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Instrument

The survey instrument was based on more than 100 open- ended interview and 2 focus groups with Hispanics in San Francisco, held to identify Hispanic men's perceptions of the consequences of condom use with primary and secondary sexual partners, difficulties with condom use, and normative aspects of condom use. The instrument was developed originally in Spanish and a back-translation procedure was used to assure that the English version was equivalent in meaning. Both the Spanish and English versions were pretested with at least 20 persons. The final version of the interview required an average of 24 minutes to complete. Most interview questions had four or five-level Likert-type response scales. The reported reliabilities were for the sample of 361 Hispanic men, reporting 1 or more secondary female sexual partners, who responded to the question on condom use with a secondary partner or partners. Frequency of using and carrying condoms. The extent of condom use with a secondary sexual partner was assessed by the question, "When you had sex with someone other than your wife or primary partner in the last 12 months, how often did you use condoms?" The extent of carrying condoms was assessed by the question, "How often do you carry a condom with you?" Each item was recorded using a five-point response scale from "always" to "never." Self-efficacy to use condoms. Four questions were developed to assess perceived ability to use condoms:

• "Would you be able to refuse sex if you partner didn't want you to use a condom?"
• "Would you use condoms even if you had to stop to buy them or look for them?"
• "Would you use condoms even if you had been drinking or using drugs?" and,
• "Would you be able to use a condom with a secondary partner?"

The self-efficacy score was the mean of the four items on a four- point yes-no response scale with higher scores meaning higher efficacy (alpha = 0.55). Those with greater self-efficacy to use condoms were expected to use them more consistently with secondary partners that did those who scored lower. Negative beliefs about condoms. Sixteen items measured beliefs about the consequences of using condoms. Beliefs included "the condom might break," "the condom might come off inside your partner," and "you would feel less sexual pleasure." Responses were "yes" "probably yes," "probably no," and "no" (alpha = 0.70). Depression scale. Ten of the 20 items of the Center of Epidemiologic Studies Depression Scale (CES-D) were selected for the questionnaire, based on their factor loading for Hispanics (alpha = 0.88). The items measure sadness in the 7 days prior to the interview and have been shown to assess depression in community samples. We expected those men who reported the most depressive symptoms to report more risky behaviors than those who reported the least depressive symptoms. The scale score was a continuous variable ranging from 0 to 30, with high scores meaning more depressive symptoms. Sexual comfort. Three items were used to assess sexual comfort: being naked in front of a partner, having sex with the lights on, and having sex with a new partner. The sexual comfort score was the mean of the three items on a four-point scale ranging from "very comfortable" to "very uncomfortable" (alpha = 0.62). Persons with high levels of sexual comfort have been shown to exhibit sexual behavior that is more self-protective than persons with low levels of sexual comfort. Number of friends using or carrying condoms. Two items assessed the proportion of the respondent's close friends who carried condoms and used them with secondary partners, a measure of perceived normative condom use behavior among peers. Responses ranged on a five-point scale from "almost all" to "almost none." Myths about HIV transmission. A measure of beliefs about the casual transmission of HIV was computed by adding responses to three items, such as the likelihood of getting HIV from using public toilets. Total scores could range from 3 to 12, with higher scores representing less accurate beliefs. Demographics. Age, education, marital status, and ethnic origin were determined for each respondent. Acculturation. Acculturation, the process by which a person learns a new culture, was assessed using four language-related items. That scale has been previously shown to have good reliability and validity. Mean scores ranged from 1 to 5, with higher scores indicating more use of English, hence higher levels of acculturation (alpha = 0.90). Other variables. Positive attitude toward condom use with a secondary partner was measured with a six-level Likert-type scale ranging from "dislike a lot" to "like a lot." Knowing someone with HIV infection or AIDS and previous use of condoms to prevent disease were assessed through single items with "yes" or "no" responses.

This text is excerpted from the article "Condom use among Hispanic men with secondary female sexual partners." Marin, Barbara VanOss; Gomez, Cynthia A.; Tschann, Jeanne M.; Public Health Reports v108, n6 (Nov-Dec, 1993):742-750. COPYRIGHT U.S. Department of Health and Human Services 1993

What are Black Men’s HIV Prevention Needs?

