are lacking in schools, homes and the media. This can lead to greater sexual inhibitions that might be eased through drinking or using drugs. The goals of HIV prevention and substance treatment are often conflicting. Many treatment programs focus on stopping substance abuse altogether, and 12 Step programs often advocate sexual abstinence while in recovery. On the other hand, many prevention programs focus on safer sex and harm reduction, acknowledging that relapse could occur. These conflicting cultures may make it difficult to integrate HIV prevention interventions into substance abuse programs.

What’s Being Done?

New Leaf (formerly 18th Street Services) in San Francisco, CA, provides substance abuse treatment for gay/bisexual men, and offers a safer sex intervention. Although evaluation of the intervention showed little difference between men who participated in the safer sex program, and men who only went through treatment, both groups showed significant reductions in sexual risk.10 Getting and retaining substance abusers in treatment is an effective preventive method; adding a safer sex program may also help. Some prevention efforts teach safer sex behaviors regardless of drug use. In “Sex, Games, and Videotapes,” a program for homeless mentally ill men in New York City, NY, the men suggested taping condoms to their crack pipes as a reminder for sexual encounters that are often quick and public. They also compete to see which man can put a condom on a banana fastest (without tearing the condom), which teaches important skills for using a condom quickly. The program allows for sex issues to be brought up in a non-judgmental way, and reduced sexual risk behavior threefold.11 Many substance abusers receive treatment only after they have been arrested and are offered treatment as an alternative to jail or prison, or while they are incarcerated. The Delaware correctional system has instituted a therapeutic community (TC) treatment program in prison and a transitional TC outside the prison for parolees. The drug-free residential program includes rehabilitation, peer education group counseling and social services. Participants in the TC program had lower rates of drug relapse and re-arrest than non-participants, and reported reduced HIV risk behaviors.12

What Still Needs To Be Done?

Gender specific programs are needed that address women’s substance use needs. Women have a higher physical vulnerability to alcohol and higher levels of traumatic events associated with substance use than men.13 Gay and lesbian-specific treatment is also needed. In addition, specific treatment is needed for drugs such as crack cocaine and new drugs as they arrive on the scene. Prevention programs for substance abusers need to be integrated into existing services. The HIV epidemic has closely paralleled the epidemics of substance use and incarceration. Substance treatment agencies and prisons and jails need training and authority to incorporate HIV prevention education into their programs. Funders should increase funds and require substance abuse programs to expand treatment to include HIV education. Prevention programs don’t need to depend on causality-that drug abuse causes risk behaviors.14 A comprehensive HIV prevention strategy uses many elements to protect as many people at risk for HIV as possible. Because of high rates of HIV and risk behaviors among substance abusers, programs are urgently needed in this population. Prepared by Pamela DeCarlo, Ron Stall, PhD, MPH, Robert Fullilove EdD **********

Says Who?

1. Leigh BC, Stall R. Substance use and risky sexual behavior for exposure to HIV. American Psychologist. 1993;48:1035-1045. 2. Grella CE, Anglin MD, Wugalter SE. Cocaine and crack use and HIV risk behaviors among high-risk methadone maintenance clients . Drug and Alcohol Dependence. 1995;37:15-21. 3. Avins AL, Woods WJ, Lindan CP, et al . HIV infection and risk behaviors among heterosexuals in alcohol treatment programs . Journal of the American Medical Association. 1994;271:515-518. 4. Seage GR, Mayer KH, Horsburgh CR, et al. The relation between nitrite inhalants, unprotective receptive anal intercourse, and the risk of human immunodeficiency virus infection . American Journal of Epidemiology. 1992;135:1-11. 5. Edlin BR, Irwin KL, Faruque S, et al. Intersecting epidemics – crack cocaine use and HIV infection among inner-city young adults . New England Journal of Medicine. 1994;331:1422-1427. 6. Wallace JI, Bloch D, Whitmore R, et al. Fellatio is a significant risk activity for acquiring AIDS in New York City street walking sex workers. Presented at the Eleventh International Conference on AIDS, Vancouver BC; 1996. Abs #Tu.C.2673. 7. Paul JP, Stall R, Davis F. Sexual risk for HIV transmission among gay/bisexual men in substance-abuse treatment . AIDS Education and Prevention. 1993;5:11-24. 8. Fullilove MT, Fullilove RE, Smith M, et al. Violence, trauma and post-traumatic stress disorder among women drug users . Journal of Traumatic Stress. 1993;6:533-543. 9. Renton A, Whitaker L, Ison C, et al. Estimating the sexual mixing patterns in the general population from those in people acquiring gonorrhoea infection: theoretical foundation and empirical findings. Journal of Epidemiology and Community Health. 1995;49:205-213. 10. Stall RD, Paul JP, Barrett DC, et al. Substance abuse treatment lowers sexual risk among gay male substance abusers. Presented at Eleventh International Conference on AIDS, Vancouver, BC; 1996. Abs #We.C.3490. Contact: Ron Stall, 415/597-9155. 11. Susser E, Valencia E, Torres J. Sex, games and videotapes: an HIV-prevention intervention for men who are homeless and mentally ill. Psychosocial Rehabilitation Journal. 1994;17:31-40. Contact: Ezra Susser, 212/960-5763. 12. Martin SS, Butzin CA, Inciardi JA. Assessment of a multistage therapeutic community for drug-involved offenders . Journal of Psychoactive Drugs. 1995;27:109-116. Contact: Steve Martin, 302/831-2091-fax. 13. el-Guebaly N. Alcohol and polysubstance abuse among women . Canadian Journal of Psychiatry. 1995;40:73-79. 14. Stall R, Leigh B. Understanding the relationship between drug or alcohol use and high risk sexual activity for HIV transmission: where do we go from here ? Addiction. 1994;89:131-134.
Reproduction of this text is encouraged; however, copies may not be sold, and the Center for AIDS Prevention Studies at the University of California San Franciso should be cited as the source of this information. For additional copies of this and other HIV Prevention Fact Sheets, please call the National AIDS Clearinghouse at 800/458-5231. Comments and questions about this Fact Sheet may be e-mailed to [email protected]. ©1996, University of California
Resource

Apego a tratamientos

¿Cuál es el papel del apego en el tratamiento del VIH?

¿por qué es importante el apego?

La introducción de la terapia antirretroviral sumamente activa o altamente activa, TARSA o TARAA respectivamente (HAART, siglas en inglés) ha extendido y mejorado la calidad de vida de las personas con VIH al disminuir la carga viral, hasta niveles muchas veces imperceptibles. Sin embargo, tras descubrir que estos medicamentos requieren un apego (o adherencia) casi perfecto para evitar la replicación y mutación del virus, el entusiasmo inicial se ha menguado en cierto grado. Estudios han demostrado que la TARSA requiere un apego del 95% para lograr la supresión viral, y que incluso una disminución mínima del apego puede aumentar enormemente la carga viral.1 Si se permite la mutación del virus en cepas resistentes a medicamentos, el régimen de tratamiento puede perder su eficacia, lo cual limita las opciones de tratamiento tanto para los individuos con poco apego como para las parejas a quienes les transmitan estas cepas.2

¿cómo se mide el apego?

