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].

What Are U.S. Latinos’ HIV Prevention Needs?

revised 4/02

Are Latinos at risk for HIV?

HIV continues to be a major health threat for Latinos in the US, many of whom are disadvantaged due to racism, economic disparities and language barriers. Latinos in the US (including residents of Puerto Rico) are disproportionately affected by HIV, accounting for 18% of total AIDS cases while comprising 14% of the US population.¹ The majority of AIDS cases among the Latino population in 2000 were concentrated among those born in the continental US (35%) and Puerto Rico (25%), followed by those born in Mexico (13%), Central or South America (8%) and Cuba (2%). An additional 18% were reported from Latinos with unknown place of birth (15%) or born elsewhere (3%).²

What puts Latinos at risk?

Latinos in the US include a diverse mixture of racial and ethnic groups and cultures. Latinos share common factors with other ethnic groups that increase vulnerability to HIV, such as discrimination,³ poverty, lack of information, substance use and negative attitudes toward condoms. AIDS case rates and risk behaviors among Latinos in the US vary by region. In the Northeast and along the eastern seaboard, where many Latinos from Puerto Rico live, Latino rates are up to three times higher than the national average.⁴ In this region, the main risk for transmission is injection drug use, believed to be fueled by the concentration of heroin availability. By comparison, in the West and Southwest, the majority of AIDS cases occurs among men who have sex with men (MSM), although cases are also high among injection drug users (IDUs) in certain areas. In 2000, 47% of AIDS cases among Latino men were attributed to sex with men, 33% to injection drug use, and 14% to sex with women. In the same year, 65% of AIDS cases among Latina women were attributed to sex with men, and 32% to injection drug use.¹ Thus, among both male and female Latinos, as with most other groups, unprotected sex with an HIV+ man is the most common route for becoming infected with HIV, followed by the sharing of an unclean syringe/needle with an HIV+ person. HIV risk dynamics among immigrant and migrant Latinos can be more complex than among US born Latinos, as they are dealing with conflicting cultural norms while trying to adjust to life in a new country. For some, this results in higher risk; for others, lower risk. Levels of acculturation, poverty, employment, migrant labor conditions and connection to traditional Latino values can influence HIV risk.⁶

What are barriers to prevention?

The social and political climate in the US today poses serious problems for effective HIV prevention in Latino communities. Racial and ethnic discrimination, anti- immigrant attitudes, policies on mandatory testing for immigrants, and fear of deportation for undocumented immigrants can prevent many Latinos from receiving and accessing adequate resources and services for HIV prevention, including HIV counseling and testing. Traditionally in Latino cultures, sex and sexuality are not discussed. For some Latina women, this sexual silence dictates that they should not know about or talk to men about sex because it suggests promiscuity. Therefore, their ability, comfort and success in insisting on condom use with male partners may be limited. Sexual silence can prevent MSM from discussing their sexual preference, instilling low self-esteem and personal shame. In addition, the lack of parental discussions and education regarding sex and condoms seems to contribute to the disproportionate number of unintended pregnancies, sexually transmitted diseases and HIV cases among Latino youth.⁹ Injection drug use is one of the main risk factors for HIV transmission, yet many IDUs do not have access to clean needles and drug treatment. Access is even more difficult for monolingual, immigrant Latino IDUs who may not use needle exchange sites or other public services due to lack of knowledge and fear of being recognized or deported.

How does culture affect prevention?

Familismo is a traditional Latino commitment to family and a central support to family members. Familismo can be a powerful incentive in helping heterosexual Latino men reduce unprotected sex with casual partners outside of primary partnerships. However, for many Latino MSM, familismo and homophobia can create conflict because families may perceive homosexuality as wrong. MSM are forced to separate their sexual identity from their family life, leading to low self-esteem and personal shame.⁸ Machismo may lead men to view sex as a way to prove masculinity. This can mean that frequency and type of sex are most often determined by men, leaving women in fear of violence or abandonment if they resist male sexual advances.7Machismo may also be used as an excuse for unprotected sex.

What’s being done?

