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Black Men
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.
National Gay Men's HIV/AIDS Awareness Day – September 27, 2017 [booklet]
- Stay up-to-date on research and learn what we found out from research
- Use the materials in trainings/presentations
- Advocate for services/funding
- Write grants
- Develop new or modify existing HIV prevention programs
- Evaluate current programs
- Connect with CAPS/PRC to develop new projects.
Spring Summer 2017 [E-Newsletter]
Health disparities and HIV/AIDS
Health disparities exist across race/ethnic, gender, sexual orientation, socioeconomic and/or geographically defined population groups. This e-newsletter features CAPS/PRC research that discusses and addresses health disparities among impacted groups that are living with or at risk of acquiring HIV/AIDS. Shout out to our Visiting Professors for summer 2017 ! We welcomed two first-year professors and welcomed back eight returning professors who all improved their programs of HIV-related health disparities research.- Local projects
- National projects
- International projects
- Fact sheets on PrEP and Opioid Use
- National HIV/AIDS Awareness Days: Research and Resources booklets
- Announcements
Heterosexual Men - 2018
What Are Heterosexual Men’s HIV Prevention Needs?
Prepared by Joshua Middleton and Reverend William Francis Community Engagement (CE) Core | March 2018
Heterosexual men are affected by HIV
HIV is a concern for heterosexual men, as almost 14% of new male HIV cases in 2016 occurred among heterosexuals, through sex with a woman (9.5%) and injecting drug use (3.9%). Most of those cases were among Black (63%) and Latino (22%) men, and men living in the Southeast (62%) and Northeast (19%) of the US.[1] These statistics, however, may not give us an accurate picture of HIV among heterosexual men. Because sexuality is complex, some heterosexually-identified men may have sex with men, but still identify as straight.[2] The CDC tracks HIV infections through means of infection, not by a person’s identity. Therefore, a heterosexual man who tells his healthcare provider he ever had a sexual encounter with a man is categorized under “men who have sex with men,” and if he says he has ever injected a drug, is categorized under “people who inject drugs (PWID).” Because of this, heterosexual men are seldom mentioned or addressed in the world of HIV prevention, care and research—where men are classified based on federal guidance and misconceptions, and not on men’s own identity.[3] This may be helpful for tracking the HIV epidemic, but it hampers service organizations who want to serve straight men who are at risk for or living with HIV, because funding for programs is linked to mode of transmission.
Fighting stigma
Misunderstanding, discrimination and HIV stigma. Heterosexual men may be reluctant to access testing and education programs at HIV-related organizations because they are concerned they might be labeled as gay or in the closet. Heterosexual men living with HIV can feel excluded from HIV clinics that brand their sites as safe and inclusive spaces for gay and bisexual men, which may be less about homophobia, and more about wanting a safe space for connection with and support from their community.[4] HIV criminalization. Straight men often are blamed for the HIV epidemic among heterosexual women, and may carry guilt, shame and fear of criminal charges. Between 2008 and 2016 in the US, there were 279 cases of HIV criminalization. This occurs when a person is prosecuted for not disclosing their HIV status to a partner. The majority of prosecutions are of heterosexual men.[5] Religion. Religion is an important part of many heterosexual men’s lives, yet sometimes the church may be the place where they are exposed to the beliefs that HIV is a punishment from God, and homosexuality and sex outside of marriage are sins.[6] These religious views may deter open dialogue around HIV, such as HIV testing and prevention, or disclosing HIV status.