Por lo general, el apego se mide mediante el autoinforme del paciente, el recuento de pastillas, el uso de dispositivos electrónicos en la tapa del frasco de medicamentos (tapas MEMS, siglas en inglés) y los análisis de laboratorio.3 El autoinforme que el paciente provee en visitas médicas, en cuestionarios, en entrevistas o en registros diarios de medicamentos es una manera sencilla y práctica de determinar autopercepción del apego.4 Pero muchos individuos no recuerdan si tomaron todas las pastillas, o se les olvida anotarlo en el registro todos los días. Otros pueden fingir un mayor apego para quedar bien con el entrevistador o con el proveedor médico. Asimismo, los registros podrían tener poca utilidad entre personas analfabetas. El recuento de pastillas, especialmente si se hace sin aviso previo, puede ofrecer una evaluación más exacta del nivel de apego que el autoinforme. Sin embargo, este método demanda mucho tiempo y puede percibirse como una intromisión, especialmente si se realiza durante una visita no programada a la casa del paciente. En estos casos, podría ser mejor contar las pastillas en la clínica. Las tapas MEMS registran cada ocasión en la que el paciente quita la tapa al frasco. Se ha demostrado una correlación estrecha entre la carga viral concurrente y el número de veces que se abre la tapa. Sin embargo, son costosas y pueden subestimar el apego en pacientes que saquen más de una dosis a la vez para guardarlas en organizadores de pastillas (Medi-sets).6 Todos estos métodos suponen que los pacientes de hecho se han tomado todas las pastillas extraídas del frasco. Los análisis de laboratorio miden el apego indirectamente y pueden incluir la carga viral, el recuento de las células CD4 y los niveles sanguíneos de metabolitos de los medicamentos. Estas mediciones son menos frecuentes y muy costosas. Los resultados no indican concretamente el número de dosis omitidas ni el apego al horario de los medicamentos, y pueden ser afectadas por otros factores tales como la presencia de un virus resistente a medicamentos. No obstante, muchas veces los análisis de laboratorio se consideran útiles para medir el apego cuando se usan en combinación con el autoinforme del paciente o el recuento de pastillas.

¿cuáles son los obstáculos?

Es difícil seguir estrictamente un régimen de medicamentos. La mayoría de las personas tienen problemas hasta para terminar una dosis de antibióticos de 5 días. El apego se dificulta aun más cuando se toman varios medicamentos con dosis diferentes y efectos secundarios intensos y molestos como la diarrea, los daños nerviosos y los cambios en la composición corporal. La vida de muchas personas con VIH se complica por otros factores que les impiden dar prioridad al apego, tales como los trastornos de la salud mental, los problemas económicos y el uso de alcohol o drogas. Se destacan comúnmente tres tipos de obstáculos al apego: los que son específicos del régimen, los sociales/psicológicos y los institucionales.7 Las dificultades debidas al régimen, como la complejidad del tratamiento y la necesidad de tomar numerosas pastillas en diferentes horarios, así como los efectos secundarios de los medicamentos, pueden causar que se pierdan algunas dosis.8 Las exigencias del tiempo, tales como el trabajo, los viajes y el horario de las comidas también pueden ser barreras. El apego se ve afectado por factores sociales y psicológicos. Los trastornos de la salud mental (como la depresión o la angustia); las actitudes hacia el tratamiento y hacia el VIH; y el apoyo de los trabajadores de salud, familiares y amigos juegan un papel clave.9 Las reacciones positivas fomentan el apego mientras que las negativas (la falta de apoyo, el pesimismo) pueden impedirlo. Los factores institucionales como el encarcelamiento, el ambiente de la clínica y el acceso a servicios médicos y medicamentos confiables afectan al apego. Los factores que promueven el apego son un ambiente clínico agradable, un horario conveniente de citas, la confidencialidad, y la disponibilidad del transporte y del cuidado infantil.10

¿qué se está haciendo al respecto?

Action Point, un centro de servicios sin cita previa en San Francisco, CA, promueve el apego en personas pobres con adicción activa a las drogas o al alcohol. Ubicado en un local que da a la calle en una zona donde los arrestos y muertes relacionadas con las drogas son muy frecuentes, Action Point opera 6 días por semana empleando un principio de reducción de daños que alienta cualquier cambio que mejore la salud. El programa ofrece manejo de casos de apego, surtido de recetas médicas, servicios de enfermería, acupuntura y recomendaciones a servicios de salud mental y del abuso de drogas o alcohol. Un mes después de la inscripción, los clientes reciben un localizador (pager) con correo electrónico para recordarles de tomar sus medicamentos. Después de seis meses, el 61% de los participantes de Action Point tomaban la terapia TARSA y el 81% de éstos reportaron un apego superior al 90%.11 En Nueva York, pacientes que nunca habían tomado TARSA participaron en un programa de tres módulos: conocimientos básicos del VIH, apego y opciones de tratamiento. Los consejeros hablaron a fondo con cada paciente sobre los posibles obstáculos al apego, las toxicidades esperadas, el trabajo de tomar las pastillas, los intervalos de las dosis y las preferencias de medicamentos. Luego de evaluar esta información, la reportaron al proveedor médico quien la aprovechó para formular un régimen individualizado. Los pacientes recibieron herramientas tales como pastilleros, tarjetas de dosificación y localizadores (bípers), según la necesidad. Tuvieron seguimiento intensivo y una línea telefónica para consultas. El programa incrementó el apego y mejoró la respuesta virológica.12 Una estrategia prometedora para promover el apego es la terapia de observación directa o TOD (DOT, siglas en inglés) que para los antirretrovirales sería TODARSA (DAART, siglas en inglés). Basada en la TOD para la tuberculosis, la TODARSA se ha usado con pacientes que tienen contacto frecuente con los trabajadores de salud, como por ejemplo en las prisiones y clínicas de metadona. Una de las complicaciones del uso de la TODARSA es la necesidad de tomar los medicamentos de por vida y por lo general más de una vez al día.13

¿qué podemos hacer?

El apego a la TARSA es un proceso complicado, por lo que las intervenciones que logren aumentarlo tendrán un diseño multifacético. Se deben considerar, entre otros factores, la complejidad del régimen, los efectos secundarios, los factores asociados al paciente y hasta la relación paciente-trabajador médico, ya que todos juegan un papel en el apego al tratamiento. En general, cuanto más el régimen “se ajuste” al estilo de vida del paciente, mayor será el apego.14 Los trabajadores de salud pueden ayudar a incrementar el apego haciendo lo siguiente: involucrar al paciente en la selección de un régimen con horarios tolerables de dosificación; anticipar y manejar los efectos secundarios, identificar y tratar los problemas de salud mental y uso de drogas; responder a obstáculos concretos tales como la falta de transporte o vivienda; proporcionar recursos que estimulen la memoria y anticipar la fatiga debido al tratamiento prolongado.15 Los pacientes pueden ayudar aprendiendo más sobre el VIH, los medicamentos para tratarlo, y cómo funcionan éstos; fijándose metas no relacionadas con el VIH (ver crecer a sus hijos, mantenerse sanos y luciendo bien, etc.); reclutando amigos o familiares que vigilen su apego y anticipando los cambios de rutina, como por ejemplo los viajes.15

¿qué queda por hacer?

