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Gay men (MSM)

What are men who have sex with men’s (MSM) HIV prevention needs?

What do MSM need?

Men who have sex with men (MSM) are not a single homogenous group, but represent a wide variety of people, lifestyles and health needs. From middle class gay men, to homeless runaways, to injection drug users (IDUs) to incarcerated men, MSM have many different identities and associated risks for HIV and other infectious diseases. MSM refers to any man who has sex with a man, whether he identifies as gay, bisexual or heterosexual. Despite success in changing sexual behaviors, MSM continue to be disproportionately affected by HIV/AIDS. MSM account for the largest percentage of persons with AIDS in the US (53%), even as the percentage of AIDS cases among IDUs (25%) and heterosexuals (10%) has increased.1 In 1997, the prevalence rate of HIV for MSM in 4 urban communities was 17% overall, 29% for African-American MSM and 40% for MSM-IDUs.2 HIV is not an issue that exists by itself, but is woven into many aspects of men’s lives. Risk for HIV is embedded in many other core issues such as dating and intimacy, sexual desire and love, as well as alcohol and recreational drug use, homophobia, abuse and coercion, racism and self-esteem.3 HIV prevention programs must be informed by of all these elements

Sexual health

There is not enough sexuality education for young people in the US, and almost no samegender sexuality education. Like many teenagers, young MSM may only learn about sex through distorted media or pornographic images. In general, men in today’s society are pressured to prove their manhood through sexual activity and aggressiveness, while women receive messages on moderation and caretaking. Given this, many MSM face additional challenges learning about dating, intimacy and forming relationships, or about desire, sexual functioning and arousal. Discomfort with one’s sexuality and identity can lead to sexual risk taking.4 In Minnesota, “Man-to-Man: Sexual Health Seminars” are based on the sexual health model. This model assumes that if MSM are more sexually literate, comfortable and competent, they are more likely to be able to reduce risk in the context of sexual behaviors and relationships. The program uses comprehensive sexuality education, cultural specificity and empirical research to help MSM reduce HIV risk long-term. The program was effective in reducing internalized homonegativity and unprotected anal intercourse.5 HIV is not the only sexual health concern for MSM. Other sexually transmitted diseases (STDs) such as herpes and genital warts can negatively affect health and sexuality. Several states have seen an increase in drug-resistant gonorrhea among MSM, making it more difficult to treat.6

Homophobia, racism and self esteem

Homophobia and racism are prevalent in the US. Internal and external homophobia and racism can lead to low self-esteem, which can lead to increased risk behavior such as sexual aggression, difficulty negotiating safer sex, and drug or alcohol abuse. MSM of color are disproportionately affected by many social and health-related ills such as HIV. African American and Latino MSM are more likely than their White counterparts to engage in high-risk activities and to be HIV-infected. Social and cultural factors may limit the ability of MSM of color to protect themselves from HIV. A study of Latino gay men in urban centers found that men who reported high-risk behavior also reported significantly higher rates of financial hardship, experiences of racism and homophobia, incidence of domestic violence and a history of coercive childhood sexual abuse.7 Hermanos de Luna y Sol, an HIV prevention intervention for Latino gay/bisexual men in San Francisco, CA, deals with the common history of oppression among Latino gay men, including issues of homophobia, machismo, sexual abuse, racism and separation from family and culture.8 In Washington, DC, US Helping US (UHU) is a multi-modal prevention program for Black MSM that addresses the psychological and emotional stress that they may experience as racially and sexually oppressed minorities. UHU provides mental health services, community building and anti-homophobia social marketing.9

Alcohol and recreational drug use

The prevalence of drug use is higher among MSM than among heterosexuals,10 although decreases recently have been noted in all alcohol and drug use categories except amphetamines.11 In many areas of the US, gay bars--often sex-charged environments where alcohol and drugs are prevalent--are the only venues for MSM to meet and socialize with each other. Drug use may vary greatly by region and subculture. Substance use puts MSM at risk for HIV for several reasons: 1) MSM-IDUs are at risk if they share infected injection equipment; 2) substance use is associated with high risk sexual behavior; 3) background HIV prevalence rates are higher for MSM-IDUs and MSM who abuse drugs but do not inject, increasing the likelihood of transmission.12 Substance use can serve as a trigger or an excuse for unprotected sex. Some MSM have trouble having sex without getting high first; others prefer having sex while high, believing recreational drugs increase their libido. For some MSM, drug use provides a sense of community and bonding at gay clubs and circuit parties. A survey of MSM who attend circuit parties found that serodiscordant unprotected anal sex was more likely to occur among men who used amphetamines (speed), Viagra and amyl nitrites (poppers).13 For many MSM-IDUs, drug use, rather than sexual orientation, forms their personal identity. Many MSM-IDUs identify as heterosexual. Too often MSM-IDUs are missed in prevention programs that target MSM but leave out IDUs, or programs that target IDUs but don’t address sexual orientation. MSM-IDUs have high rates of HIV infection, high frequency of unprotected sex and high rates of poverty, addiction and its related social and physical ills.12 The Stonewall Project in San Francisco, CA is a harm reduction program for MSM who use speed. The project provides education and assistance and has been successful at reaching MSM of different sexual and social identities.14 Across the US, several cities have opened social centers for gay men where no alcohol is served and drugs are not allowed. One HIV prevention program for young gay men helps develop community centers where young men can socialize without alcohol.15

What is sexual risk?

The perception of sexual risk for HIV varies among MSM and may change from one sexual situation to another. Throughout the HIV epidemic, MSM have engaged in sophisticated decision-making about what they consider to be risky.16 Some men decide for themselves it is OK to not use a condom if they are the top (insertive partner), if they are having oral sex or if their or their partner’s viral load is undetectable. MSM may make these decisions because the scientific evidence of HIV risk is cloudy, or simply because they are comfortable with some level of risk. HIV prevention programs should help MSM to make realistic and healthy choices based on factual information. MSM have engaged in a hierarchy of strategies for maintaining safer sex that are fluid and context-dependent. Most MSM are able to manage sexual risk with effective strategies such as monogamy with concordant partners, consistent condom use with repeated testing, condom use outside of relationship or abstinence. Other MSM use strategies that are not known to be effective (see above paragraph). A small minority of MSM choose to engage in known risk activities such as unprotected anal intercourse without knowledge of partner serostatus. Unprotected anal intercourse between an HIV+ and an HIV- man remains the greatest risk for HIV transmission among MSM. This has proven to be the biggest challenge for HIV prevention. The intimacy of skin-to-skin contact during intercourse is a powerful and important draw. Many MSM feel their sexual identity, as well as the hard-won goals of gay sexual liberation, are based on having sex--including anal intercourse--in a free and unconstricted manner. A majority of MSM consistently manage sexual risk, yet there is little understanding or research of men who are largely safe, and how their values of nurturance and caretaking, ethics, hopes for collective survival, or relations with friends and community help support them. Only recently have HIV+ MSM been targeted with messages and programs featuring “prevention altruism” that make use of MSM’s strengths. HIV prevention efforts need broader, more emotionally-resonant concepts that build on what is good in MSM’s lives.17

Says who?