Prepared by Bob Haas & Barbara Green-Ajufo, DrPH, MPH Community Engagement (CE) Core | August 2017

Who are black men?

In the U.S., Black men include different ethnic groups from the African Diaspora. They are friends and diverse family members: fathers, grandfathers, husbands, partners, brothers, uncles, sons, nephews, and cousins. They are colleagues working in professional and blue-collar jobs. They also represent different sexual orientations, have diverse spiritual and religious beliefs, and speak different languages, among having other demographic differences.

Why is HIV a concern among black men?

HIV is a health emergency among Black men of every age and sexual orientation. In 2015, 33% of HIV infections diagnosed in the U.S. were among Black men. They were diagnosed eight times more than white men and two times more than Hispanic men.[1] One in every twenty Black men will be diagnosed with HIV in their lifetime. Among the general population of men, Black men have a higher risk of HIV, noted by the differences below that will continue if current trends are not reversed.[2-4]

• Men who have sex with men (MSM): black (1 in 2); general MSM population (1 in 6)
• Injection drug users (IDU): black men (1 in 9); general male IDU population (1 in 36)
• Heterosexual men: black (1 in 86); general heterosexual male population (1 in 473)

Among MSM, Black MSM (BMSM) – including gay and bisexual men – are more likely than others to be diagnosed with HIV (39% in 2015).[5] Young Black MSM (YBMSM) are most at risk. Seventy-five percent of all BMSM diagnosed with HIV in 2015 were ≤ age 34 – split equally between those aged 13-24 (37.7%) and aged 25-34 (37.3%).[6] Many studies have shown that BMSM’s engagement in unprotected “condomless” anal intercourse (UAI) and number of sexual partners are similar to or less than MSM of other race or ethnic groups. However, BMSM are more likely to be diagnosed with HIV. This finding is true for different populations of BMSM.[7-10] In one study, YBMSM were nine times more likely to be living with HIV than white participants with similar risks.[7] The demand for and awareness of PrEP – a proven biomedical intervention – is lower for BMSM than white MSM (WMSM).[11] From January 2012 to September 2015, 74% of the PrEP prescriptions in the U.S. were to whites, 12% to Latinos, and 10% to African Americans.[12]

What are HIV risk factors for black men?

Many factors affect Black men’s risk of HIV infection.

Stigma and Discrimination – When Black men experience stigma or discrimination, they are less likely to use PrEP [13] or disclose their HIV status.[14] Moreover, discrimination-related traumas, based on being gay, black or living with HIV, are associated with greater UAI.[15] High HIV infection rates, racist attitudes of non-Black gay men, and social networks and environments where gay men gather have been found to stigmatize and isolate BMSM from other MSM.[16]

HIV Care Continuum Disparities – Poor retention of Black men in health care is deeply rooted in discriminatory practices of the medical system towards the Black community.[17] Consequently, BMSM are less likely than WMSM to know their HIV status, more likely to be diagnosed later, and less likely to stay engaged in care and on treatment.[18-19]

Poverty – Discrimination and reduced access to and retention in quality education are reasons that Black men experience more unemployment or are underemployed, compared to white men.[20] Consequently, Black men are more likely to be living in poverty, which usually means reduced access to quality health care.[20] HIV rate increases 3.0 to 5.5 times with increasing neighborhood poverty level from < 10% (low poverty) to more than 30% (very high poverty level).[21-22] For Black individuals living with HIV, poverty is associated with lower levels of engagement in HIV care.[23]

Sexual Trauma – Sexual abuse and assault rates are high among MSM and are related to greater risks of HIV infection. In the EXPLORE Study, 39% of MSM reported childhood sexual assault; Black participants were more likely to have a history of assault than no history of assault.[24-25]

Sexually Transmitted Diseases (STDs) – Having an STD can increase the chances of a person transmitting or becoming infected with HIV.[26] STD and HIV disparities in the Black community increase the likelihood of HIV transmission.[27-29]

Social networks and sex with men of their race – The high HIV rate among BMSM and their preference for sex with MSM of their same race increase the chances of BMSM having a sexual partner that is living with HIV. A review of studies found that at least 29% of BMSM in networks having sexual contact were living with HIV and 47% of men living with HIV in these networks did not know their status.[30]

What is being done?