Con el apoyo adecuado, toda persona VIH+ puede apegarse al tratamiento. Muchas personas VIH+ no sólo combaten el VIH, sino también la drogadicción, la falta de vivienda o el encarcelamiento. Con el tratamiento y las herramientas adecuadas, muchos de los obstáculos al apego se pueden superar. Por ejemplo, la depresión y otros trastornos mentales que impiden el apego óptimo deben ser diagnosticados y tratados, lo cual es posible en muchos casos. La complejidad del apego muchas veces requiere “un equipo de apego”. La colaboración entre pacientes, médicos, manejadores de casos, trabajadores sociales, farmacéuticos, consejeros y familiares o amigos es esencial.

¿quién lo dice?

1. Paterson DL, Swindells S, Mohr J, et al. Adherence to protease inhibitor therapy and outcomes in patients with HIV infection. Annals of Internal Medicine. 2000;133:21-30. 2. Bangsberg DR, Deeks SD. Is average adherence to HIV antiretroviral therapy enough? Journal of General Internal Medicine. 2002;17:812-813. 3. Fogarty L, Roter D, Larson S et al. Patient adherence to HIV medication regimens: a review of published and abstract reports. Patient Education and Counseling. 2002;46:93-108. 4. Chesney MA, Ickovics JR, Chambers DB, et al. Self-reported adherence to antiretroviral medications among participants in HIV clinical trials: The AACTG Adherence Instruments. AIDS Care. 2000;12:255-266. 5. Samet JH, Sullivan LM, Traphagen ET, et al. Measuring adherence among HIV-infected persons: is MEMS consummate technology? AIDS and Behavior. 2001;5:21-30. 6. Wendel CS, Mohler MJ, Kroesen K, et al. Barriers to use of electronic adherence monitoring in an HIV clinic. The Annals of Pharmacotherapy. 2001;35:1010-1015. 7. Ickovics JR, Meade CS. Adherence to HAART among patients with HIV: breakthroughs and barriers. AIDS Care. 2002;14:309-318. 8. Altice FL, Mostashari F, Friedland GH. Trust and the acceptance of and adherence to antiretroviral therapy. Journal of Acquired Immune Deficiency Syndromes. 2001;28:47-58. 9. Gordillo V, Del Amo J, Soriano V, et al. Sociodemographic and psychological variables influencing adherence to antiretroviral therapy. AIDS. 1999;13:1763-1769. 10. Ciccarone D, Bangsberg D. , Bamberger J, et al. HIV-Related hospitalization before and during participation in ‘Action Point’ an adherence case management program. Presented at the American Public Health Association Conference. 2003. 11. Bamberger JD, Unick J, Klein P et al. Helping the urban poor stay with antiretroviral HIV drug therapy. American Journal of Public Health. 2000;90:699-701. 12. Esch L, Hardy H, Wynn H, et al. Intensive adherence interventions improve virologic response to antiretroviral therapy (ART) in naive patients. Presented at the 8th Conference on Retroviruses and Opportunistic Infections, Chicago, IL. 2001. Abst #481. 13. Lucas GM, Flexner CW, Moore RD. Directly administered antiretroviral therapy in the treatment of HIV infection: benefit or burden? AIDS Patient Care and STDs. 2002;16:527-535. 14. Chesney MA, Malow RM. Adherence in Chronic Diseases: Lessons learned from HIV/AIDS. World Health Organization volume on Adherence in Chronic Diseases. in press 15. Bartlett JA. Addressing the challenges of adherence. Journal of Acquired Immune Deficiency Syndromes. 2002;29:S2-S10. Información sobre cómo el apego afecta en la prevención en la Hoja Informativa #27 “¿Las nuevas medicinas afectan la prevención del VIH?”
Preparado por Maria Ekstrand, Michael Crosby y Pamela DeCarlo, CAPS Traducción Rocky Schnaath Abril 2003. Hoja Informativa 47S
Resource

Testing & link to care

Can HIV testing plus linking HIV+ people to care and treatment reduce HIV transmission?

Why is this an important question?

Despite major progress against HIV, 21% of HIV+ people in the US are unaware that they are positive1 and an estimated 33% of those who know they are HIV+ are not engaged in care and treatment for their infection.2 Another 38% of newly diagnosed HIV+ individuals test so late that they receive an AIDS diagnosis at the same time as, or within one year of, learning they are positive.3 There were an estimated 56,300 new HIV infections per year between 1996 and 2006.4 Clearly, the US can and must do better in responding to the HIV/AIDS epidemic. One way to increase the percentage of HIV+ people engaged in care and treatment for their infection and improve their health outcomes is to focus on coordinating or co-locating HIV testing, care and treatment, social services and prevention programs. Increasing the percentage of HIV+ people who know their serostatus and are receiving care and antiretroviral treatment could also have benefits for HIV prevention.5 The National HIV/AIDS Strategy places testing and linkage to care, treatment and support services at the heart of the effort to improve the health outcomes of HIV+ individuals and prevent new infections.6 What is the scientific basis for this approach, how might it actually be implemented, and will it have the desired results in the real world?

Can HIV testing and linking HIV+ persons to care plus treatment reduce HIV incidence?

Although it is not proven conclusively, there are strong data showing that HIV treatment reduces an individual’s viral load and thus the potential for them to transmit HIV.7,8 A Swiss study concluded that HIV+ individuals whose virus was suppressed at or below 50 copies for more than six months and who had no STIs were very unlikely to transmit the virus to HIV- partners through sexual contact.8 A study of over 3,000 serodiscordant heterosexual couples in Africa found a much lower transmission rate when the HIV+ partner was receiving treatment (only 1 seroconversion for a rate of 0.37 per 100 person years), compared to couples where the HIV partner was not receiving treatment (102 seroconversions, for a rate of 2.24 per 100 person years).9 Mathematical models predict some level of reduction in new HIV cases from high levels of participation in testing and treatment.10 A study in San Francisco found that expansion of HIV treatment was linked to a reduction in “community viral load,” the estimated average viral load of all HIV+ persons in a community. This reduction was thought to be at least partly responsible for declines in new HIV cases in San Francisco in recent years.11Additionally, studies in British Columbia, Canada have suggested that reductions in the number of new HIV infections among injection drug users may also be linked to expanded HIV treatment.12

How can this be accomplished?