Prevention Point Philadelphia, in collaboration with other AIDS organizations, operated a full service needle exchange site from a van that traveled to an area with many shooting galleries. The van offered needle exchange, oral HIV testing, bilingual social service and drug treatment referrals and medical care. The van reached many homeless, Spanish-speaking Puerto Rican IDUs who were regular shooting gallery users. Many of them had never accessed preventive medical care or social services. In San Antonio, TX, a three-session small group intervention was offered to English-speaking Mexican-American women who had a sexually transmitted disease (STD). The intervention sought to help women recognize their risk for HIV and other STDs, make a plan to change and then build skills to help reduce those risks. The intervention significantly reduced rates of subsequent STDs.¹¹ Hermanos de Luna y Sol, is an ongoing intervention for Latino gay/bisexual men at Mission Neighborhood Health Center in San Francisco, CA, based on empowerment education and social support. The program provides outreach, six structured discussion sessions and ongoing support to maintain behavior change. Sessions deal with the common history of oppression among Latino gay men, social support and community and emotional issues around sex and sexuality. The impact of AIDS and HIV transmission are discussed in the final two sessions. The program has been successful in recruiting men and increasing condom use among participants.¹² Mujeres Unidas y Activas is a community education, organizing and advocacy project created by and for Latina immigrant and refugee women in San Francisco, CA. The project includes components such as information meetings, friendship circles, workshops and advocacy. Although the project was not developed to specifically target HIV risk behaviors, women who attended up to nine types of activities showed increases in sexual communication comfort, were less likely to maintain traditional sexual gender norms and reported changes in decision-making power.¹³

What still needs to be done?

Latinos are concerned about the HIV epidemic and are motivated to learn and to teach their children about prevention.¹⁴ Providers and social service agencies should capitalize on this by providing Spanish-language or bilingual education and services such as anonymous and confidential HIV testing. Incorporating HIV prevention messages into general health services, Spanish media and religious settings would decrease stigma and increase access to HIV prevention programs. As Latinos, we must attempt to break the silence around sexuality in our communities and overcome homophobia. Latinos can encourage healthy sexuality by discussing gender role expectations, teaching children about sexuality and accepting diversity in our own community. Programs can build upon the protective aspects of Latino culture and emphasize resiliency. Larger societal factors such as poverty, racism and homophobia must also be addressed in order to reduce their impact on risk behavior.

Says who?

1.Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report, Midyear Edition. 2001;13. https://www.cdc.gov/hiv/library/reports/hiv-surveillance.html  2. Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report, Year End Edition. 2000;12. https://www.cdc.gov/hiv/library/reports/hiv-surveillance.html  3. Díaz RM, Ayala G. Social discrimination and health: the case of Latino gay men and HIV risk. National Gay and Lesbian Task Force. 4. Kaiser Family Foundation. Key Facts: Latinos and HIV/AIDS. November 2001. 5. Klevens RM, Díaz T, Fleming PL, et al. Trends in AIDS among Hispanics in the United States, 1991-1996. American Journal of Public Health. 1999;89:1104-1106. 6. Organista K, Carrillo H, Ayala G. HIV prevention with Mexican migrants: review, critique and recommendations. Journal of Acquired Immune Deficiency Syndrome. 2004;37:S227-39 7. Gómez CA, Marín BV. Gender, culture and power: barriers to HIV prevention strategies for women. The Journal of Sex Research. 1996;33:355-362. 8. Díaz RM. Latino Gay Men and HIV: Culture, Sexuality and Risk Behavior. New York: Routledge Press, 1998. 9. The National Campaign to Prevent Teen Pregnancy. Whatever Happened to Childhood? The Problem of Teen Pregnancy in the United States. 1997. 10. Porter J, Perez G. Taking it to the street: shooting gallery needle exchange site for drug injectors at highest risk for HIV. Presented at the International Conference on AIDS, Geneva, Switzerland; 1998. Abst #33402. 11. Shain RN, Piper JM, Newton ER, et al. A randomized, controlled trial of a behavioral intervention to prevent sexually transmitted disease among minority women. New England Journal of Medicine. 1999;340:93-100. 12. Hermanos de Luna y Sol. Contact: 415/552-1013 x296 13. Gómez CA , Hernandez M, Faigeles B. Sex in the New World: An Empowerment Model for HIV Prevention among Latina Immigrant Women. Health Education & Behavior. 1999;26:200-212. 14. Kaiser Family Foundation. Latinos’ View of the HIV/AIDS Epidemic at 20 Years: Findings from a National Survey. 2001. 15. Ortiz-Torres B, Serrano-Garcia I, Torres-Burgos N. Subverting culture: promoting HIV/AIDS prevention among Puerto Rican and Dominican women. American Journal of Community Psychology. 2000;28:859-881. 16. Raj A, Amaro H, Reed E. Culturally tailoring HIV/AIDS prevention programs: Why, when and how. In: Kazarian & Evans (Eds) Handbook of Cultural Health Psychology. San Diego: Academic Press, 2001; 195-239.