  1. Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report. 2000;12.
  2. Catania JA, Osmond D, Stall RD, et al. The continuing HIV epidemic among men who have sex with men. American Journal of Public Health. in press.
  3. Seal DW, Kelly JA, Bloom FR, et al. HIV prevention with young men who have sex with men: what young men themselves say is needed. AIDS Care. 2000;12:5-26.
  4. Robinson BE, Bockting W, Rosser BRS, et al. The sexual health model: a sexological approach to long-term HIV risk reduction. Presented at the XIII International Conference on AIDS, Durban, South Africa, July 2000. Abst #ThPeD5613.
  5. Rosser BRS, Bockting WO, Rugg DL, et al. A sexual health approach to long-term HIV risk reduction among men who have sex with men: results from a randomized controlled intervention trial. Presented at the XIII International Conference on AIDS, Durban, South Africa, July 2000. Abst #WePeD4718.
  6. Altman LK. Gonorrhea shows its resistant side; disease control agency tells doctors of new recommendations. Milwaukee Journal Sentinel. October 2, 2000. p. 5G.
  7. Diaz RD, Ayala G, Bein E. Social oppression, resiliency and sexual risk: findings from the national Latino gay men’s study. Presented at the National HIV Prevention Conference, Atlanta, GA, Aug 29-Sep 1, 1999. Abst#287
  8. Díaz RM. Latino Gay Men and HIV: Culture, Sexuality, & Risk Behavior. NY:Routledge. 1998.
  9. Simmons R. Towards developing a comprehensive program for effective HIV prevention among racially oppressed gay men, bisexuals and MSM. Presented at the XIII International Conference on AIDS, Durban, South Africa, July 2000. Abst #TuPeD3839.
  10. Stall R, Wiley J. A comparison of alcohol and drug use patterns of homosexual and heterosexual men: the San Francisco men’s health study. Drug Alcohol Dependency. 1988;22:63-73.
  11. Crosby M, Stall R, Paul J, et al. Alcohol and drug use patterns have declined between generations of younger gay/bisexual men in San Francisco. Drug and Alcohol Dependence. 1998;52:177-182.
  12. Rhodes F, Deren S, Wood MM, et al. Understanding HIV risks of chronic drug-using men who have sex with men. AIDS Care. 1999;11:629-648.
  13. Colfax G, Mansergh G, Vittinghoff E, et al. Drug use and high-risk sexual behavior among circuit party participants. Presented at the XIII International Conference on AIDS, Durban, South Africa, July 2000. Abst #TuPeC3422.
  14. Stonewall Project. 415/502- 1999.
  15. Kegeles SM, Hays RB, Pollack LM, et al. Mobilizing young gay and bisexual men for HIV prevention: a two-community study. AIDS. 1999;13:1753-1762.
  16. Williams AM. Condoms, risk and responsibility. Presented at the HIV Prevention Summit, Half Moon Bay, CA, June 2000.
  17. Nimmons D. In this together: the limits of prevention based on self-interest and the role of altruism in HIV safety. Journal of Psychology & Human Sexuality. 1998;10:75-87

Prepared by Michael Crosby PhD and Pamela Decarlo, CAPS December 2000

Resource

Latino gay men in the US

What are the HIV prevention needs of Latino gay men in the US?

Fact Sheet 28, March 2012

Why focus on Latino gay men?

The ever changing mosaic of Latino demographics in the US creates unique challenges to address health disparities of the population, especially when it comes to HIV prevention needs.  Latinos are the largest and fastest growing ethnoracial minority group in the US, experiencing a 43% growth between 2000 and 20101. Data also show that Latinos are one of the fastest growing populations at risk for HIV transmission:

  • Latino men who have sex with men (MSM*) represent 81% of new infections among Latino men, and 19% among all MSM2,3
  • Latinos are 16% of the US population, but make up 17% of living HIV/ AIDS cases and 20% of new HIV infections each year3
  • Youth (ages 13-29) accounted for 45% of new HIV infections among Latino MSM4

In light of these data there is a need to identify culturally-specific health concerns of Latino gay men so that effective interventions may be developed to address current and prevent future disparities. The US National HIV/AIDS Strategy highlights the call for HIV programs that reduce health inequities among both ethnoracial and sexual minority populations5.  Latino gay men have distinct cross-cultural identities that place them into both prioritized categories6.

What are the prevention challenges?

Most work related to Latino gay men has been based on a sociocultural model of health, which shows that experiences of social discrimination, defined as racism, homophobia and poverty, are strong predictors of mental health outcomes7. Mental health outcomes, such as psychological distress, have been shown to increase sexual risk and decrease sexual resiliency. A recent study of Latino MSM living in New York and Los Angeles8 reported that:

  • Over 40% of the participants reported experiences of both racism and homophobia in the past year
  • Low self-esteem and decreased levels of social support among Latino gay men are associated with increased rates of sexual risk behaviors, including unprotected anal sex
  • Men who had both homophobic and racist experiences were more likely than men who reported no form of discrimination to engage in unprotected anal sex as a bottom, and to also be binge drinkers

Late testing (that is, those individuals who have an AIDS diagnosis within one year of testing HIV-positive) and lack of access to health insurance also create challenges to prevention, treatment and care.