One possible approach is called Testing and Linkage to Care Plus, or TLC+, a framework for integrating HIV testing, care and treatment, social services and prevention-with-positives activities into a comprehensive initiative that can be implemented by individual providers or jurisdictions.13 This approach is not new; many providers and jurisdictions have been implementing TLC+ in whole or part for some time. TLC+ proponents have argued that this approach should be replicated nationwide. A study is being conducted in Washington, DC and the Bronx, NY on the feasibility of the TLC+ approach in highly impacted urban settings.14 TLC+ is a reframing of the “Test & Treat” concept, which generally seeks to achieve near universal knowledge of serostatus and treatment of all individuals found to be HIV+ in order to improve health outcomes and reduce incidence.13 The TLC+ approach emphasizes informed patient choice in HIV care decisions and the importance of securing social services in order to successfully engage and retain HIV+ people in care and treatment.15 TLC+ acknowledges that supporting HIV+ persons’ participation in primary medical care and needed social services is more likely to engage them in addressing HIV than immediately encouraging them to start HIV treatment. Elements of TLC+ include:

  • Expanding and promoting HIV testing both as a routine part of medical care population-wide and through programs targeting individuals who are members of high-risk groups or engaging in high-risk behaviors
  • Linking newly diagnosed HIV+ individuals ASAP to a primary care provider, and innovative programs to re-engage previously diagnosed individuals who have fallen out of care or treatment
  • Assessing and meeting the social services needs of HIV+ people in order to support their initial engagement in care
  • Measuring CD4s and viral load and thoroughly counseling patients about the role of HIV treatment in assuring individual health and preventing transmission of HIV, as well as options for when to start treatment
  • Testing for STIs, TB and hepatitis B and C
  • Supporting retention in care and treatment adherence by ensuring ongoing linkage to needed social services and support
  • Prevention-for-positives counseling and linkage to services that support engagement in safe behaviors

Should HIV+ people be on treatment to prevent HIV transmission?

The potential benefits of HIV treatment, both for the individual and community, have much to do with when an individual decides to initiate HIV treatment and how much support they have to remain adherent to treatment. Earlier treatment might benefit both individual and community health. Federal treatment guidelines recommend starting treatment at 500 CD4s or below, and support consideration of treatment at 500 or above.16 Some providers, notably the San Francisco Department of Public Health, are now offering HIV treatment to all diagnosed HIV+ people, and even encouraging consideration of treatment at 500 CD4s and above. Providers should fully inform their HIV+ patients about the risks and benefits of either treatment strategy. A current study called START seeks to determine the risks and benefits of initiating HIV treatment at different CD4 thresholds. It is essential that HIV+ people make treatment decisions primarily to benefit their own health, with secondary consideration of the possible benefits for prevention. In keeping with values of patient empowerment and informed choice, providers can explain to an HIV+ person that engaging in treatment might help them in their goal of preventing transmission, but the choice of whether, when and why they decide to take medications must be left in the patient’s hands.

What are concerns about TLC+?

Concerns have been raised that expanded HIV testing and treatment of HIV+ people as a prevention intervention is intended to replace behavioral prevention programs. However, behavioral counseling and other forms of support for safe behaviors are an important component of the TLC+ model. Additionally, successful HIV prevention must take many forms and should include educational, behavioral, structural and biomedical interventions. Concerns have also been raised that describing the possible benefits of treatment for prevention may cause HIV+ people who are taking medications to abandon safe sex and syringe use behaviors. However, a range of studies have shown that HIV+ people on treatment do not exhibit increased sexual risk behavior, even when they achieved an undetectable viral load.17 Most HIV+ people are concerned about not infecting others and make efforts to prevent transmission.18 Nevertheless, it is essential to counsel HIV+ patients to practice safe sex, including condom use, whether on treatment or not and whether they achieve undetectable viral loads or not.

What steps needs to be take place to implement TLC+ nationally?

The concepts behind TLC+ are contained in the National HIV/AIDS Strategy, and it is critical that the federal government achieve unprecedented coordination in the planning and funding of this approach across all agencies, as well as with state and local governments and AIDS service organizations. TLC+ may take several years to be fully implemented because it depends upon the thoughtful coordination of surveillance, testing, care and treatment, social services and prevention programs and their funding streams to support it. TLC+ also demands improved reimbursement and targeting of HIV testing activities, and increased coverage of the cost of care and treatment, which could be achieved largely through effective implementation of national health care reform. The Ryan White Program will need to be reconfigured to support the high level of staffing necessary to link HIV+ people to care, treatment and social services when it is reauthorized by Congress in 2013.

Says who?

1. Centers for Disease Control and Prevention. HIV in the United States. Fact Sheet. July 2010. 2. HRSA. HIV/AIDS Bureau. Outreach: Engaging people in HIV care. August 2006. 3. Valdiserri RO. Late HIV diagnosis: Bad medicine and worse public health. PLoS Medicine. 2007; 4:e200. 4. Hall HI, Song R, Rhodes P, et al. Estimation of HIV Incidence in the United States. JAMA. 2008;300:520-529. 5. Cohen J. Treatment as Prevention. Science. 2010;327:1196-1197. 6. Office of the White House. National HIV/AIDS Strategy for the United States.July 2010. 7. CDC. Effect of antiretroviral therapy on risk of sexual transmission of HIV infection and superinfection. Fact sheet. August 2009. 8. Engsig F, Omland L, Larsen M, et al. Risk of high-level viraemia in HIV-infected patients on successful antiretroviral treatment for more than 6 months. HIV Medicine. 2010. 9. Donnell D, Baeten JM, Kiarie J, et al. Heterosexual HIV-1 transmission after initiation of antiretroviral therapy: a prospective cohort analysis. Lancet. 2010;375:2092-2098. 10. Granich RM, Gilks CF, Dye C, et al. Universal voluntary HIV testing with immediate antiretroviral therapy as a strategy for elimination of HIV transmission: a mathematical model. Lancet. 2009;373:48-57. 11. Das M, Chu PL, Santos G-M, et al. Decreases in community viral load are accompanied by reductions in new HIV infections in San Francisco. PLoS ONE. 2010;5:e11068. 12. Montaner J, Wood E, Kerr T, et al. Association of expanded HAART coverage with a decrease in new HIV diagnoses, particularly among injection drug users in British Columbia, Canada. Presented at the CROI. 2010. 13. Project Inform. TLC+: Testing, Linkage to Care and Treatment. 14. El-Sadr W. TLC-Plus: Feasibility of an enhanced test, link-to-care plus treat approach for HIV prevention in the US. 15. Statement on ART as prevention: Scaling down HIV requires scaling up human rights, testing and treatment. Sign-on letter from the International Council of AIDS Service Organizations. 2009. 16. Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents.Department of Health and Human Services. 2009;1-161. 17. Crepaz N, Hart TA, Marks G. Highly active antiretroviral therapy and sexual risk behavior: A meta-analytic review. JAMA. 2004;292:224-236. 18. Marks G, Crepaz N, Senterfitt JW, et al. Meta-analysis of high-risk sexual behavior in persons aware and unaware they are infected with HIV in the United States. Journal of AIDS. 2005;39:446-453.