Research findings for black men of diverse ages, sexual orientations, and HIV serostatus, discussed below, have been shown to reduce sexual risk behaviors and increase engagement in HIV care.[31]

Randomized Comparison Group Interventions: Two studies, Many Men Many Voices (3MV) and Brothers to Brothers, report positive findings for either a reduction in number of UAI occurrences with casual partners, number of any unprotected insertive anal intercourse, number of male sex partners, and/or a greater likelihood to test for HIV.

Pre- Post-Test/Repeated Survey Interventions: Black MSM who participated in D-up! Connect with Pride, BRUTHAS, Motivational Interviewing (MI), or Special Projects of National Significance (SPNS) interventions report improved outcomes, compared to those with limited or no participation. Studies found either a reduction in any UAI at different times during the intervention, a reduction in occurrences of UAI with main partners, reduced number of sexual partners, greater condom use with main partners, reduced number of high-risk sexual encounters with female sex partners, and/or a reduction in sex under the influence of drugs. Different studies also reported improvements in social support, self-esteem, and loneliness, as well as improved likelihood of HIV counseling and testing, return for test results, and fewer missed HIV medical visits. For one study, as the number of hours spent attending case management meetings increased, the time in HIV care increased.

Blended Pre- Post-Test and Control Group: Young MSM of color who participated in STYLE (Strength Through Youth Livin’ Empowered) reported 83% retention in care, and the chances of attending a clinic visit was greater for the STYLE participants than non-participants (2.58, 95% CI 1.34-4.98).

What still needs to be done?

HIV prevention targeting Black men should not simply address high-risk sexual behaviors but also societal and structural issues. We need policies that will prevent new infections and add to our understanding of Black/White HIV infection disparities, including the role of structural interventions.[32-33]. We need to combine behavioral and biomedical interventions; abandon a “one size fits all” approach; address high STD rates, traumatic events and structural and access barriers; and, consider the intersection of health and social conditions. The need to address stigma – including ones that are unapparent – must not be lost. For example, data must be presented with background, community perspective, and accurate explanation. HIV disclosure must include strategies to help partners and family members receive information that their loved one is gay or living with HIV. Broad implementation of successful interventions in areas where HIV is highest for Black men is necessary.

Says who?

1. CDC. HIV among Afr. Americans. Feb 2017.

2. Gavett G. Timeline: 30 Yrs. of AIDS in Blk. Americans. KQED Frontline. Jul 10, 2012.

3. Hess K, et al. Est. lifetime risk of dx of HIV infect in the U.S. CROI 2016. Boston, abstract 52.

4. CDC. Lifetime risk of HIV dx. Feb 2016.

5. CDC. HIV in the U.S.: At A Glance. Dec 2, 2016.

6. CDC. HIV among Afr. Am. gay and bisexual men. Jul 2016.

7. Millett GA, et al. Greater Risk for HIV Infect of Blk MSM: Lit Rev. AJPH. Jun 2006;96(6):1007-19.

8. Millet GA, et al. Disparities in HIV Infect among Blk and Wht MSM: Meta-Analysis. AIDS. Oct 1 2007;21(15):2083-91.

9. Magnus M, et al. Elevated HIV Prev. Despite Lower Rates of Sexual Risk Behav among Blk MSM in DC. AIDS Patient Care STDS. Oct 2010;24(10): 615–22.

10. Maulsby C, et al. HIV among Blk MSM in the U.S.: Lit. Rev. AIDS and Behav Jan 2014;18(1):10-25.

11. Cohen SE, et al. Response to race and PH impact potential of PrEP in the U.S. J Acquir Immune Defic Syndr. Sep 1 2015;70(1):e33-e35.

12. Highleyman L. PrEP use rising in U.S. but large racial disparities remain. nam aidsmap. Jun 24, 2016.

13. Chaill S, et al. Stigma, med mistrust, and racism affect PrEP awareness and uptake in Blk compared to Wht MSM in Jackson, MS and Boston, MA. AIDS Care, 2017.