Prepared by Cynthia Gómez, PhD, CAPS April 2002. Fact Sheet #17ER Special thanks to the following reviewers of this Fact Sheet: Hortensia Amaro, George Ayala, Jaime Calderón-Soto, Alejandra Cano, Dennis De Leon, José Ramón Fernandez-Peña, Francisco Gonzales, Barbara Marín, Kurt Organista, Prisci Quijada, Carlos Soles, Carlos Velazquez, Luis Villanueva.

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. Comments and questions about this Fact Sheet may be e-mailed to [email protected]. © September 2001, University of California

What are the HIV prevention needs of Mexican immigrants in the US?

Why do Mexicans migrate?

The most common motivation for Mexicans to move to the US is economic, followed by a desire to reunite with spouses, parents or other immediate family, particularly among women and children. However, for some an additional important reason to leave Mexico is the need to find a new social space where they can redefine their sexual and gender identities.^1,2 This phenomenon–labeled “sexual migration”–is known to happen among Mexican women and among men who are sexually attracted to other men (MSM). Sexual migration is of particular interest in terms of HIV risk. Contrary to what is often assumed, the population of Mexicans who move to the US is considerably diverse. Mexicans are from cities and rural areas, poor and middle-class, undocumented and legal immigrants, monolingual and bilingual. Some emigrate permanently or come for a short period and then return to Mexico.

Who is at risk for HIV infection?

There are an estimated 3 to 6 million Mexican undocumented residents in the US, and most of them live in California and Texas.³ Many Mexicans frequently travel back and forth over the border. One-fourth of the AIDS cases in Mexico are among persons who have spent prolonged periods in the US.⁴ AIDS statistics in Mexico report a slight trend toward the “ruralization” of AIDS that might be linked to male migration to the US.⁵ The limited data on HIV infection in Mexicans living in the US suggests that the groups that have been most greatly affected are MSM, heterosexuals-some of whom have injecting drug user (IDU) partners-and IDUs. Of the US AIDS cases reported in 2000 among persons born in Mexico, 44% were among MSM, 14% among heterosexuals, 9% among IDUs, and 3% among MSM IDUs.⁶ The cause of transmission was not known for 29% of cases.

What puts them at risk?

Different subgroups of Mexicans living in the US confront different challenges in terms of HIV risk. Among other factors, such challenges depend on 1) how their identities and behaviors (sexual and drug-related) change after moving to the US; 2) their access to health services, appropriate HIV education, and condoms; 3) norms about safe sex and drug use in their new communities; 4) the nature of their relationships with sexual partners in the US and in Mexico; and 5) the degree to which they experience racism, discrimination, and poverty in the US. One study of 374 young Latino MSM in the San Diego/Tijuana region found high rates of HIV: 19% in Tijuana, Mexico and 35% in San Diego, CA.⁷ In Tijuana, only half had ever received HIV prevention information and less than half had ever been tested for HIV. Young MSM in Tijuana were more likely to report sex with females and injection drug use than young MSM in San Diego. In San Diego, young MSM were more likely to report unprotected sex with men. HIV risk also exists among heterosexual Mexican migrants, especially among male urban day laborers and those working in agriculture. Often these men come without a spouse and are young, lonely, and isolated, making them likely to seek sex. In addition, they often are not well educated, speak little English, and have limited access to healthcare, making it difficult for them to receive HIV prevention messages⁸. Some of these men engage in sex work, regularly have unprotected sex with female sex workers, or have spouses in Mexico with whom they use no condoms.⁹ Many married Mexican women, whether they are living in the US or in border towns, or living in Mexico with a spouse who migrates to the US, believe strongly in marital fidelity and have negative beliefs about condom use. In one study, many women acknowledged that men who spend long periods of time away from home are at risk for HIV, but most believed that it did not pertain to their marriages or their spouses.¹⁰ Both younger and older women said they did not want to know about any extra-marital affairs their spouses may have had, and did not want to infer infidelity by using condoms.