Special thanks to the following reviewers of this Fact Sheet: Julia Dombrowski, Reuben Granich, Peter Kilmarx, Kim Koester, Monica Ruiz, George Rutherford, Allison Zerbe. Reproduction of this text is encouraged; however, copies may not be sold, and the University of California San Francisco should be cited as the source. Fact Sheets are also available in Spanish. To receive Fact Sheets via e-mail, send an e-mail to [email protected] with the message “subscribe CAPSFS first name last name.” ©October 2010, University of CA. Comments and questions about this Fact Sheet may be e-mailed to [email protected].

Resource

Hombres transgénero

¿Quienes son los hombres trans?

Transgenero (‘trans’) es un término sombrilla para aquellas personas las cuales la identidad de género y expresión no conforman las normas y expectaciones tradicionales asociadas al género asignado al nacer. Hombres transgenero, también conocidos como hombres trans, son personas a las que se les asigno ‘femenino’ a la hora de nacer y tienen una identidad de género y/o una expresión de genero masculina. Personas transgenero pueden auto identificarse y expresar su género en una variedad de formas y en muchas ocasiones prefieren ciertos términos y no otros. Algunos que transicionan de mujer a hombre no se identifican para nada como transgenero sino solamente como hombres, a un hombre trans se les debe de referir con pronombres masculinos. De cualquier manera, si uno no está seguro, lo mejor es de que con respeto se les debe preguntar en qué términos y que proverbios estar personas prefieren ser referidas. Información precisa sobre la diversidad de los cuerpos de los hombres trans no está al alcance ampliamente. Los hombres trans tienen diferentes tipos de cuerpos, dependiendo en el uso que hacen de testosteronas y cirugías usadas para la confirmación de su género (las cuales puede incluir la reconstrucción del pecho, histerectomía, metodioplastia, falloplastia,1 etc.; visitar la página de internet en ingles: www.ftmguide.org para más información. Los hombres trans utilizan una amplia gama de términos y lenguajes para identificar su sexo y/o genero, describir sus partes corporales, y divulgar su estatus trans a otros. Por ejemplo, algunos hombres trans no se sienten cómodos con términos como “vagina” o “sexo vaginal” y suelen preferir llamarle “hoyo frontal” y “sexo frontal” o “sexo del hoyo frontal”, aunque esto no sea verdadero para todos los hombres trans. Esta diversidad crea necesidades únicas y barreras al negociar y adherirse a prácticas sexuales más seguras las cuales no son mencionadas en actuales programas de prevención del VIH.

¿Qué es lo que sabemos sobre el VIH y los hombres trans?

La comunidad transgenero es diversa y no se han llevado a cabo suficientes estudios con gente trans en general. En particular, tenemos información muy limitada sobre los hombres trans. Hasta la fecha, estudios relacionados con el VIH entra las personas trans han sido enfocadas casi exclusivamente en mujeres trans (personas las cuales se les asigno “masculino” al nacer y tiene una identidad de género femenina y/o una expresión de género femenina). De cualquier manera, existe evidencia que hay un subgrupo significante de hombres trans que llevan a cabo en sexo sin protección con otros hombres no-trans (trans MSM), incluyendo algunos hombres trans que están envueltos en el trabajo sexual. Varias ciudades han llevado a cabo estudios de necesidades que se enfocan en, o son inclusivas a los hombres trans y los riesgos de contrael el VIH, como Philadelphia, Washington D.C, San Francisco, y la provincia de Ontario. Los escasos estudios publicados que muestran casos entre los hombres trans reportadan un prevalencia del 0 – 3%.2-4 Estas cifras son auto-reportadas, de cualquier forma, y están basadas en muestras pequeñas y no representativas, así que no tenemos información final sobre cifras actuales. Dado a que se asume número bajos de infección del VIH entre hombres trans este es relavito a otros grupos de alto riesgo, no han habido muchos estudios sobres actividades de riesgo entre los hombres trans. Nosotros si sabemos que los mensajes de prevención del VIH no están llegando a la mayoría de los hombres trans.5 También sabemos que trans MSM buscan servicios en organizaciones donde proveen servicios a hombres gay, donde hay poca o no hay educación para los hombres trans y sus parejas non-trans.4 Proveedores generalmente no están entrenados para identificar o dar servicios a los hombres trans gay o bisexuales en formas culturalmente sensitivas, ni entienden sus riesgos o necesidades de prevención especificas.

¿Qué es lo que no sabemos sobre el VIH y los hombres trans?

Nosotros no tenemos suficiente información sobre el VIH y los hombres trans. Métodos de colección de información en lugares donde se llevan a cabo estudios no identifican exactamente, no mantienen un control de los hombres trans ni capturan sus experiencias, lo cual contribuye a la falta de clarificación de las cifras de infección del HIV entre los hombres trans. Cifras del VIH y actividades sexuales de riesgo entre los hombres trans tampoco son muy entendidas puesto que continuamente se asume que las relaciones sexuales de los hombres trans son primariamente con mujeres non-trans. De cualquier manera, como cualquier otro hombre, los hombres trans pueden ser de cualquier orientación sexual y pueden tener sexo con diferentes tipos de parejas, incluyendo (pero no limitándose a) hombres non-trans, mujeres transgenero, y hombres transgenero.6,7

¿Qué pone a riesgo a los hombres trans?