14. Overstreet NM, et al. Internalized stigma and HIV status disclosure among HIV-pos MSM. AIDS Care 2013;25 4, 466-471.

15. Fields EL, et al. Assoc. of Discrimination-Related Trauma with Sexual Risk among HIV-Pos Afr. Am. MSM. AJPH. May 2013;103(5):875-80.

16. Raymond HF, et al. Racial Mixing and HIV Risk among MSM. AIDS Behav Aug 2009;13(4):630-37.

17. Lisa Eaton, et al. Role of Stigma and Med Mistrust in Routine Hlth Care Engagement of MSM. AJPH. Feb 2015;105(2): e75–e82.

18. Levy ME, et al. Understand Structural Barriers to Accessing HIV Test & Prev Servs among Blk MSM in the U.S. AIDS Behav. 2014 May; 18(5): 972–996.

19. Christopoulos KA, et al. Link and Retention in HIV Care among MSM in the U.S. Clin Infect Dis. 2011 Jan 15; 52(Suppl 2): S214–S222.

20. Ethnic and Racial Minorities and SES. Factsheet. APA. http://www.apa.org/pi/ses/resources/publications/factsheet-erm.pdf

21. Alameda Co. CA eHARS data (2008-2012). Verbal communication with Nina Murgai, Dir, HIV/AIDS Surv Unit.

22. Wiewel EW, et al. Assoc bwt Neighborhood Poverty and HIV Dx among Males and Females in NYC, 2010-2011. PH Rep. Mar-Apr 2016;131(2):290-302.

23. Lechtenberg RJ, et al. Poverty, Race, Engagement: Diff Assoc with Retention in Care among PLWH in Alameda Co. UCSF CFAR HIV Hlth Disparities Symposium, Mar 24, 2017.

24. Mimiaga MM, et al. Child Sexual Abuse Assoc with HIV Risk–Taking Behav and Infect among MSM in the EXPLORE Study. J Acquir Immune Defic Syndr. 2009 Jul 1:51(3):340-348.

25. Millett GA, et al. Rev of HIV epidemics in Blk MSM across African diaspora. Lancet. Jul 28 – Aug 3;380(9839):411-23.

26. CDC. STDs and HIV – CDC Factsheet. Nov 17, 2015.

27. CDC. 2015 STDs Surveillance – STDs in Racial and Ethnic Minorities. Jan 23, 2017.

28. Scott HM, et al. Racial/ethnic and sexual behav disparities in rates of STIs, SF (1999-2008). BMC Pub Hlth. Jun 6, 2010;10:315.

29. Pathela P, et al. MSM have higher risk for newly dx HIV and syphilis compared with heterosexual men in NYC. J Acquir Immune Defic Syndr. Dec 1, 2011;58(4):408-16.

30. Hurt CB, et al. Invest Sexual Network of Blk MSM: Implications for Transmission and Prev of HIV Infect in U.S. J Acquir Immune Defic Syndr. Dec 1, 2012;61(4):515-21.

31. Maulsby C, et al. Rev of HIV Interv for Blk MSM. BMC Pub Hlth. 2013;13:625.

32. Peterson, JL, et al. Soc. discrimination and resiliency not assoc with differ in HIV infect in blk and wht MSM. JAIDS 2014:66;538-543.

33. Sullivan PS, et al. Understand racial HIV/STI disparities in blk and wht MSM. PLoS One 2014;9: e90514.

Special thanks to the following reviewers of this Fact Sheet: Emily Arnold, Jesse Brooks, Lorenzo Hinojosa, Loren Jones, Micah Lubensky, Daryl Mangosing, Janet Myers, Nasheedah Bynes-Muhammad, Rob Newells, John Peterson, Greg Rebchook, Andrew Reynolds, and Wilson Vincent 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. ©2017, University of CA. Comments and questions about this Fact Sheet may be e-mailed to [email protected]. This publication is a product of a Prevention Research Center and was supported by Cooperative Agreement Number 5U48DP004998 from the Centers for Disease Control and Prevention.