Does acculturation affect HIV risk?

Research is somewhat contradictory about whether HIV risk increases or decreases as immigrants adopt norms and values of mainstream communities in the US. Some studies argue that acculturation is protective because it promotes individuality, self-esteem and self-empowerment. Others argue that acculturation increases HIV risk because immigrants adopt sexual and drug-related behaviors that were not part of their more conservative, previous worldviews. What is clear is that immigrants change over time in the US, that the changes are complex, and that they have to be taken into account when designing HIV prevention programs for immigrant populations.

What’s being done?

Few HIV prevention programs for Mexican immigrants currently exist, although the number of programs is increasing. In addition, cooperation between the Mexican and American governments in addressing HIV/AIDS has increased. In San Francisco, CA, Hermanos de Luna y Sol has been designed to address the HIV prevention needs of Latin American MSM who have migrated to the US. The program deals with the common history of oppression among Latino gay men, social support, and community and emotional issues around sex and sexuality. This program explicitly ties HIV prevention to other developmental and identity-related needs in ways that contextualize safe sex in the participants’ larger lives. In El Paso, TX, prevention case management services (PCMS) are provided in a large homeless shelter serving undocumented immigrants. PCMS uses a holistic approach to address homelessness, being HIV+, an IDU, a sex worker, or a partner of any of the above. The program concentrates on survival needs first, providing referrals for housing, food banks and medical and mental health treatment. PCMS also locates clinics to give free Pap smears to undocumented women. The Promotoras de Salud Project, sponsored by the Farmworker Justice Fund and Centro de Salud Familiar la Fe, trains farmworker women as health educators or promotoras to provide counseling and education about HIV prevention, care and services in their communities. The promotoras link farmworker women with healthcare facilities, often accompanying the women and interpreting for them. They also provide condoms and emotional support for women using them.

What needs to be done?

Prevention programs for immigrant Mexicans need to contextualize HIV risk in the lives of participants in order to ensure that potential safety measures are relevant and that participants can strategize realistic ways of adopting them. Programs should address the challenges of being a Mexican immigrant living in the US; experiences of racism and homophobia; and barriers that may be imposed by poverty and social marginality. These factors may influence sexual and drug-related behaviors. In addition to prevention programs in US cities with large concentrations of Mexicans, such as Los Angeles, CA and Chicago, IL, border cities such as Ciudad Juárez and Tijuana, Mexico, El Paso, TX, and San Diego, CA are key locations for HIV prevention efforts. Similarly, there is a need for programs focusing on rural areas that attract Mexican migrant workers. Access to basic needs such as healthcare, housing, and jobs, may help reduce HIV risk in Mexican immigrant populations. Culturally-relevant educational and training materials in Spanish, as well as educational programs tailored for the needs of specific subgroups of immigrants, are also needed. HIV surveillance must be improved to understand the scope of HIV among both documented and undocumented immigrants. Because many Mexicans travel back and forth between the US and Mexico, bi-national cooperation is key in addressing these issues. Fostering participation of Mexican immigrants in HIV Prevention Community Planning is key to further identifying effective prevention interventions, and to expanding funding and availability of prevention services for this population.

Says who?