Holistic approach
Addressing issues that impact heterosexual men as a whole person—body, mind and spirit—can be more effective than addressing HIV transmission mode. Health inequalities and structural barriers, not necessarily sexual risk taking behaviors, make men more likely to contract HIV and less likely to seek and have access to HIV programs.[3] Family, relationships and intimacy. It is important for heterosexual men to explore their identity as a father, a romantic partner and a member of a family unit.[7] Men view intimacy in many different ways, including being able to communicate with their partner, being transparent and comfortable expressing their feelings, spending quality time with their partners, and having healthy and satisfying sexual lives.[8] Men and boys may need support developing communication skills with their partners. Social injustice and resilience. The largest proportion of heterosexual HIV cases occur among Black men in the Southeast. This is also true for other race/ethnic groups except American Indian/Alaska Native where the largest number is in the West. The second largest number of cases among Black, Latino, and White men occur in the Northeast US. Latino men, the second largest race/ethnic group with HIV also are most affected in the South and Northeast US. Black and Latino men also face disproportionate rates of unemployment, racism, incarceration and lack of education, which can be more pressing issues to contend with than HIV and healthcare. Despite these challenges, many Black men have supportive communities, are highly resilient and persevere. HIV prevention and care services can support Black men by partnering with educational and vocational services to bolster men’s efforts to survive and thrive amid their adversities.[8] Incarceration and post-incarceration services. Programs for heterosexual men should address the impact of incarceration on men, their partners, family and community. Sex with men, sexual assault and injection drug use are risks while incarcerated. People living with HIV (PLWH) may face treatment interruption both in prison and jail, and upon release—which can increase their viral loads and infectivity. Programs can provide education and risk reduction for men affected by incarceration,[9] as well as support finding employment, healthcare and housing upon release.[3]
Quality healthcare
Talking about health. Many men don’t feel comfortable talking about their sexual health and behaviors with their doctors, and doctors typically don’t ask these questions. Cultural male stereotypes and seeing the bulk of health services and promotions focused on women, hamper men’s willingness to seek out health care services, including HIV testing.[10] Healthcare providers need to take a proactive role engaging men, and provide a non-judgmental, safe environment where men can feel free and safe to talk about their sexual health. HIV testing. Providers and clinics need greater awareness that heterosexual men can be at risk for HIV, and should offer all men HIV testing, pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP). Half of heterosexual men living with HIV were diagnosed 5 years or more after they were infected, later than any other population. Providers should talk to men of every age about HIV and HIV risk reduction, and let them know that HIV testing is a part of routine healthcare.[11] HIV treatment and PrEP. PLWH who are on antiretroviral treatment and have undetectable viral loads do not transmit the virus to their partners.[5] PrEP, a medication for people who do not have HIV, can be used by men and women to protect themselves from HIV safely. These medical breakthroughs can help heterosexual men avoid HIV transmission, safely have children, reduce stress and worry, and increase trust and sexual pleasure in relationships.
Resources and programs
There has been resistance in the HIV community to track, fund, research and provide HIV services for heterosexual men, perhaps due to the focus on the mode of transmission and reluctance to acknowledge men’s own heterosexual identity.[3] For example, for the past five years there have been more new HIV cases from heterosexual transmission than from injecting drug use transmission among men,[1] yet programs and services for PWID far outnumber those for straight men. Programs for heterosexual men should collaborate with mainstream organizations, as straight men are less likely to use HIV-specific services. Programs should reach out to places where straight men go, such as the grocery store, gym, barbershops, sporting events, clubs, churches, colleges, vocational services. Heterosexual men prefer to hear messages from other straight men in community locations.[12] Programs, providers and researchers can do a better job of supporting Black men’s strengths and stop highlighting weaknesses. Increasing HIV testing, education, care and treatment, including PrEP for heterosexual men, can help address HIV. Increasing quality education, job and housing opportunities, as well as providing safe spaces for Black men that foster social support can also address HIV.[7]
Making a difference
It is time to recognize and fully address HIV among heterosexual men. Organizations, health departments and clinics should consider the needs of heterosexual men when planning their budgets, and include men in program planning, service delivery, research and policymaking. Straight men can help fight stigma and invisibility by speaking up, disclosing their status, working in HIV organizations and taking their place at the table to advocate for funding and programs. "Until we all come together, HIV is not going to end." -Rev. Francis
Says who?
1. Centers for Disease Control and Prevention. HIV Surveillance Report, 2016. November 2017; vol. 28. 2. Carrillo H, Hoffman A. From MSM to heteroflexibilities: Non-exclusive straight male identities and their implications for HIV prevention and health promotion. Global Public Health. 2016;11:923-36. 3. Bowleg L, Raj A. Shared communities, structural contexts, and HIV risk: prioritizing the HIV risk and prevention needs of Black heterosexual men. American Journal of Public Health. 2012;102:S173-S177. 4. Kou N, Djiometio JN, Agha A, et al. Examining the health and health service utilization of heterosexual men with HIV: a community-informed scoping review. AIDS Care. 2017;29:552-558. 5. Halkitis PM, Pomeranz JL. It’s time to repeal HIV criminalization laws. Huffington Post. August 1, 2017. 6. Wilson PA, Wittlin NM, Muñoz-Laboy M, et al. Ideologies of Black churches in New York City and the public health crisis of HIV among Black men who have sex with men. Global Public Health. 2011;6: S227–S242. 7. Abrahams C, Jones D, Viera A, et al. The forgotten population in HIV prevention: Heterosexual Black/African American men: Key findings and strategies. Harm Reduction Coalition position paper. December 2009. 8. Teti M, Martin AE, Ranade R, et al. “I’m a keep rising. I’m a keep going forward, regardless”: Exploring Black men’s resilience amid sociostructural challenges and stressors. Qualitative Health Research. 2012; 22:524–533. 9. Valera P, Chang Y, Lian Z. HIV risk inside US prisons: A systematic review of risk reduction interventions conducted in US prisons. AIDS Care, 2017;29:943-952. 10. Marcell AV, Morgan AR, Sanders R. The socioecology of sexual and reproductive health care use among young urban minority males. Journal of Adolescent Health. 2017;60:402-410. 11. CDC. HIV testing. CDC National HIV Surveillance System, 2015. 12. Murray A, Toledo L, Brown EE, et al. “We as Black men have to encourage each other:» Facilitators and barriers associated with HIV testing among Black/African American men in rural Florida. Journal of Health Care for the Poor and Underserved. 2017;28:487-498.