A pesar del alto riesgo de transmisión del VIH al compartir jeringas, la relación que existe entre el VIH y el uso de drogas va mucho mas allá del tema de las jeringas. Las personas adictas al alcohol, al “speed” y a la cocaína-crack, los “poppers” o cualquier otra droga no inyectada, están más propensos que aquellos que no usan drogas a ser portadores del VIH y a convertirse en seropositivos. Aún aquellos personas que no usan drogas intravenosas están mas propensas a participar en actividades sexuales de alto riesgo. Muchos de los usuarios de drogas intravenosas (UDIs) primordialmente usan otras drogas no inyectadas. Cuando un UDI porta el VIH, compartir jeringas puede ser el factor de mayor riesgo, pero el uso de drogas no inyectadas, puede además propiciar conductas de riesgo. Por ejemplo, en un estudio de clientes en programas de tratamiento con “Methadone” que presentaban conductas de alto riesgo, se descubrió que los de mayor riesgo de infectarse con el VIH eran los que usaban cocaína-crack. Al hacer una encuesta a heterosexuales en programas de tratamiento de alcohol en San Francisco, CA se encontraron tasas de infección del 3% entre hombres no UDIs y no homosexuales y del 4% entre mujeres no UDIs. Estas tasas resultan considerablemente altas en comparación con otra encuesta a una población similar en la que los resultados fueron del 0.5% entre hombres y el 0.2% entre mujeres. Un estudio realizados a hombres homosexuales de la ciudad de Boston, MA encontró una estrecha relación entre el uso de inhalantes o “poppers” y la infección del VIH. Los hombres que tuvieron sexo anal bajo los efectos del inhalante estaban 4.2 veces más propensos a ser VIH positivos que los que no estaban bajo estos efectos al tener sexo anal. La cocaína-crack siempre ha estado estrechamente ligada con la transmisión del VIH. Al realizarse un estudio entre jóvenes adultos de 3 vecindarios urbanos que fumaban crack y que nunca se habían inyectado drogas, se obtuvieron tasas de infección del 15.7%. Los más propensos a tener la infección eran las mujeres que habían accedido a tener sexo sin protección a cambio de drogas o dinero y los hombres que tuvieron sexo anal con otros.

HIV counseling and testing (C&T) is an important part of a continuum of HIV prevention and treatment services. C&T is one of the main times when a comprehensive individual risk assessment is taken, making it the best opportunity for accurate referrals to more intensive services. C&T is also one of the primary entry points into prevention and other services. C&T uses short, client-centered counseling that can be effective in increasing condom use and preventing sexually transmitted diseases (STDs). Knowing one’s HIV status, whether HIV- or HIV+, is key to preventing the spread of HIV and accessing counseling and medical care. It is estimated that one-fourth of all HIV+ persons in the US do not know they’re infected. A survey of young men who have sex with men (MSM), found that 14% of young Black MSM were HIV+. Among those, 93% were unaware of their infection, and 71% reported it was unlikely they were HIV+. Recently, the Centers for Disease Control and Prevention (CDC) announced an initiative aimed at expanding C&T in the US. Their Strategic Plan for 2005 strives to decrease by 50% the number of people who don’t know their HIV status. If this goal is met by 2010, an estimated 130,000 new HIV infections may be prevented, saving over $18 billion.

Young injection drug users (IDU) are at high risk for viral infections, such as HIV, hepatitis C virus (HCV), and hepatitis B virus (HBV), due to frequent injecting, needle/syringe and other drug preparation equipment sharing, high numbers of sexual partners, and exchange of sex for money or drugs. Street youth who inject have high unemployment, poor education, and mental health issues. In San Francisco, young IDU are typically homeless runaways who often are involved in an illegal street economy, including prostitution, drug sales, theft, panhandling, pornography and selling stolen property. They experience a large number of negative and traumatic events prior to leaving home. Many fear and mistrust authority and consequently avoid or delay contact with the public health system. The combination of youth, drugs, survival sex and disenfranchisement make this group extremely vulnerable to multiple negative health outcomes.