  • 38% of Latinos test late in their illness9.
  • In a study of 21 major US cities, 46% of Latino MSM who tested positive for HIV were unaware of their infection3.
  • HIV+ Latinos are more likely than Whites to postpone care due to issues such as lack of transportation, and more likely to delay initiation of care after their diagnosis9.
  • 24% of Latinos living with HIV/ AIDS are uninsured, compared to 17% of Whites; and only 23% of HIV+ Latinos have private health insurance, compared to 44% of Whites10.

Reviews of research with Latino gay and bisexual men also report that cultural influences and socioeconomic forces impact sexual well being. For example, residency status, HIV-related stigma, machismo, immigration and migration patterns, language, insurance status and educational attainment have all been associated barriers to HIV prevention services and programming11, 12

What other factors affect sexual risk and resiliency?

Latino gay men are often faced with unique socio-sexual situations that place them at risk for HIV transmission. Prior work with MSM populations, including Latino gay men, has documented that various factors are associated with sexual-risk:

  • Serosorting (choosing sexual partners based on perceived HIV status), seropositioning (choosing sexual roles [e.g., top or bottom] based on the perceived HIV status of each partner), and sexual stereotypes and preferences13
  • Alcohol and drug use (including methamphetamine and injection use), as well as having had a history of STDs, like syphilis and gonorrhea14,15
  • High rates of condomless anal sex (“barebacking”) and multiple partners16
  • Childhood sexual abuse and a social context of discrimination17

Defined as adopting cultural ways of mainstream society, work on acculturation suggests that: Latinos who are less acculturated to mainstream US culture are protected by traditional Latino (sexual) values; and that acculturation of US mainstream values serves as a protective barrier because it increases a sense of individualism and self-determination18 Understanding the role of sociocultural factors helps to refine definitions of sexual resiliency among Latino gay men. Innovative work exploring protective factors among Latino gay men notes that: HIV prevalence was higher among US born than non-US born Latinos in San Francisco, while in Chicago the opposite was true19

  • Community involvement moderates sexual risk behaviors20
  • Volunteering with HIV/ AIDS organizations can decrease psychological stressors20

As the majority of these data came from quantitative surveys, more public health focused qualitative studies are needed to further examine the context of the sexual situations in which Latino gay men find themselves, as well as the cultural factors and sexual scripts21 that influence their harm reduction behaviors.

What is being done?

  • Hermanos de Luna y Sol, born out of the Mission District in San Francisco, CA is a longstanding HIV prevention intervention for immigrant Spanish speaking Latino gay and bisexual men that is based on empowerment education and social support, and has been successful in increasing condom use among participants22.
  • Latinos D (based in Queens, NY23) and Somos Latinos Salud (based in Ft. Lauderdale, FL24) are dynamic and promising adaptations of the MPowerment program, an effective community-level, evidence-based HIV intervention for young gay and bisexual men25.
  • SOMOS, a homegrown and culturally responsive NYC-based HIV prevention program, has been shown to lower risk behaviors and decrease number of sexual partners among Latino gay men26.

Still, even with these programs and CDC recommendations to address Latino MSM health disparities, most adaptations of evidence-based interventions have largely been linguistically, but not necessarily culturally, translated versions of established programs.

What are the recommendations?

  • Celebrate the diversity of Latino cultures in programming. Different experiences of historical events, political environments, immigration patterns and regional cultures exist within Latino communities (e.g., Chicanos in Los Angeles, Nuyoricans in New York, Tejanos in San Antonio).
  • Conduct more research on structural and environmental influences on Latino gay men’s sexual health including issues relating to undocumented HIV+ Latinos.
  • Understand that serving populations is not the same as being culturally competent. Including Latino participation does not equate to providing appropriate services.
  • Cultivate Latino gay community collaboration and empowerment by ensuring that Latino gay men participate in local HIV prevention and care planning councils.
  • Develop programs that address the unique concerns of both immigrants and U.S. born Latino gay men. Assuming that all Latino gay men are monolingual Spanish speakers minimizes the needs of bicultural (but not necessarily bilingual) Latino gay men.
  • Reduce gay-related and HIV-related stigmas in Latino communities. Breaking sexual silences will help promote healthy sexual identity development.
  • Work with policy makers and political stakeholders to advocate for sustainable health care access.
  • Highlight social norms and cultural values that enhance sexual resiliency. Focusing solely on risk factors leads to limited insights and opportunities for interventions.
  • Foster programs that address the impact of isolation and identity validation. Lessening stressors that Latino gay men face will improve their overall well-being.

Says who?

