HIV Prevention Research: Are We Meeting the Needs of African American Men Who Have Sex With Men?

Branched sexuality and sexual health among Black cisgender sexual minority men in Baltimore, Maryland: an exploratory study

Branched sexuality - in form of combinations of sexual identity, behaviour and attraction (e.g. heterosexual identity, sex with men, attraction to women) that differ from coincident combinations (e.g. gay/homosexual/same-gender-loving identity, sex with men, attraction to men) - has been observed among Black sexual minority men and may correlate with sexual health. Using baseline survey data from Black sexual minority men (N = 323) enrolled in a sexual health intervention trial, we examined sexual identity, behaviour and attraction to determine the prevalence of branched sexuality and used modified Poisson regression with robust variance estimation to test associations with sexual health. Black sexual minority men reporting branched sexuality (n = 50, 15.5%) were marginally more likely to endorse negative condom-use attitudes compared to those reporting coincident sexuality (n = 273, 84.5%; adjusted prevalence ratio [aPR] = 1.48, 95% confidence interval [CI] = 0.94, 2.32) and significantly more likely to endorse negative condom-use attitudes compared to those reporting gay/homosexual/same-gender-loving-coincident sexuality (aPR = 1.85, 95% CI = 01.07, 3.22). Those reporting branched sexuality were significantly less likely to report past-year testing for sexually transmitted infections compared to those reporting coincident (PR = 0.52, 95% CI = 0.28, 0.94) or gay/homosexual/same-gender-loving-coincident sexuality (PR = 0.46, 95% CI = 0.25, 0.84) in bivariate analyses only. Increased understanding of Black sexual minority men's sexuality and improved sexuality data collection efforts are needed.

Multilevel Stigma and Its Associations with Medical Care Ratings Among Men Who Have Sex With Men in HPTN 078

INTRODUCTION

Our research assessed associations between stigma-related variables and medical care ratings among clients with HIV in HIV Prevention Trials Network (HPTN) 078 who were men who have sex with men (MSM).

METHODS

Logistic regression explored care ratings, stigma, socio-demographics (N = 637). Qualitative thematic coding and themes explored stigmatizing experiences in different settings (N = 111).

RESULTS

Whites were twice as likely as African-Americans to report high care ratings (P < .05). Clients who reported familial exclusion due to having sex with men were 40% less likely to report high medical care ratings (P < .05). Clients who agreed healthcare providers think people with HIV "sleep around" were half as likely to report high care ratings (P < .08). Stigmatization included "treating me like they'll catch HIV from my hand," and care avoidance so others didn't "know I was having sex with men".

CONCLUSIONS

Providers can promote African American MSM client retention with more affirming healthcare provision, namely minimizing assumptions and addressing identities and client needs beyond just HIV care.

Association of Race and Other Social Determinants of Health With HIV Pre-Exposure Prophylaxis Use: A County-Level Analysis Using the PrEP-to-Need Ratio

Research is limited on the effect of racism and social determinants of health on HIV pre-exposure prophylaxis (PrEP) use. This study used the PrEP-to-Need Ratio (PNR), which measures PrEP prescriptions divided by HIV diagnoses in the county, to evaluate sufficient PrEP use. AIDSVu datasets were compared to county-level social determinants of health. Standardized regression coefficients (β) were compared to identify strongest associations with PNR. Overall, factors including percent African American and percent uninsured had negative correlations with PNR, whereas median household income and severe housing cost burden had positive associations. Stratifying for population size, percent African American, percent uninsured, and severe housing cost burden were significant for low population areas, whereas median household income, percent in poverty, percent uninsured, and percent African American were significant for large populations. To reduce PrEP disparities, public health must develop strategies to reach those most in need, especially historically disadvantaged communities.

Elevated Perceived Risk for HIV as a Barrier to Accessing Health Care Among Black Men Who Have Sex with Men

We sought to examine how self-perception of risk for HIV and HIV status information avoidance are related to HIV testing uptake and engagement in routine health care among Black men who have sex with men (BMSM)-the group at highest risk for HIV in the USA. To do so, we used generalized linear modeling and serial mediation modeling to assess data from 342 HIV-negative BMSM collected from 2017 to 2019 in Atlanta, GA, USA. Participants reported considerable concern for testing HIV-positive; 40% reported believing they would test positive for HIV; 27% reported being "extremely concerned about getting HIV"; and 17% reported worrying about HIV "all the time". Mediation analyses demonstrated that greater concern for HIV was associated with longer intervals since the last HIV test and the last health-care appointment. BMSM perceived themselves to be at considerable risk for HIV, but critically, this outlook did not yield improved health-care behaviors. Findings highlight the need to reconceptualize our public health approach to reaching BMSM. Emphasizing risk behavior and targeting efforts toward BMSM may have unintended consequences and need to be reevaluated. Despite continued efforts to improve HIV-related outcomes, we are failing to meet the needs of BMSM.