Special thanks to the following reviewers of this Fact Sheet: Tony Antoniou, Lisa Bowleg, Derek Canas, Hector Carrillo, Todd Genre, Barbara Green Ajufo, Davina Jones, Steve Kogan, Steven Lamm, Daryl Mangosing, Arik Marcell, Ashley Murray, Bob Siedle-Khan, Michelle Teti, Pamela Valera, Bill Woods 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. ©2018, 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.
Qualitative interview instrument
While you are setting up your equipment, getting the consent form, etc. take note of the surroundings for your field notes.
1. I’d like you to think back to the last time you got an HIV test. Take a minute to remember everything you can about it and then tell me the whole story. Starting from what led up to the test, why you went to get it, where it was done and then how you felt afterwards?
If they have never tested, skip to question # 6: Let interviewee describe the episode. Listen for answers to each of the following questions. Once interviewee's story is told, probe for any questions not answered. Content Areas for HIV Testing: Motivation: including why they decided to test, whether strictly voluntary, coerced or mandatory testing (prison, hospital), where they found out about testing/test site Location: Where was the test site? Procedures: Describe the actual test? (blood/Orasure) Who administered? How was the counseling? What was discussed in counseling? (Probe for discussion of risk behaviors, results, follow-up appointment) How did you feel after you left? Confidentiality: avoid using the words "confidential" or "anonymous" Were you concerned about privacy at all? (Probe for name or number given, familiar test site, familiar test counselor/administrator) Waiting Period: How was the waiting period? Tell me about any changes that occurred during this time period. Did you talk to anyone about HIV and/or the test during the waiting period? Results: When did you go back for results? IF didn’t get results ask why. If had another test where did get results, what was different this time? Where did you go for results? Who gave them? (probe for familiarity with results counselor) How was the result explained/presented to you? What were your results? Was this the result you were expecting? Why? How did you feel after receiving the results? What was discussed after you received the results? (probe for discussions around risk, 6 month window period, referrals given, IF NEGATIVE — ways to stay negative, any plans made to stay negative) Was talking to them useful/helpful? Did you just want to get out of there? Who did you share your results with? 2. How did this compare to other tests you’ve had, did you like it or not? Was it typical of other tests? 3. After this HIV test, did anything change in your life? (drug use, sex, views on risk) If yes, explain what changed. If NO ask: 4. Have you ever had an HIV test that caused you to change your beliefs or behaviors? If yes, please explain what changed. (Probe for what aspect of C&T caused the change; i.e. was it the risk assessment counseling, or receiving the test results) 5. Is there anything [else] that caused you to change your beliefs or behaviors? (i.e. drug use, sex, views on risk) If yes, please explain what it was, and what changed. 6. Have you ever thought about testing/or been approached about testing? What happened? How did you hear about it? Why did you decide not to test? What do you think would happen if you did test?
Now I’d like to ask you a few more general questions about HIV testing. If they have already discussed their testing pattern above skip 1,2 & 3. 1. How many times have you tested in your life? 2. How often do you test? 3. Do you test regularly? If so, why?
This next section is very general. We are just trying to get a sense of people’s everyday lives. 1. Describe yesterday. What did you do when you got up in the morning until you went to bed? Content Areas for Daily Life: Location(s) Who respondent interacted with during the day Drug Use Resources: eating, getting money Time frames (what time did they get up, what time to bed, etc.) 2. How, in any way, was this different from a typical day?