1 US Census Bureau (2011).  Overview of Race and Hispanic Origin: 2010 – U.S. Census Bureau. 2 CDC. (2011). CDC Fact Sheet: HIV and AIDS among Latinos.  3 CDC. (2008).  HIV Surveillance in Men Who Have Sex with Men (MSM). https://www.cdc.gov/hiv/group/msm/index.html. 4 Prejean J, et al. (2011). Estimated HIV Incidence in the United States, 2006-2009. PLoS ONE. 5 ONAP. (2010). National HIV/AIDS Strategy: Federal Implementation Plan. https://www.hiv.gov/federal-response/national-hiv-aids-strategy/federal-implementation#:~:text=The%20Federal%20Action%20Plan%20presents,within%203%20to%205%20years. 6 Diaz, RM (1998). Latino gay men and HIV: culture, sexuality, and risk behavior. Routledge. 7 Díaz RM, et al. (2001). The impact of homophobia, poverty, and racism on the mental health of gay and bisexual Latino men: findings from 3 US cities. Am J Public Health. 91(6):927-932. 8 Mizuno Y, et al. (2011). Homophobia and Racism Experienced by Latino Men Who Have Sex with Men in the United States: Correlates of Exposure and Associations with HIV Risk Behaviors. AIDS Behav. [Epub ahead of print] 9 CDC. (2011). HIV Surveillance Report, Vol. 21. 10 RAND. (2011). HIV Cost and Services Utilization Study (HCSUS). http://www.rand.org/health/projects/hcsus.html.\ 11 Zea MC, et al. (2004). Methodological issues in research on sexual behavior with Latino gay and bisexual men.  Am J Community Psychol. 31(3-4):281-291. 12 National Latino AIDS Awareness Day. HIV/ AIDS and Latino/ Hispanic men who have sex with men. 13 Rosenberg ES, et al. (2011). Number of casual male sexual partners and associated factors among men who have sex with men: results from the National HIV Behavioral Surveillance system. BMC Public Health. 25: 11-89. 14 CDC. (2010). HIV among Hispanics/ Latinos. https://www.cdc.gov/hiv/group/racialethnic/hispaniclatinos/index.html15 Balan IC, et al. (2009). Intentional Condomless Anal Intercourse Among Latino MSM Who Meet Sexual Partners on the Internet. AIDS Educ Prev. 21(1): 14-24. 16 Diaz RM et al. (2005). Reasons for stimulant use among Latino gay men in San Francisco: a comparison between methamphetamine and cocaine users. Journal of Urban Health. 82(Supp1): 71-78. 17 Arreola SG, et al. (2009). Childhood sexual abuse and the sociocultural context of sexual risk among adult Latino gay and bisexual men. Am J Pub Hlth. 99 Suppl 2:S432-8. 18 Abraído-Lanza AF, et al. (2005). Do healthy behaviors decline with greater acculturation? Implications for the Latino mortality paradox. Soc Sci Med. 61:1243–1255. 19 Ramirez-Valles J, et al. (2008) HIV Infection, Sexual Risk, and Substance Use among Latino Gay and Bisexual Men and Transgender Persons. American Journal of Public Health. 98: 1036-1042. 20 Ramirez-Valles J (2002). The proactive effects of community inolvment for HIV risk behavior: A conceptual framework. Health Education Research. 17(4): 389-403. 21 Carrillo H, et al. (2008). Risk across borders: Sexual contexts and HIV prevention challenges among Mexican gay and bisexual immigrant men. Findings and recommendations from the Trayectos Study (Monograph). San Francisco: UCSF and SFSU. 22 Hermanas de Luna y Sol.http://sfresourceconnect.org/detail.php?id=41275840  23 Latinos Diferentes. https://www.facebook.com/LatinosD. 24 Latinos Salud – Somos. http://www.latinossalud.org 25 Mpowerment. http://mpowerment.org. 26 Vega MY, et al. (2011). SOMOS: evaluation of an HIV prevention intervention for Latino gay men. Health Educ Res. 26(3):407-418.

Prepared by Gabriel R. Galindo DrPH, UCSF Center for AIDS Prevention Studies Fact Sheet 28, March 2012 Special thanks to the following reviewers of this Fact Sheet: Ana F. Abraido-Lanza, Sonya Arreola, Maricarmen Arjona, George Ayala, Alida Bouris, Hector Carrillo, Rafael Diaz, Lizette Rivera, Ramon Ramirez and Jesus Ramirez-Valles.

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 Francisco 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]. © July 2012, University of California

Resource

Transgender men

What are transgender men’s HIV prevention needs?

Prepared by Jae Sevelius, CAPS; Ayden Scheim and Broden Giambrone, Gay/Bi/Queer Trans Men’s Working Group, Ontario Gay Men’s Sexual Health Alliance Fact Sheet 67 – Revised September 2015

Who are transmen?

Transgender (‘trans’) is an umbrella term for people whose gender identity and expression do not conform to norms and expectations traditionally associated with their sex assigned at birth. Transgender men, or transmen, are people who were assigned ‘female’ at birth and have a male gender identity and/or masculine gender expression. Transgender people may self-identify and express their gender in a variety of ways and often prefer certain terms and not others. Some who transition from female to male do not identify as transgender at all, but simply as men. In general, transmen should be referred to with male pronouns. However, if you are unsure it is best to respectfully ask a person what terms and pronouns they prefer. Accurate information about the diversity of transmen’s bodies is not widely available. Transmen have different types of bodies, depending on their use of testosterone and gender confirmation surgeries (which may include chest reconstruction, hysterectomy, metoidioplasty, phalloplasty1, etc.; see www.ftmguide.org for further information). Transmen use a broad range of terms and language to identify their sex/gender, describe their body parts, and disclose their trans status to others. For instance, some transmen are not comfortable with the terms ‘vagina’ and ‘vaginal sex’ and may prefer ‘front hole’ and ‘front sex’ or ‘front hole sex’, although this is not true for all transmen. This diversity creates unique needs and barriers for negotiating and adhering to safer sex practices that are not addressed by current HIV prevention programs.

What do we know about HIV and transmen?

The transgender community is diverse and not enough research has been conducted with trans people in general. We have very limited information about transmen in particular. To date, research related to HIV among trans people has almost exclusively focused on transwomen (people who were assigned ‘male’ at birth and have a female gender identity and/or feminine gender expression). However, there is evidence that there is a significant subgroup of transmen that engage in unprotected sex with non-trans men (trans MSM), including some transmen who engage in sex work. Several cities have conducted needs assessments that focus on or are inclusive of transmen and HIV risk, such as Philadelphia, Washington D.C, San Francisco, and the province of Ontario. The few published studies that report HIV rates among samples of transmen have reported 0–3% prevalence.2,4 These rates are self-reported, however, and are based on small, non-representative samples, so we do not have conclusive data about the actual rates. Due to the assumption of low rates of HIV among transmen relative to other high-risk groups, there has not been much research on risk behaviors among transmen. We do know that HIV prevention messages are not reaching most transmen.5 We also know that many trans MSM seek services at gay men’s organizations, where there is little to no education for transmen and their non-trans male partners.4 Providers are generally not trained to identify or serve gay and bisexual transmen in culturally sensitive ways or understand their specific risks and prevention needs.

What don’t we know about HIV and transmen?

We do not have enough information about HIV and transmen. Data collection methods at testing sites do not accurately identify and track transmen or capture their experiences, which contributes to the lack of clarity around HIV rates among transmen. Rates of HIV and sexual risk behaviors among transmen are also not well understood because transmen are often assumed to be primarily having sex with non-trans women. However, transmen, like other men, can be of any sexual orientation and may have sex with different types of partners, including (but not limited to) non-trans men, transgender women, and transgender men.6,7

What puts transmen at risk?