En un estudio, la mayoría de trans MSM reportaron consistentemente no usar condones durante el sexo anal receptivo y/o sexo frontal (vaginal) con otras parejas masculinas non-trans, y bajos el número de exámenes del VIH y baja percepción de riesgo.4 En áreas urbanas en donde la prevalencia de números del VIH entre non-trans MSM son estimadas de ser 17-40% y los números de Infecciones Transmitidas Sexualmente (ITS) están incrementando, trans MSM quienes practican sexo anal receptivo sin protección y/o copula (penetración) con non-tran MSM pueden ser especialmente vulnerable al VIH/ITS.8,9 Los hombres trans pueden enfrontar complicados juegos de poderes y dinámicas de género en sus relaciones sexuales con otros hombres non-trans. Para un trans MSM, el tener sexo con una pareja hombre gay es una validación muy fuerte para identidad gay/queer, especialmente en los años iniciales de su transición, y puede esto ser más importante que el de insistir a usar un condón. Algunos hombres trans que usan testosteronas han reportado un incremento es su deseo sexual y un incremento en el interés sexual con hombres no trans después de comenzar el uso de hormonas, el cual puede contribuir al deseo de tomar riesgos seuxales.4,10 Los hombres trans pueden enfrontar complicados juegos de poderes y dinámicas de género en sus relaciones sexuales con otros hombres non-trans.4 Para un trans MSM, el tener sexo con una pareja hombre gay es una validación muy fuerte para identidad gay/queer, especialmente en los años iniciales de su transición, y puede esto ser más importante que el de insistir a usar un condón. Algunos hombres trans que usan testosteronas han reportado un incremento es su deseo sexual y un incremento en el interés sexual con hombres no trans después de comenzar el uso de hormonas, el cual puede contribuir al deseo de tomar riesgos seuxales. 4,10 Los hombres trans en testosterona y/o quienes hayan tenido una histerectomía pueden tener sequedad frontal (vaginal), lo cual incrementa sus riesgos de trauma frontal (vaginal) durante la penetración, y así incrementando sus riesgos de infección de las ITS, incluyendo el VIH10 Baja autoestima puede contribuir a practicar sexo de riesgo entre los hombres trans. Los números de depresión, uso de substancias, y atentos de suicidios son altos en esta población, pero existen múltiples barreras al tratar de obtener apoyo y tratamiento que sea culturalmente competente. 3,11 El uso de drogas y alcohol es un gran factor de riesgo en cualquier comunidad, sin importar su identidad de género. Los hombres trans puede usar alcohol o drogas para realzar sus experiencias sexuales o para ayudar a aliviar o reducir ansiedades sobres sus cuerpos durante el sexo.4 Algunos hombres trans pueden sentir presión de usar drogas para poder pertenecer a algunas comunidades o subculturas de hombres gay. Aunque tenemos muy poca información sobre el compartir agujas para hormonas o uso de drogas entres los hombres trans, este también puede ser un factor de riesgo para algunos de ellos.

¿Qué puede ayudar?

Noviasgo en el Internet. Varios hombres trans conocen a sus parejas sexuales no-trans en el internet. Conocer parejas por medio de anuncios personales puede permitir los hombres trans describir sus cuerpos y genero inicialmente (si ellos deciden hacerlo) y así discutir sexo más seguro con posible parejas antes de encontrarse en persona.4 Materiales educacionales para parejas no-trans. Parejas hombres no-trans de los hombres trans frecuentemente no tienen experiencia con los hombres trans ni acceso a educación sexual con ellos, lo cual los lleva a tener una idea equivocada sobre sexo más seguro. Para hombres gay no-trans, sexo más seguro frecuentemente solo significa usar condón para el sexo anal y pueden no estar consientes del riesgo asociado con el sexo frontal (vaginal). Vea la próxima sección que contiene informacion en materiales disponibles. Gran visibilidad en la comunidad gay. Hombres gay y bisexuales necesitan ser educados sobre la presencia de los hombres trans en sus comunidades. Visibilidad incrementada y conocimiento sobre los hombres trans puede ayudar a crear un medioambiente de bienvenida, ayuda a incrementar inclusividad, y ayuda los hombres trans a sentirse con más poder es sus relaciones con otros hombres no-trans.7

¿Qué es lo que se está haciendo?

tm4m (tm4m.org) es un projecto basado en San Francisco para los hombres trans que juega con otros hombres (o que quiere jugar con ellos). Este provee información, educación, y apoyo a los hombres trans que tienen sexo con otros hombres por medio de talleres educacionales mensuales y grupos de discusión, materiales informativos y continuamente trabajan en adoptar aceptación y crear comunidad. tm4m es un esfuerzo colaborativo co-patrocinado por Eros, Trannywood Pictures y TRANS:THRIVE (un programa del Centro de Salud para Asiaticos y personas de las islas del pacifico). El Grupo de Trabajo de Hombres Trans Gay/Bi/Queer ha conducido un estudio de necesidades con trans MSM, creado recursos de salud sexual,12 y la página electrónica www.queertransmen.org También proveen entrenamiento y consulta sobre la inclusión de trabajadores de prevención a través de la provincia. All Gender Health Online (www.allgenderhealth.org) es un estudio que explora la salud sexual de hombres no-transgenero que tienen sexo con personas transgenero. Los resultados serán usados para crear una intervención en el internet para prevenir la extensión del VIH y promover la salud sexual de personas transgeneros y sus parejas. El proyecto STOP AIDS de San Francisco, California se esfuerza en incluir los hombres trans en su programación y educación comunitaria. Estos incluyen transgenero hombres en la declaración de la misión de su agencia y han cambiado los métodos de colectar información que mejor reflejen cuerpos en transición e identidades de géneros en comunidades de hombres gay.

¿Qué queda por hacer?

Necesitamos implementar métodos de colección de información mas inclusiva para mejor captar subgrupos de personas transgenero. Proveedores de salud no deben asumir que todos los hombres que ellos ven han sido asignados ‘hombre’ al nacer. 13 Uno no puede decir que alguien es trans al solo mirarlo. El mejor método para colección de información es una pregunta de dos partes: 1) pregunta sobre identidad de género actual y 2) pregunta que sexo fue asignado al nacer. Si uno no está seguro, debería de preguntar los hombres trans por su nombre y pronombres preferidos y usar estos términos. Si los números del VIH entre los hombres trans están de hecho bajos, tenemos nosotros la oportunidad de envolvernos en un trabajo verdadero de prevención para mantener esos números bajos. Adquirir un mayor entendimiento de los comportamientos de riesgo de los hombres trans y las diferente formas en las cuales ellos mismos se protegen, ayudara a proveer educacion apropiada y efectiva de prevención del VIH para los hombres trans y sus parejas sexuales.

¿Quién lo dice?

1. Es importante notar que pocos hombres trans tienen penes completamente funcionales, debido primariamente a las bajas tasas del éxito de la cirujía, altos números de complicaciones y el alto costo de la cirujía. 2. Herbst J, Jacobs E, Finlayson T, et al. Estimating HIV prevalence and risk behaviors of transgender persons in the United States: A systematic review. AIDS and Behavior. 2007. 3. Clements-Nolle K, Marx R, Guzman R, et al. HIV prevalence, risk behaviors, health care use, and mental health status of transgender persons: Implications for public health intervention. American Journal of Public Health. 2001;91:915-921. 4. Sevelius J. ‘‘There’s no pamphlet for the kind of sex I have’’: HIV-related risk factors and protective behaviors among transgender men who have sex with non-transgender men. Journal of the Association of Nurses in AIDS Care. 2009;20:398-410. 5. Hein D, Kirk M. Education and soul-searching: The Enterprise HIV prevention group. In: Bockting W, & Kirk, S., editor. Transgender and HIV: Risks, prevention, and care.Binghamton, NY: The Haworth Press; 2001. p. 101-117. 6. Schleifer D. Make me feel mighty real: Gay female-to-male transgenderists negotiating sex, gender, and sexuality. Sexualities 2006;9(1):57-75. 7. Bockting W, Benner A, Coleman E. Sexual identity development among gay and bisexual female-to-male transsexuals: Emergence of a transgender sexuality. Archives of Sexual Behavior. 2009;38(5). 8. Colfax G, Coates T, Husnik M, Huang Y, Buchbinder S, Koblin B, et al. Longitudinal patterns of methamphetamine, popper (amyl nitrite), and cocaine use and high-risk sexual behavior among a cohort of San Francisco men who have sex with men. Journal of Urban Health. 2005;82:i62-i70. 9. CA Department of Health Services. California HIV counseling and testing annual report: January - December 2003. Sacramento, CA: Office of AIDS; 2006. 10. Gorton N, Buth J, Spade D. Medical therapy and health maintenance for transgender men: A guide for health care providers: Lyon-Martin Women’s Health Services; 2005. 11. Newfield E, Hart S, Dibble S, Kohler L. Female-to-male transgender quality of life. Quality of Life Research 2006;15(9):1447-57. 12. Gay/Bi/Queer Transmen’s Working Group of the Ontario Gay Men’s HIV Prevention Strategy. Primed: The Back Pocket Guide for Transmen & The Men Who Dig Them. Toronto, Ontario; 2007. 13. Center of Excellence for Transgender HIV Prevention. Recommendations for inclusive data collection of trans people in HIV prevention, care, and services. University of California, San Francisco. 2009. www.transhealth.ucsf.edu