1. Hogdagneu-Sotelo P. Gendered transitions: Mexican experiences of immigration. University of California Press: Berkeley, CA, 1994. 2. Cantú, L. Border crossings: Mexican men and the sexuality of migration. Doctoral Dissertation. University of California, Irvine, 1999. 3. Lowell BL, Suro R. How many undocumented: the numbers behind the US-Mexico migration talks. Report by the Pew Hispanic Center. March 2002 4. Rangel G, Lozada R. Factores de riesgo de infección por VIH en migrantes mexicanos: el caso de los migrantes que llegan a la Casa del Migrante “Centro Escalabrini y Ejército de Salvación. El Colegio de la Frontera Norte, ISESALUD/COMUSIDA. 5. Magis-Rodríguez C et al. La situación del SIDA en México a finales de 1998. Enfermedades Infecciosas y Microbiológicas. 1998; 18, 6: 236-244. 6. CDC. HIV AIDS Surveillance Report. 2001. Volume 12, No.2 https://www.cdc.gov/hiv/library/reports/hiv-surveillance-archive.html.Ruiz JD. HIV prevalence, risk behaviors and access to case among young Latino MSM in San Diego, California, and Tijuana, Mexico. Presented at the Binational Conference on HIV/AIDS. Oakland, CA, 2002. 8. Bronfman N, Moreno L. Perspectives on HIV/AIDS prevention among immigrants on the US-Mexico border. In: Mishra S, Conner R, Magaña R (eds) AIDS crossing borders: The spread of HIV among migrant Latinos. Westview Press: Boulder, CO, 1996. 49-76. 9. Organista KC, Organista PB. Migrant laborers and AIDS in the United States: A review of the literature. AIDS Education and Prevention. 1997; 9:83-93. 10. Hirsch JS, Higgins J, Bentley ME, et al. The social constructions of sexuality: marital infidelity and sexually transmitted disease-HIV risk in a Mexican migrant community. American Journal of Public Health. 2002; 92:1227-1237 11. Flaskerud JH, et al. Sexual practices, attitudes, and knowledge related to HIV transmission in low income Los Angeles Hispanic women. The Journal of Sex Research. 1996: 33:343-353. 12. Marín BV, Flores E. Acculturation, sexual behavior, and alcohol use among Latinas. International Journal of the Addictions. 1994; 29:1101-1114 13. Díaz RM. Latino gay men and HIV. New York and London: Routledge. 1998. prevention.ucsf.edu/uploads/projects/hlsindex.php 14. Moore EF. Sub-culturally competent HIV prevention case management on the Mexican-American border. Presented at the National AIDS Prevention Conference, Atlanta, GA. 1999. Abs#659. 15. Hernández A. Promovision/ USMBHA: Proyecto para fortaleces la capacidad de la comunidad en la prevención del VIH/SIDA. Presented at the United States-Mexico Border Health Association (USMBHA) Conference, Las Cruces, New Mexico. 2001. https://www.hhs.gov/about/agencies/oga/about-oga/what-we-do/international-relations-division/americas/border-health-commission/index.html  16. US-Mexico Border Health Association. The State of Latinos in HIV Prevention Community Planning. 2002.  Prepared by Héctor Carrillo, DrPH and Pamela DeCarlo, CAPS April 2003. Fact Sheet #48E Special thanks to the following reviewers of this Fact Sheet: María Chaparro, Frank Galvan, Apolonia Hernández, Barbara Marin, Octavio Vallejo.

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 Prevention Information Network at 800/458-5231. Comments and questions about this Fact Sheet may be e-mailed to [email protected]. © April 2003, University of California

¿Qué necesítan los afro-americanos en la prevención del VIH? (revisado 8/00)

¿corren el riesgo de contraer el VIH los afro-americanos?

Sí. Muchos Afro-Americanos corren alto riesgo de infectarse con VIH, no por razones étnicas o raciales, sino por los comportamientos de riesgo en los que pueden estar participando. Igual que ocurre en otros grupos raciales/étnicos, el riesgo de infección con VIH no solo depende de la identidad, sino del tipo de conductas riesgos que se estén llevando a cabo con una pareja VIH+, y si se tiene acceso a servicios médicos y prevención. La mayoría de los casos de SIDA en Afro-Americanos ocurre en personas de 25 a 44 años de edad y en hombres. A pesar de contar con el 13% de la población total estadounidense, los Afro-Americanos se ven desproprocionadamente afectados por el VIH ya que cuentan con el 37% de todos los casos de SIDA. En 1998, casi dos tercios (62%) de los casos de SIDA entre mujeres estuvo compuesto por Afro-Americanas. Al unísono, el 37% de todos los casos de SIDA en la categoría de Usuarios de Drogas Intravenosas (UDIs) pertenecia a Afro-Americanos. En 1998, los niños Afro-Americanos representaron el 62% de todos los casos de SIDA infantil.