In one study, a majority of trans MSM reported not using condoms consistently during receptive anal and/or frontal (vaginal) sex with non-trans male partners and low rates of HIV testing and low perception of risk.4 In urban areas where HIV prevalence rates among non-trans MSM are estimated to be 17-40% and STI rates are increasing, trans MSM who engage in unprotected receptive anal and/or frontal (vaginal) intercourse with non-trans MSM may be especially vulnerable to HIV/STIs.8,9 Transmen may face complicated power and gender dynamics in their sexual relationships with non-trans men.4 For some trans MSM, having sex with a non-trans gay male partner is a powerful validation of their gay/queer male identity, especially in the early years of transition, and may be more important than insisting on condom use. Some transmen who use testosterone have reported increased sex drive and increased interest in sex with non-trans men after beginning hormone use, which may contribute to their willingness to take sexual risks.4,10 Transmen on testosterone and/or who have had a hysterectomy may have frontal (vaginal) dryness, which increases their risk for frontal (vaginal) trauma during penetration, thus increasing their risk for STIs, including HIV.10 Low self-esteem may contribute to sexual risk-taking among transmen. Rates of depression, substance use, and suicide attempts are high in this population, but multiple barriers exist to accessing culturally competent support and treatment.3,11 Drug and alcohol use is a major risk factor for every community, regardless of their gender identity. Transmen may use alcohol or drugs to enhance sexual experiences or help to relieve anxiety about their bodies during sex.4 Some transmen may feel pressure to use drugs in order to fit into some gay men’s communities or subcultures. Although we have very little information about needle sharing for hormone or drug use among transmen, it may also be a risk factor for some.

What can help?

Online dating. Many transmen meet their non-trans male sexual partners on the Internet. Meeting partners through personal ads may allow transmen to describe their body and gender identity upfront (if they choose to do so) and discuss safer sex with potential partners before meeting in person.4 Educational materials for non-trans partners. Transmen’s non-trans male partners often do not have experience with transmen nor access to education about sex with transmen, which can lead to misconceptions about safer sex. For non-trans gay men, safe sex often simply means condom use with anal sex and they may not be aware of the risks associated with frontal (vaginal) sex. See the next section for information on available materials. Greater visibility in the gay community. Gay and bisexual men need to be educated about the presence of transmen in their community. Increasing visibility and knowledge about transmen may help create a welcoming environment, help increase inclusivity, and help transmen feel more powerful in their relationships with non-trans men.7

What’s being done?

tm4m (tm4m.org) is a San Francisco-based project for transmen who play with men (or want to). They provide information, education, and support to transmen who have sex with men through monthly educational workshops and discussion groups, informational materials and continuously working to foster acceptance and build community. tm4m is a collaborative effort co-sponsored by Eros, Trannywood Pictures and TRANS:THRIVE (a program of the API Wellness Center). The Gay/Bi/Queer Trans Men’s Working Group in Ontario has conducted a needs assessment with trans MSM, developed a sexual health resource12, and a website at www.queertransmen.org. They are also providing training and consultation about trans MSM inclusion for prevention workers serving gay men across the province. All Gender Health Online is a study exploring the sexual health of non-transgender men who have sex with transgender people. The results will be used to develop an online intervention to prevent the spread of HIV and promote the sexual health of transgender people and their partners. The STOP AIDS Project in San Francisco, CA strives to include transmen in their programming and community education. They include transgender men in their mission statement and have changed their data collection methods to better reflect varying bodies and gender identities in gay men’s communities.

What needs to be done?

We need to implement more inclusive data collection methods to better capture subgroups of transgender people. HIV prevention and care providers should not assume that all men they see were assigned ‘male’ at birth. You cannot tell if a guy is trans just by looking at him. The best method for data collection is a two-part question: 1) ask about current gender identity and 2) ask what sex was assigned at birth.13 If unsure, programs should ask transmen for their preferred name and pronoun and use those terms. If rates of HIV among transmen are indeed low, we now have the opportunity to engage in true prevention work to keep those numbers low. Gaining a better understanding of transmen’s risk behaviors and the different ways that they protect themselves will aid in providing appropriate and effective HIV prevention education to transmen and their sexual partners.

Says who?

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

Special thanks to the following reviewers of this Fact Sheet: Walter Bockting, AJ King, Niko Kowell, Dan Lentine, Vel McKleroy, Sarah Morgan, Emily Newfield, David Schleifer, Hale Thompson, Erin Wilson.   Reproduction of this text is encouraged; however, copies may not be sold, and the University of California San Francisco should be cited as the source. Fact Sheets are also available in Spanish. To receive Fact Sheets via e-mail, send an e-mail to [email protected] with the message “subscribe CAPSFS first name last name.” ©January 2010, University of CA. Comments and questions about this Fact Sheet may be e-mailed to [email protected].

Resource

Young gay men

What are the HIV Prevention Needs of Young Men Who Have Sex with Men?

revised 4/01

Are young MSM at risk for HIV?

Yes. Over half of all the reported HIV and AIDS cases among males aged 13-24 in the US were due to male-male sexual contact.1 Various studies found that 26% to 50% of young men who have sex with men (MSM) report recent unprotected anal intercourse, and much of this unprotected sex occurred with a partner of unknown or different HIV status.2-4 Rates of sexual risk-taking among young MSM are also increasing.5 The term young MSM includes men who self-identify as gay or bisexual, as well as non-gay/bi-identified MSM under 30 years old.6 A large number of urban young MSM are already infected with HIV. A study of 15- to 22-year-old young MSM in seven cities (Baltimore, MD; Dallas, TX; Los Angeles, CA; Miami, FL; New York, NY; San Francisco Bay Area, CA and Seattle, WA) showed a high overall HIV prevalance: 7%, ranging from 2% -12%. Moreover, 82% of the HIV+ men had no idea they were HIV+ before this testing. Young MSM of color, especially African American men, are disproportionately impacted. In the multi-city study, 14% of the African Americans tested HIV+, compared to 13% among mixed race men, 7% among Hispanics, 3% among Asians and 3% among whites.6

Why do young MSM take risks?