Una publicación del Centro de Estudios para la Prevención del SIDA (CAPS) y el Instituto de Investigaciones sobre SIDA (ARI), Universidad de California en San Francisco (UCSF). Se autoriza la reproducción (citando a UCSF) más no la venta de copias este documento. También disponibles en inglés - https://prevention.ucsf.edu/resources/factsheets-english-and-spanish. Para recibir las Hojas de Datos por correo electrónico escriba a [email protected] con el mensaje “subscribe CAPSFS nombre apellido” ©UCSF 2010    

Resource

Black Gay Men and the Church

What is the role of the Black church for Black gay men and HIV prevention?

Why the Black church?

Many Black men in the US grow up in families that are significantly involved with the Black church. As a long-standing institution developed for and by Black people, the Black church provides religious education and spiritual formation, and buffers against societal oppressions. The church has been a vital and trusted institution in the Black community, providing support, defining values, and building community.1 Using the biblical themes of social justice and inherent dignity of all people, the Black church helped restore and promote the self esteem and self-worth of Black people who were victims of racial and other kinds of oppression. However, some Black gay men feel alienated from Black religious congregations. These men experience various homophobic and AIDS-phobic messages that increase their feelings of shame, diminish their religious identity, and are separated from important resources of the Black church.1 The Black church is a part of many Black gay men’s lives, and, unfortunately, so is HIV. The HIV/AIDS epidemic has had a devastating effect on Black gay men in the US. Black gay and bisexual men are the most heavily impacted population in the Black community. Among all men who have sex with men (MSM), black MSM accounted for 10,600 (36%) estimated new HIV infections in 2010. From 2008 to 2010, new HIV infections increased 22% among young (aged 13-24) MSM and 12% among MSM overall—an increase largely due to a 20% increase among young black MSM.2 At the end of 2010, of the estimated 872, 990 persons living with an HIV diagnosis, 440,408 (50%) were among MSM with 31% of those living with the disease being African American.2 Black men who have sex with other men may self-identify as gay, same gender-loving, bisexual, straight, or may refuse to be categorized at all. For this Fact Sheet, we use the term “Black gay men” to refer to all Black men who have sex with men.

How has the church positively affected Black gay men?

Churches have traditionally occupied a special place in the African American experience.3 For many Black gay men, church is a part of their identity. Often, generations of families are involved in the church: their great grandparents helped build the church, their grandparents provided leadership, their parents work and volunteer at the church. For many, going to church was a requirement as children and they may have gone to Sunday school, sang in the choir or participated in other church activities. As adults, Black gay men are often involved in church leadership positions. Spirituality is a resource for HIV- and HIV+ Black gay men.4 Spirituality has been used to cope with life-threatening events, physical illness and emotional and psychological stresses. Belief in God is an important strength for many Black Americans. Religious participation also provides positive health benefits, increased life satisfaction, and is especially supportive in crisis moments.

How has the church negatively affected Black gay men?

Many religious traditions view homosexuality as a sin and have strictly defined visions of masculinity and femininity. Black gay men experience homophobia and AIDS phobia that is sanctioned by the Black church. These oppressions and messages experienced in church increase Black gay men’s internalized homophobia, which can increase risk taking and decrease access to support.5 Many Black gay men attend church knowing that homosexuality is considered a sin, and pastors may know or believe that they have gay men in their congregations. The common yet contradictory scene of gay men singing in the choir while homosexuality is denounced in the pulpit, creates an “open closet” at the center of church life.6 This contradiction in the church has a damaging effect on gay men’s personal and sexual lives.7 The Black church’s views on homosexuality also negatively affect the Black community at-large. These views and attitudes influence the entire congregation, increasing stigma against homosexuality in the community,6 and presenting potential problems for friends and family of gay men who are torn between their personal love for the men and their religious beliefs. These tensions play a role in reducing the amount of social support gay men receive from the community.

How can the church help in HIV prevention?

Within the context of the Black church, religion is an extraordinary opportunity to expose oppression and marginalization (homophobia and heterosexism) and create a framework for all people to be validated by virtue of their humanity, regardless of their sexual orientation. The Black church can also be a practical setting for health promotion interventions and can serve key roles in developing and/or delivering interventions.8Using the justice and liberation themes of religion, HIV prevention messages can be framed in validating and life-affirming ways to everyone, including Black gay men. Thus, religion can encourage Black gay men and couples to engage in sexual behaviors that promote their emotional, psychological, and sexual well being, maximizing HIV prevention efforts.

What can gay men do?

Most Black gay men do not regularly engage in HIV risk behaviors such as having unsafe sex, but may cycle in and out of risk at different times in their lives.9 Similar to many people, risk for Black gay men often occurs during periods of stress and life changes—death of a family member or friend, loss of employment, relationship breakdowns, or depression.10 In times of profound crisis, spirituality and support from the church can protect Black gay men from falling into risky behaviors. Despite negative views on homosexuality, Black gay men have forged many ways to deal with the condemnation of the Black church and move in and out of these different paths.1 Some Black gay men reject their homosexual identity and pray to God to help change them. Some Black gay men co-exist with church doctrine. They may participate actively in the church and socialize with other gay members of the congregation, yet remain “in the closet,” never publicly identifying as gay within the church.11 Some Black gay men reject their religious identity, unable to accept a religion that labels them as sinners. However, to walk away from the church is to walk away from family, and the absence of religious affiliations can be a void in their lives. Many may reject religious traditions but remain deeply spiritual. Some Black gay men are able to integrate their own identity with the teachings of the bible, developing a personal relationship with a higher power that may or may not include traditional religious institutions, but incorporate religious communion in more affirming and welcoming environments.12 These gay men remain deeply spiritual, but seek to express their spirituality, including prayer, music and fellowship via other outlets, believing that God created them as worthy and capable of living healthy loving lives that include sexually fulfilling relationships.12

What can the Black church do?