¿cuáles afro-americanos están a riesgo?

Los Afro-Americanos, igual que otros grupos raciales o étnicos, representan una población diversa. Su diversidad se evidencia en el estado migratorio, religioso, nivel económico, posicióngeográfica y el idioma que hablan. Por ejemplo, los Afro-Americanos incluyendo a oficinistas y la clase trabajadora, Musulmanes y Cristianos. Pueden residir en el centro de la ciudad y en áreas rurales, pueden ser descendientes de esclavos o Caribeños recién emigrados. Los datos de vigilancia epidemiológica actuales, no registran la identidad social, cultural, económica, geográfica, política y religiosa que pudiera predecir con mayor exactitud el nivel de riesgo. Dentro de las comunidades Afro-Americanas, la transmisión del VIH se toma como un problema de los heterosexuales UDIs y de sus parejas sexuales. Sin embargo, la proporción acumulativa de casos de SIDA atribuida a la actividad homosexual/bisexual (38%) es mayor que la atribuida al uso de drogas inyectadas (35%). En general, los adolescentes Afro-Americanos registran tasas de seroprevalencia mucho mayores que las de los adolescentes Anglo-Sajones. Las jóvenes Afro-Americanas, especialmente las sexualmente activas y de los barrios pobres son las que tienen un mayor nivel de riesgo de infección con VIH. En un estudio a jóvenes desertores escolares de bajo nivel económico en los “Job Corps” (Cuerpos de Trabajo) se descubrió que las mujeres entre los 16 a 18 años de edad tenían tasas de infección 50% mayores a las de los varones Afro-Americanos.

¿cómo se exponen al riesgo?

El uso de drogas inyectadas ha sido el factor determinante de la infección con VIH entre los Afro-Americanos. Si bien es cierto que la mayoría de los UDIs en los EEUU son Blancos, las tasas de infección son mayores en UDIs Negros. El desempleo y la probreza son co-factores significativos que pueden estar contribuyendo al aumento en los índices de adicción y comporta-mientos de riesgo. En efecto, la epidemia del VIH y del uso de drogas en Afro-Americanos se concentra en un número reducido de barrios urbanos del centro de la ciudad, lo cual indica que la epidemia puede estar mas ligada a la geografía y a la pobreza que a la raza o etnia. Si bien las actitudes en la comunidad Afro-Americana cambian poco a poco, la homofobia y las actitudes negativas hacia el hombre homosexual continúan vigentes. Para los hombres jóvenes Afro-Americanos que tienen sexo con otros hombres, estas actitudes negativas pueden ocasionar una baja auto-estima, falta de conección comunitaria y malestares psicológicos, factores que a su vez contribuyen a las conductas de riesgo. Muchas mujeres Afro-Americanas, las adolescentes en especial, presentan alto riesgo de adquirir el VIH por la vía heterosexual. Las mujeres Afro-Americanas pueden no querer o no estar aptas para negociar el uso del condón puesto que pueden pensar que esto va a interferir con la intimidad física y emocional; puede implicar infifelidad propia o de su pareja o puede ocasionar abuso físico. Algunas mujeres pueden, además, estar en un estado de negación o hasta desconocer el riesgo que corren. Más de un tercio (35%) de los casos de SIDA en mujeres Afro-Americanas reportados en 1998 se clasificaron como “riesgo no reportado” o “no identificado”. Se creee que la mayoría de estas mujeres se infectan por medio del sexo heterosexual con UDIs y/o parejas “gay” o bisexuales.

¿cuáles son los obstáculos en la prevención?