Unfortunately, there are no simple answers to this question. The explanations for unsafe sex are complex and multi-faceted.3,7 Adolescence and young adulthood are often characterized by experimentation and exploration of sexuality and drug using. While most young MSM will engage in some HIV risk behaviors at some point in their lives, only a small percentage are consistent risk takers. Many young MSM struggle with individual, interpersonal and societal stressors that may interfere with their ability to protect themselves.8 For some young MSM, individual factors can lead to unsafe sex, such as: feeling invulnerable to HIV; having high levels of optimism about HIV antiviral medications; perceiving that unsafe sex is more pleasurable than safer sex; being depressed or sad; having conflicting allegiance with either their racial or sexual identity; and using alcohol or other drugs (e.g. speed/crystal, poppers).8 Protecting one’s health is not necessarily a young MSM’s top concern. Interpersonal motivations may be more pressingwanting to fit in, to find companionship and intimacy. However, interpersonal issues can also contribute to unsafe sex, such as finding it difficult to communicate or negotiate safer sex with a sexual partner. Young MSM who are in a relationship are more likely to have unsafe sex than single young MSM.4 Societal factors may also influence the risk-taking of young MSM. Many young MSM find themselves isolated or rejected by traditional sources of support like family, school, or religious community.9 Homophobia, racism and poverty also place young MSM at risk. Some young MSM, especially those living on the street, are struggling with daily needs like avoiding violence, finding a place to live, or obtaining food. These pressing needs may overshadow the concern for safer sex and injection practices. Young MSM have few public places to meet each other. Gay bars and public cruising areas are some of the more visible and accessible places, offering anonymity for young men exploring their sexual identity. These venues are also associated with high levels of risk-taking. They are highly sex-charged and the bar scene’s emphasis on alcohol sets the stage for engaging in sex while intoxicated. This is consistently found to contribute to unsafe sex.10 Little is known about the Internet’s role in the lives of young MSM, including how young MSM use the Internet to obtain social support, make new friends, find romantic partners, and/or cruise for sex.

What’s being done?

The Mpowerment Project is a multilevel, sex- and gay-positive, peer-based intervention in which young men take charge. Because HIV may not be particularly compelling for many young MSM, the project focuses on young MSM’s social concerns. The young men plan and coordinate activities to create a stronger and healthier community for themselves in which safer sex becomes the mutually accepted norm. Participants in the Project have reduced rates of unprotected anal intercourse with casual partners and boyfriends. Mpowerment, proven effective as an HIV prevention intervention, provides CBOs with training and a manual for replication.11 The COLOURS Organization in Philadelphia, PA targets young MSM of color with support groups, peer educator training and individual case management. They do street outreach at sex clubs and bars frequented by MSM of color, providing condoms and counseling to young MSM who partner with older men. They also promote gay-friendly drug and alcohol treatment services for young MSM.12 The American Psychological Association has implemented the Healthy Schools Project for Lesbian and Gay Students. The Project trains school psychologists, counselors, nurses and social workers to work effectively with gay, lesbian and bisexual students. The goal is to make schools a friendlier environment for these students and make HIV prevention education more relevant to them.13 “Chico Chats,” a program of the STOP AIDS Project in San Francisco, CA, consists of a one-month intensive series of workshops. Participants get to know each other while engaging in facilitated conversations about body image, relationships and identity and how these issues relate to HIV. Learning community organizing and mobilization techniques is a key component of these workshops as well. Participants formed an activist group called ¡Ya Basta! (Enough Already) and designed a video and workshop examining the issues of sexual silence and coming out in Latino families. The video is being shown throughout Latino communities in San Francisco.14

What else needs to happen?

Effective programs for young MSM must address the context of their lives and the individual, interpersonal and societal factors that put them at risk. Comprehensive health and sexuality education must target both those who identify as gay or bisexual and those who do not. Unfortunately, many school-based programs focus on reproduction or abstinence until marriage, further marginalizing young MSM. There is an urgent need to create prevention and wellness programs specifically for young MSM of color. Existing programs for older MSM of color should also be accessible to young MSM. These programs should address issues of sexuality, gay identity, culture, race/ethnicity, racism, homophobia, poverty and violence. Programs must also consider the HIV prevention needs of both HIV positive and HIV negative young MSM. Special attention is necessary to reach marginalized young MSM, such as those who are homeless, engaged in commercial sex work or involved with the criminal justice system. These young men may not identify as gay or bisexual, and may have immediate needs for food and shelter to address. Programs are needed that foster support for young MSM and involve them directly in planning and implementation. Support might encompass creating safe places for young MSM to socialize and access services, developing school-based sexuality and gay-awareness programs and helping young MSM advocate for greater acceptance by schools, families, religious communities, the gay community at large and communities of color.15 Societal homophobia may impede implemention of prevention programs for young MSM and may discourage young MSM from accessing prevention services.16 Political concerns must not be allowed to interfere with HIV prevention services for young MSM. Targeting young MSM with HIV prevention messages and services is an appropriate response to a grave public health threat. Unless action is taken quickly, we will lose many young men to HIV.

Says who?

  1. Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report . 2000;12.
  2. Molitor F, Facer M, Ruiz JD. Safer sex communication and unsafe sexual behavior among young men who have sex with men in California. Archives of Sexual Behavior. 1999;28:335-343.
  3. Kegeles SM, Hays RB, Pollack LM, et al. Mobilizing young gay and bisexual men for HIV prevention: a two-community study . AIDS. 1999;12:1753-1762.
  4. Hays RB, Kegeles SM, Coates TJ. Unprotected sex and HIV risk-taking among young gay men within boyfriend relationships . AIDS Education and Prevention. 1997;9:314-329.
  5. Ekstrand ML, Stall RD, Paul JP et al. Gay men report high rates of unprotected anal sex with partners of unknown or discordant HIV status . AIDS. 1999;13:1525-1533.
  6. Valleroy LA, MacKellar DA, Karon JM et al. HIV prevalence and associated risks in young men who have sex with men . Young Men’s Survey Study Group. Journal of the American Medical Association. 2000;284:198-204.
  7. Strathdee SA, Hogg RS, Martindale SL et al. Determinants of sexual risk-taking among young HIV-negative gay and bisexual men . Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology. 1998;19:61-66.
  8. Choi KH, Kumekawa E, Dang Q et al. Risk and protective factors affecting sexual behavior among young Asian and Pacific Islander men who have sex with men: Implications for HIV prevention . Journal of Sex Education & Therapy. 1999;24:47-55.
  9. Beeker C, Kraft JM, Peterson JL, et al. Influences on sexual risk behavior in young African-American men who have sex with men. Journal of the Gay and Lesbian Medical Association. 1998;2:59-67.
  10. Greenwood GL, White EW, Page-Shafer K, et al . Correlates of heavy substance use among young gay and bisexual men: The San Francisco Young Men’s Health Study . Drug and Alcohol Dependence. 2001:61:105-112.
  11. CDC. Compendium of HIV prevention interventions with evidence of effectiveness . 1999.
  12. The COLOURS Organization, Inc . Philadelphia, PA. 215/496-0330.
  13. Clay RA. Healthy Schools project hoped to ease discrimination . APA Monitor. 1999;30.
  14. The STOP AIDS Project . Q Action, ¡Ya Basta! San Francisco, CA. 415/865-0790×303.
  15. Seal DW, Kelly JA, Bloom FR, et al. HIV prevention with young men who have sex with men: what young men themselves say is needed . AIDS Care. 200;12:5-26.
  16. 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.