I have a couple general questions about drugs and then I’d like to ask you more specifically about the last time you used.1. What kinds of drugs do you use now? Probe for all drugs, including alcohol and those used sporadically 2. When do you use and how much? Ask for each drug mentioned above 3. Can you describe to me what happened the last time you used. Tell me the whole story from when it began until where you think it ended. I’d like to know who you were with, what you used, etc. Let interviewee describe the episode. Listen for answers to each of the following questions. Once interviewee's story is told, probe for any questions not answered. Content Areas for Drug Narrative: In this section we want to get at settings, people, and social and physical conditions which shape use; decisions and rules, spoken and tacit. Before Using: How were you feeling/What kind of mood were you in? What was going on at the time? Buying and preparing: Time and place. How were drugs procured? Who got them? Who paid? How did you get money for the drugs/buy in? If didn’t have money, how did you get your portion? Who was there? What are your relationships with these people? Who prepared drugs, how? How were drugs measured? Probe for using ONE syringe to divide up drugs into other syringes— was the loader’s syringe new or used; were receivers’ syringes new or used. Who or what determined how much each person got? Taking: How did you take the drugs (inject self, injected by another person, smoke, snort) Where did you get the (pipe, works)? Whose (rigs, pipe) did you use? Who went first (second, third, etc.) and why? Afterwards: How did you feel, what did you do afterwards? Did you need any other drugs to come down? 4. How, in any way, was this different from your usual experience using? 5. How does your drug use fit into your sex life? How does your drug use impact your sex life? Probe for drugs used before, during and after sex.
Let me ask you a few general questions about your relationships. 1. Do you currently have a steady partner(s) (girlfriend, boyfriend, husband, wife, etc.)? If so, tell me about her/him or them? Individual characteristics of their partner. (age, gender, and ethnicity). Relationship with this partner (duration and nature of relationship, where/when/how met partner; main, casual, paying or exchange) Probe around past sexual experiences with this partner. What attracted you to her/him? What did you like about her/him? (if appropriate)
Now I would like to ask some personal questions about your sexual behavior. We realize that this is a very personal subject, but your answers are very important to our research. Your answers will remain completely confidential and remember names will not be attached to any of this information. 1. I would like to talk about the last time you had sex with someone without a condom. When was that? NOTE: This includes when a condom broke and when there was dipping. 2. Could you think back now and try to remember as much as you can about that time, and tell me the story of how it happened? Try to remember when it happened, who you were with, what you were doing and how you felt. Let interviewee describe the episode. Listen for answers to each of the following questions. Once Interviewee's story is told, probe for any questions not answered. Content Areas for Sexual Interactions: Sexual partner: Individual characteristics of this sex partner. (age, gender, and ethnicity). Relationship with this partner (duration and nature of relationship, where/when/how met partner; main, casual, paying or exchange) Past sexual experiences with this partner What attracted you to him/her? (if appropriate) Before Sex: What was going on at that time? How did it happen? (When did it happen?, who initiated?, where were you?) How were you feeling? (Were you expecting to have sex? Did either one of you talk about it first? What were you hoping to get out of it?) Sexual Events: What happened? (types of sex: anal, oral, vaginal, mutual masturbation, digital, etc.) What determined the kinds of sex you had? (active vs. passive roles, verbal vs. nonverbal c communication, payment, consent, etc.) How did you make a decision to NOT use a condom?/Why didn’t you use condoms? Birth control method of any kind used Using (Drugs): Drugs or alcohol used by you or this sex partner before, during or after having sex. (Injected drugs/non-injected drugs/alcohol; levels of intoxication) What did using have to do with this sexual encounter? (sex/drug exchanges, drugs enhancing sex, sex enhancing drug, etc.) HIV/AIDS: Issue of HIV ever discussed (Your status? Partner’s status? If so, how? Before or after sex?) If not discussed, then what did you believe (or assume)? Before or after sex? How did knowing or not knowing your partner’s HIV status affect having sex this time. After Sex: Thinking back over this particular experience, is there anything that you would have wanted to happen differently? Tell me about that. Generalizability - Typical or unusual compared to most of other sexual interactions Relationship potential - Someone you wanted to see again? To have sex with again? 3. How was this different from your usual experience having sex without a condom? 4. How was this different from the last time you had sex WITH a condom? 5. Thinking about when you have sex in general, what makes it easier to use condoms/protection with your partners? (Probes: nature of relationship; how long they knew their partner; serostatus) 6. Thinking about when you have sex in general, what are some of the reasons you haven’t used condoms/protection? 7. How are these situations (using a condom verses not using a condom) different. 8. How is having sex with your "steady partner" (whatever term interviewee uses) different from having sex with others, such as casual partners, one-night stands or tricks?