Las comunidades de color de este país, incluyendo a la Afro-Americana, han experiementado persistentes desigualdades en beneficios sociales, cuidados médicos, educación y oportunidades de trabajo. Las disparidades económicas continúan deteriorando el estado de salud de los Afro-Americanos y de otras comunidaes de color en los EEUU. Dando como resultado altos índices de muerte y enfermedeades en la comunidad Afro-Americana. Adicionalmente, muchos Afro-Americanos mantienen una desconfianza hacia los programas gubernamentales y hacia las intituciones de salud. Algunos Afro-Americanos piensan que los efectos del SIDA en la comunidad forman parte de los esfuerzos deliberados y de omisión de responsablidad por parte del gobierno estadounidense. La eficacia de los programas de prevención de índole comunitaria deben tomar en cuenta estos factores. El problema del SIDA dentro de la comunidad Afro-Americana se entiende como un problema principalmente “gay”. Adicionalmente, la homofobia está presente en la familia, la iglesia y la comunidad Afro-Americanas tanto a nivel personal como institucional. Muchos homosexuales Afro-Americanos sexualmente activos pueden estar renuentes a responder ante la epidemia del SIDA por temor a ser alienados.

¿qué se está haciendo?

A los jóvenes Afro-Americanos de Filadelfia, PA, se les ofreció un programa de prevención que integraba intervenciones de abstinencia y de sexo seguro. Los participantes en las intervenciones de abstinencia reportaron menos relaciones sexuales 3 meses después, pero no a los 6 o 12 meses de seguimiento. De los jóvenes que reportaron previa experiencia sexual, los que recibieron la intervención de sexo seguro reportaron menos relaciones sexuales que los que recibieron la intervención de abstinencia a 3-, 6-, y 12-meses de seguimiento. Ambas alternativas, el sexo seguro y la abstinencia redujeron las conductas sexuales de riesgo a corto plazo, pero las intervenciones de sexo seguro pueden tener efectos más duraderos y pueden ser más eficaces para los jóvenes con previa experiencia sexual. Algunas comunidades que promulgan la fé están respondiendo al VIH de forma innovadora. En Tennessee, la Iglesia Interdenominacional inició un programa para atraer a UDIs de 4 barrios pobres predomantemente Afro-Americanos. El programa ofrece agujas esterilizadas, condones, manejo de casos y educación preventiva. Ellos están creando un programa modelo de reducción de riesgo con base en la iglesia para ser utilizado en otras comunidades de este tipo. “The Well,” un centro para mujeres Afro-Americanas al que se acude sin previo aviso, diseñado para esta comunidad, promueve la auto-eficacia y el bienestar en un proyecto de viviendas para personas de bajos ingresos en Los Angeles, CA. Este centro ofrece servicios de apoyo por parte de personas que reciben los servicios en “círculos de hermanas”, clases de ejercicio, educación sobre salud comunitaria, una sala/biblioteca, una oficina de enfermería y mantiene asociaciones con otras organizaciones comunitarias de salud. “The Well” mezcla la educación sobre VIH/ETS con la educación general que trata todos los aspectos de la vida de estas mujeres.

¿qué es necesario hacer?

Los científicos y proveedores de servicio necesitan conocer más a fondo cual es el papel de la cultura y los factores socio-económicos en la transmisión del VIH asi como la desigualdad racial en salud pública. Adicionalmente, las autoridades de salud pública deben considerar un cambio al sistema de vigilancia epidemiológica para que incluya otros tipos de información demográfica tales como los factores culturales, sociales y económicos. Estos esfuerzos necesitan tener una influencia en el diseño de los mensajes de prevención del VIH, servicios y programas. En la segunda década de la epidemia del SIDA, falta por tomar en cuenta la homofobia y la negación de la problemática del SIDA. Las instituciones de salud pública deben buscar formas de establecer asociaciones con las comunidades Afro-Americanas que promulgan la fé e incorporar la compasión a la enseñanza espiritual que logre despertar la respuesta de la comunidad. La prevención del VIH para los Afro-Americanos debe llevarse a cabo a nivel de comunidad. Los programas complejos deben establecer nexos con otros servicios de salud tales como los programas de abuso de sustancias ilícitas, servicios de planificación familiar y clínicas de ETS.