Prepared by Pilgrim Spikes MPH Phd, Bob Hays PhD, Greg Rebchook PhD, Susan Kegeles PhD, CAPS April 2001. Fact Sheet 8ER

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 2001, University of California

Resource

Hombres negros

¿Qué necesitan los hombres negros para evitar el VIH?

¿quiénes son los hombres negros?

Los hombres negros y los afroamericanos no se pueden encasillar en una sola categoría “unitalla”. Ellos son padres, hermanos, tíos e hijos en las comunidades negras. Son médicos, abogados, barberos y conductores de autobuses; son cristianos y musulmanes y hablan muchos idiomas. Sin embargo, no toda persona de aspecto negro o afroamericano se identifica con estas etiquetas. En EEUU, los hombres negros son un grupo diverso que abarca, entre otros, a afrocubanos, caribeños, brasileños y africanos.

¿por qué el VIH es una preocupación?

Actualmente, el VIH es una crisis de salud mayúscula entre los hombres negros y afroamericanos de cualquier edad u orientación sexual.1 En el año 2000, el SIDA fue la primera causa de muerte entre los hombres negros de 35-44 años de edad y la tercera causa de muerte de hombres negros entre 25 y 44 años de edad.2 Las tasas del VIH entre afroamericanos jóvenes que tienen sexo con otros hombres (HSH) son más elevadas que entre cualquier otro grupo racial o étnico.2 El VIH/SIDA no es la primera crisis de salud que encaran los hombres negros, ni será la última. Los hombres negros afrontan muchas disparidades médicas y están desproporcionadamente afectados por muchas enfermedades como la hipertensión, el cáncer y las cardiopatías. El VIH plantea otro tipo de desafío debido a su transmisión por medio del contacto sexual y del consumo de drogas, temas difíciles de tocar y cargados de estigma en muchas comunidades.

¿cuáles son los factores de riesgo del VIH?

La primera causa de infección por VIH entre los hombres afroamericanos es el sexo, ya sea con hombres o con mujeres.1 En EE.UU. hemos confundido la conducta sexual con la identificación sexual de los hombres negros.3 Por ejemplo, un hombre negro que tiene sexo con hombres y mujeres puede pertenecer a la clasificación de riesgo de los CDC (centros de control de enfermedades) de “contacto sexual de hombre a hombre;” por los investigadores como “bisexual” o “HSH,” por la prensa como “incógnitos” o que tienen relaciones con otros hombres discretamente (on the down low), por grupos activistas como “amante del mismo sexo” o por sus parejas como “heterosexual.” El consumo de drogas inyectables es la segunda causa de infección por VIH entre hombres negros1. Muchos consumidores de drogas padecen adicción, pobreza, falta de vivienda, estigma, depresión, enfermedad mental y trauma anterior, todas éstas situaciones que favorecen la transmisión del VIH, por ejemplo al compartir equipos de inyección.4

¿qué afecta al riesgo del VIH?

Sabemos que el VIH se transmite entre hombres (sean negros o no) por medio del sexo anal o vaginal sin protección con una persona VIH+ o por usar los equipos de inyección de una persona VIH+. Sabemos mucho menos sobre el efecto de las fuerzas psicosociales, contextuales, políticas e históricas sobre las prácticas de riesgo de los hombres negros. Es necesario resolver los problemas de educación, empleo y encarcelamiento, especialmente entre los hombres marginados económicamente. Los hombres negros y afroamericanos son discriminados en la educación y en el empleo. En la escuela, muchos niños negros son etiquetados como “problemáticos” y son remitidos a clases de “educación especial,” lo cual reduce el número de varones negros que ingresan a la escuela secundaria.5 Consecuentemente, muchos hombres negros no consiguen empleo bien remunerado y quedan sumamente desfavorecidos en nuestra economía tecnológica. La falta de empleo está vinculada con condiciones que pueden aumentar el riesgo del VIH, tales como el consumo de alcohol y drogas, el sexo comercial, la falta de vivienda y el encarcelamiento. Casi la tercera parte de los hombres negros han estado encarcelados como adolescentes o adultos.6 El ciclo de entrar, salir y regresar a la cárcel puede perjudicar la capacidad de los hombres negros de encontrar y mantener tanto empleo como relaciones personales. Entre menos hombres negros haya en la comunidad, menos oportunidades tendrán las parejas negras para la monogamia a largo plazo y mayores serán las posibilidades de tener múltiples parejas, lo que puede aumentar el riesgo de transmitir el VIH/ETS.7 En EE.UU. existe una larga historia de explotación y objetivización sexual del varón negro. Con frecuencia a los hombres negros se les describe según su supuesta afición o proeza sexual en lugar de reconocerlos como seres complejos y multidimensionales con sus fortalezas y debilidades.8

¿cuáles son los factores protectores?

Muchas organizaciones en todo el país promueven la fuerza y la unidad entre hombres negros. Grupos fraternales, barberías y grupos cívicos, como “100 Black Men” y otros, fortalecen a los hombres negros ofreciéndoles modelos positivos a seguir, promoviendo la historia y cultura afroamericana y colaborando con empresas y universidades.9 Los sistemas de apoyo familiares, comunitarios y espirituales son importantes para proteger a los jóvenes negros contra el VIH. Las familias unidas con padres que vigilen a sus hijos y hablen con ellos son la clave para promover conductas saludables.10 Las iglesias negras pueden ofrecer información sobre la prevención del VIH; también pueden poner el ejemplo respondiendo a las necesidades de los consumidores de drogas, homosexuales y personas VIH+ sin estigmatizarlos.11

¿qué se está haciendo al respecto?