HIV/AIDS has posed a significant challenge to Black churches and their congregations. Each church is different—some may be able to create change and address AIDS and homophobia and some may not be able or willing to.13 HIV prevention programs need to respect the philosophical differences between the church and public health and be open to negotiation. A number of programs and organizations exist to address HIV/AIDS within the Black Church. For example, the Balm in Gilead Inc. provides support for faith-based institutions to address HIV and other health challenges.14 The Ark of Refuge is a faith-based HIV prevention program that provides HIV/AIDS education and prevention services for African Americans.15 Project Bridge is a faith-based substance abuse and HIV/AIDS prevention program for African American adolescents.16 YOUR Blessed Health (YBH) is a program designed to increase the capacity of faith-based organizations and faith leaders to prevent HIV/AIDS among African American youth in their organizations.17 In response to the homophobia of many traditional Black churches, several inclusive churches have arisen across the country. For example, the Unity Fellowship Church was founded in 1982 for openly gay and lesbian African Americans.18 The Fellowship, a coalition of Christian churches and ministries, supports mostly Black churches and faith organizations to move towards radical inclusivity of all marginalized populations.18 The Metropolitan Community Church was founded in 1968 as a Christian church for LGBT persons of all races.19 A survey of Black churches in California that excluded the most conservative churches found a range of institutions with four patterns of acceptance for homosexuality and HIV prevention: non-condemning, accepting, open and affirming, and radically inclusive. Churches classified as gay friendly and radically inclusive tended to be racially diverse.12

What needs to be done?

The growing disparities in HIV/AIDS and other health problems, particularly among African American and other poor racial/ethnic groups, coupled with dwindling financial resources requires even greater attention to and help from religious and faith-based organizations.20 While some Black churches may continue to struggle with interpreting scripture related to same sex behavior, others have found success utilizing community based participatory research (CBPR) approaches to fully involve church leaders in the development, implementation, and evaluation of HIV intervention strategies.21 Community-level interventions have strong effects on normative and structural influences on HIV-risk behavior and can work across broad segments of the MSM population. 22 Mobilizing Black churches against HIV/AIDS require active involvement of community members, putting them in control of the questions and issues investigated.23 Due to the institution’s elevated social standing in the lives of many Black gay men, the Black church represents a logical, yet largely untapped venue for HIV intervention programming. HIV continues to ravage Black gay men—an already disenfranchised and highly stigmatized population. Given its mandate for love, justice and mercy, the Black church has a history of confronting injustice and oppression. Black church leadership and Black gay men must develop a strategy that values the lives of Black gay men. HIV+ and HIV- Black gay men are a vulnerable population who are entitled to compassionate and courageous support. HIV related anti-stigma efforts by church leaders, as well as the mobilization of community utilizing themes of compassion for prevention and outreach, may be effective ways for the church to use their teachings to engage with this population.

Says Who?

1. Miller RL Jr.  Legacy denied: African American gay men, AIDS, and the black church. Social Work. 2007;52:51-61. 2. HIV Among Gay and Bisexual Men Fact Sheet, Centers for Disease Control, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. March 2013 3. Francis SA, Liverpool J. A review of faith-based HIV prevention programs. J Relig Health. 2009;48(1):6–15. doi: 10.1007/s10943-008-9171-4. 4. Miller RL Jr. An appointment with God: AIDS, place, and spirituality. Journal of Sexuality Research. 2005;42:35-45. 5. Peterson JL, Jones KT. HIV prevention for Black men who have sex with men in the US. American Journal of Public health. 2009;99:976-980. 6. Fullilove MT, Fullilove RE. Stigma as an obstacle to AIDS action: The case of the African American community. American Behavioral Scientist. 1999;42:1117-1129. 7. Yakushko O. Influence of social support, existential well-being, and stress over sexual orientation on self-esteem of gay, lesbian and bisexual individuals. International Journal for the Advancement of Counseling. 2005;27:131-1143. 8. Kim, K., Linnan, L., Campbell, M., Brooks, C.,Koenig, H., & Wiesen, C. (2008). The WORD (Wholeness, Oneness, Righteousness, Deliverance): A faith-based weight-loss program utilizing a community-based participatory research approach. Health Education & Behavior, 35, 634-650. 9. Elam G, Macdonals N Hickson FCI, et al. Risky sexual behaviour in context: qualitative results from an investigation into risk factors for seroconversion among gay men who test for HIV. Sexually Transmitted Infections. 2008;84:473-477. 10. Grinstead O. Seroconversion narratives and insights for HIV prevention. FOCUS. 2006;21:1-4. 11. Pitt RN.”Still looking for my Jonathan”: gay Black men’s management of religious and sexual identity conflicts. Journal of Homosexuality. 2010;57:39-53. 12. Foster ML, Arnold E, Rebchook G, Kegeles SM. ‘It’s my inner strength’: spirituality, religion and HIV in the lives of young African American men who have sex with men. Cult Health Sex. 2011 Oct;13(9):1103-17. Epub 2011 Aug 9. 13. Francis SA, Liverpool J. A review of faith-based HIV prevention programs. Journal of Religious Health. 2009;48:6-15. 14. Balm in Gilead (http://www.balmingilead.org) 15. The Ark of Refuge (http://www.arkofrefuge.org) 16. Marcus MT, et al. Community-based participatory research to prevent substance abuse and HIV/AIDS in African-American adolescents. Journal of Interprofessional Care. 2004;18:347-59. 17. YOUR Blessed Health (YBH)  18. Unity Fellowship Church, The Fellowship, Metoropolitan Community Church 19. Metropolitan Community Churches (http://mccchurch.org) 20. Agatha N. Eke, Aisha L. Wilkes & Juarlyn Gaiter. Organized religion and the fight against HIV/AIDS in the Black community: the role of the Black church. African Americans and HIV/AIDS, 2010, pp 53-68. 21. Berkley-Patton J, Bowe-Thompson C, Bradley-Ewing A, Hawes S, Moore E, Williams E, Martinez D, Goggin, K. Taking it to the pews: A CBPR-guided HIV awareness and screening project with black churches. AIDS Education and Prevention. 2010;22(3):218–237. 22. Peterson JL, Jones KT. HIV prevention for Black men who have sex with men in the United States. Am J Public Health 2009;99(6):976–980. 23. Hill WA, McNeely C. HIV/AIDS disparity between African-American and Caucasian men who have sex with men: Intervention strategies for the Black church. Journal of Religion and Health 2011   Special thanks to the following reviewers of this Fact Sheet: Michael Foster, Shelley Francis, Susan Kegeles, Eddie Kornegay, Joan Liverpool, Maureen Miller, Richard Pitt Jr., Sylvia Rhue, Leo Wilton Reproduction of this text is encouraged; however, copies may not be sold, and the University of California San Francisco should be cited as the source. Fact Sheets are also available in Spanish. ©2009, University of CA. Comments and questions about this Fact Sheet may be e-mailed to [email protected].