¿quién lo dice?

1. Centers for Disease Control and Prevention. HIV/AIDS Sur-veillance Report . 1998;10:1-43. 2. National Commission on AIDS. The challenge of HIV/AIDS in communities of color. 1994. 3. Moss N, Krieger N. Measuring social inequalities in health: report on the conference of the National Institutes of Health . Public Health Reports. 1995;110:302-305. 4. Valleroy LA, MacKellar DA, Karon JM, et al. HIV infection in disadvantaged out-of-school youth: prevalence for US Job Corps entrants, 1990 through 1996 . Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology. 1998;19:67-73. 5. Substance Abuse and Mental Health Services Administration . Preliminary results from the 1997 national household survey on drug abuse . US Department of Health and Human Service: Rockville, MD; 1999. 6. Fullilove, RE, Fullilove MT. HIV prevention and intervention in the African American community: a public health perspective. In: AIDS Knowledge Base. PT Cohen, ed. Lippincott, Williams & Wilkins. 1999. 7. Stokes JP, Peterson JL. Homophobia, self-esteem, and risk for HIV among African American men who have sex with men . AIDS Education and Prevention. 1998;10: 278-292. 8. Wingood GM, DiClemente RJ. Pattern influences and gender-related factors associated with noncondom use among young adult African American women . American Journal of Community Psychology. 1998;26:29-52. 9. Wingood GM, DiClemente RJ. The effects of having a physically abusive partner on the condom use and sexual negotiation practices of young adult African-American women . American Journal of Public Health. 1997;87:1016-1018. 10. Dalton HL. AIDS in blackface . Daedalus. 1989:118:205-227. 11. Thomas SB, Quinn SC. The Tuskegee Syphilis Study, 1932 to 1972: implications for HIV education and AIDS risk education programs in the black community . American Journal of Public Health. 1991;81: 1498-1506. 12. Peterson JL. AIDS-related risks and same-sex behaviors among African American men. In AIDS, Identity and Community. Herek GM, Greene B, eds. Sage Publications: Thousand Oaks, CA; 1995:85-104. 13. Jemmott JB III, Jemmott LS, Fong GT. Abstinence and safer sex HIV risk-reduction interventions for African American adolescents: a randomized controlled trial . Journal of the American Medical Association. 1998;279:1529-1536. 14. Sander E. Church based harm reduction programs. Presented at the 12th World AIDS Conference, June 1998,Geneva, Switzerland. Abst. #33380. 15. Elliott Brown KA, Jemmott FE, Mitchell HJ, et al. The Well: a neighborhood-based health promotion model for black women . Health and Social Work. 1998;23:146-152.

PREPARADO POR JOHN PETERSON PHD*, GINA WINGWOOD SCD, MPH**, RALPH DICLEMENTE PHD**, KATHLEEN QUIRK MA***; TRADUCIDO POR ROMY BENARD RODRÍGUEZ*** *DEPARTMENT OF PSYCHOLOGY, GEORGIA STATE UNIVERSITY, ** ROLLINS SCHOOL OF PUBLIC HEALTH, EMORY UNIVERSITY, ***CAPS Agosto 2000. Hoja Informativa 15SR.

El VIH sigue siendo una gran amenaza para la salud de los latinoamericanos en EEUU. Muchos de ellos se encuentran en desventaja debido al racismo, a las desigualdades económicas y a barreras lingüísticas. En EE.UU., los latinos (incluyendo los habitantes de Puerto Rico) se ven desproporcionadamente afectados por el VIH, ya que representan el 18% de todos los casos de SIDA aún cuando sólo son el 14% de la población. En el año 2001, la mayoría de los casos de SIDA entre latinos en EE.UU. la componían personas nacidas en la parte continental de EE.UU. (35%) y Puerto Rico (25%), seguidos por personas nacidas en México (13%), Centro o Sudamérica (8%) y Cuba (2%). Otro 18% lo componían latinos con un lugar de nacimiento desconocido (15%) o nacidos en otra parte (3%).