Se implementó un programa de prevención el VIH con adolescentes afroamericanos en Filadelfia, PA, que abarcaba tanto la abstinencia sexual como la protección durante las relaciones sexuales. Los participantes de la intervención de abstinencia reportaron menos actos sexuales después de 3 meses, pero no en las encuestas de seguimiento realizadas a los 6 y 12 meses después. Entre los jóvenes con experiencia sexual anterior al programa, aquellos que participaron en la intervención sobre el sexo más seguro reportaron menos actos sexuales que los participantes de la intervención de abstinencia según las encuestas de seguimiento realizadas a los 3, 6 y 12 meses. Ambos métodos redujeron a corto plazo las conductas riesgosas con respecto al VIH, pero es posible que las intervenciones enfocadas en la protección en el sexo tengan efectos más duraderos que las intervenciones sobre la abstinencia, y que también logren mejores resultados entre jóvenes con previa experiencia sexual.12 Desde hace muchos años, “People of Color in Crisis” (POCC) en Brooklyn, NY ofrece actividades de prevención del VIH/SIDA y otras intervenciones para hombres y mujeres negras. “Many Men, Many Voices” es una intervención grupal interactiva y experiencial para hombres homosexuales no caucásicos. Sus facilitadores capacitados dirigen seis sesiones semanales para ayudar a los hombres a sentirse protegidos y aceptados con un apoyo social positivo.13 “Concerned Black Men” (CBM) es una organización de servicio establecida y dirigida por hombres negros con el fin de ofrecer modelos positivos a seguir a los niños negros. CBM tiene 21 sedes a lo largo de EE.UU. que brindan programas de prevención de la violencia, el consumo del alcohol y drogas, del embarazo y de ETS/VIH, al tiempo que promueven la autoestima, resolución de conflictos y plantación para asistir a la universidad.14 El “Down Low Barbershop Project” colabora con barberos y estilistas en comunidades negras para brindar a los hombres negros información sobre el VIH, condones y recomendaciones para pruebas y consejería de VIH gratuitas. Los barberos participan en dos capacitaciones de 8 horas sobre la prevención del VIH y luego reclutan a diez clientes para que asistan a una capacitación de 4 horas. La participación de los propietarios de barberías, barberos y clientes es pagada, y los clientes que asisten reciben un vale para un corte de pelo gratuito. El Down Low Barbershop Project se realiza a través de los programas “Brother to Brother” en Seattle, WA y “Us Helping US” en Washington, DC.15

¿qué queda por hacer?

Las agencias de prevención del VIH deberán reconocer las bases culturales y sociales de la comunidad negra.16 La brecha entre ricos y pobres sigue creciendo y la mayoría de las infecciones por VIH ocurre en comunidades pobres.3 Los programas deben responder a los problemas de empleo, educación, encarcelamiento, adicción y estigma, además de las conductas riesgosas relacionadas con el sexo y con el consumo de drogas. Para contar con un ambiente de confianza que favorezca las conversaciones abiertas sobre temas delicados relacionados con el sexo y con el consumo de drogas, los programas de investigación y de prevención deben llevarse a cabo en ambientes familiares lejos de los clubes, bares y otros lugares donde prevalece el sexo.17 La colaboración con organizaciones culturales, religiosas y cívicas que históricamente han llegado a los hombres negros puede ayudar a reclutar e involucrar a estos hombres.18 Los programas de prevención deben vincularse con programas de tratamiento de drogas, prevención de la violencia, enriquecimiento académico, planificación familiar, fortalecimiento cultural y organizaciones empresariales; todo esto con el fin de apoyar a los hombres negros en general tomando en cuenta la riqueza y la complejidad de la vida moderna del hombre negro.

¿quién lo dice?

1.Centers for Disease Control and Prevention. HIV/AIDS among African Americans. 2003.https://www.cdc.gov/hiv/group/racialethnic/africanamericans/index.html&…; 2. Key Facts: African Americans and HIV/AIDS. Report published by the Kaiser Family Foundation. September 2003.http://www.kff.org/hivaids/hiv6090chartbook.cfm 3. Beatty LA, Wheeler D, Gaiter J. HIV prevention research for African Americans: current and future directions. Journal of Black Psychology. 2004;30:40-58. 4. Galea S, Vlahov D. Social determinants and the health of drug users: socioeconomic status, homelessness and incarceration. Public Health Reports. 2002;117: S135-S145. 5. Davis JE. Early schooling and academic achievement of African American males. Urban Education. 2003;38:515-537. 6. Braithwaite RL, Arriola KR. Male prisoners and HIV prevention: a call for action ignored. American Journal of Public Health. 2003;93:759-763. 7. Adimora A, Schoenbach VJ. Contextual factors and the Black-White disparity in heterosexual HIV transmission. Epidemiology. 2002;13:707-712. 8. Whitehead TL. Urban low-income African American men, HIV/AIDS, and gender identity. Medical Anthropology Quarterly. 1997;11:411-447. 9. Bailey DF, Paisley PO. Developing and nurturing excellence in African American male adolescents. Journal of Counseling and Development. 2004;82:10-17. 10. “This is my reality–the price of sex: an inside look at Black urban youth sexuality and the role of the media.” Report published by Motivational Educational Entertainment. January 2004. https://www.meeproductions.com/ 11. Miller RL. African American churches at the crossroads of AIDS. FOCUS. 2001;10:1-5. 12. 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. 13. People of Color in Crisis (POCC), Brooklyn, NY. http://www.pocc.org/ 14. Concerned Black Men, Washington, DC. http://www.cbmnational.org/ 15. Sanders E. Seattle HIV program enlists barbershops: Black men get a trim and a frank discussion. The Boston Globe. January 1, 2004. The Down Low Barbershop Program: www.brotobro.com, www.ushelpingus.com. 16. Darbes LA, Kennedy GE, Peersman G, et al. Systematic review of HIV behavioral prevention research in African Americans. The Cochrane Review. March 2002. 17. Malebranche DJ. Black men who have sex with men and the HIV epidemic: next steps for public health. American Journal of Public Health. 2003;93:862-865. 18. Summerrise R, Wilson W. “The Black Print” model for recruitment of African-American males. Published by the Chicago, IL, Prevention Planning Group. 2000.

Preparado por Darrell P. Wheeler, PhD, MPH, ACSW; Hunter College, NY Traducción Rocky Schnaath Enero 2005. Hoja Informativa 54S