Conceptualizing the Effects of Continuous Traumatic Violence on HIV Continuum of Care Outcomes for Young Black Men Who Have Sex with Men in the United States

The United States (US) is on track to achieve the 90-90-90 targets set forth by UNAIDS and the National HIV/AIDS strategy, yet significant racial disparities in HIV care outcomes remain, particularly for young Black men who have sex with men (YBMSM). Research has demonstrated that various types of violence are key aspects of syndemics that contribute to disparities in HIV risk. However, little research has looked collectively at cumulative violent experiences and how those might affect HIV treatment and care outcomes. Drawing on extant literature and theoretical underpinnings of syndemics, we provide a conceptual model that highlights how continuous traumatic violence experienced by YBMSM may affect HIV outcomes and contribute to racial disparities in HIV outcomes. The findings of this focused review suggest a need for research on how continuous exposure to various types of violence influence HIV prevention and treatment outcomes for young Black MSM.

Structural Determinants of Black MSM HIV Testing Coverage (2011-2016)

Over 30 years into the US HIV/AIDS epidemic, Black men who have sex with men (BMSM) continue to carry the highest burden of both HIV and AIDS cases. There is then, an urgent need to expand access to HIV prevention and treatment for all gay and bisexual men, underscoring the importance of the federal initiative 'Ending the Epidemic: A Plan for America'. This research examines structural factors associated with BMSM HIV testing coverage over time (2011-2016) in 85 US Metropolitan Statistical Areas (MSAs). We calculated MSA-specific annual measures of BMSM HIV testing coverage (2011-2016). Variables suggested by the Theory of Community Action (i.e., need, resource availability, institutional opposition and organized support) were analyzed as possible predictors of coverage using multilevel modeling. Relationships between BMSM HIV testing and the following covariates were positive: rates of BMSM living with HIV (b = 0.28), percent of Black residents employed (b = 0.19), Black heterosexual testing rate (b = 0.46), health expenditures per capita (b = 0.16), ACT UP organization presence in 1992 (b = 0.19), and syringe service presence (b = 0.12). Hard drug arrest rates at baseline (b = - 0.21) and change since baseline (b = - 0.10) were inversely associated with the outcome. Need, resources availability, organized support and institutional opposition are important determinants of place associated with BMSM HIV testing coverage. Efforts to reduce HIV incidence and lessen AIDS-related disparities among BMSM in the US require improved and innovative HIV prevention approaches directed toward BMSM including a fuller understanding of structural factors that may influence place variation in BMSM testing patterns and risk behavior in places of high need.

The Social Environmental Context of Resilience Among Substance-Using African American/Black Men Who Have Sex With Men

Resilience theory has been suggested as a framework for research on HIV prevention among men who have sex with men. Among this population, literature indicates that African American/Black men who have sex with men experience additional health disparities including elevated HIV incidence rates, victimization, and poor physical health. Conceptualizing resilience as a part of one's social environment, this qualitative study investigates resilience processes and HIV transmission risk among a sample of 21 substance-using African American/Black men who have sex with men. Data from in-depth interviews describe the social environmental context in which resilience is exhibited and document the influence of homophobia, expressions of agency, and access to social, economic, and cultural capital on resilience processes. Central to this are expressions of hidden resilience, in which African American/Black men who have sex with men mitigate risk and experience their lives as subjectively successful, whether or not outsiders see it as such.

An Intersectional Approach to HIV Vulnerabilities and Testing Among Heterosexual African Caribbean and Black Men in London, Ontario: Results From the weSpeak Study

Heterosexual African, Caribbean and Black (ACB) men are a vulnerable group to HIV infection in Canada, but little is known about their uptake of HIV testing services. Studies on ACB men HIV vulnerabilities have largely focused on behavioural factors. While these studies have contributed to the current HIV prevention success in Canada, little attention has been paid to structural factors that intersect with prevailing behaviours to reinforce vulnerabilities. Drawing insights from intersectionality theory, we examined healthcare access and HIV testing among heterosexual ACB men in London, Ontario. We fitted the negative log-log link function to 155 individuals' survey. Results show that participants, who had difficulty accessing healthcare, experienced discrimination, and were young, were all less likely to test for HIV. Even though the probability of testing for HIV increased after accounting for the effect of structural factors, the marginal impact was higher for those without any difficulty accessing healthcare than those with difficulty. Findings are discussed within the broader theory of intersectionality and recommendations made for public health policy.

Changes in Characteristics and Behavior Among African American Men Who Have Sex with Men and Women in the Context of Reductions in HIV Diagnoses Among Women

Men who have sex with men and women (MSMW) connect lower prevalence populations of women to higher prevalence populations of men who have sex with men only. We hypothesize that HIV testing and treatment among MSMW have increased in recent years, and this increase can help explain the declining rates of new HIV diagnoses among African American women. We analyzed data from 2008, 2011, and 2014 of the National HIV Behavioral Surveillance system. African American men who have sex with men (MSM) were surveyed from 19 United States cities using venue-based sampling and tested for HIV infection. We used generalized estimating equations, using year of survey as an independent variable, adjusting for age, to determine differences for selected outcomes regarding healthcare and risk behaviors over time. Among the 1299 African American MSMW interviewed, significant increases were observed in the percent of men who had an HIV test in the previous 12 months (2008: 54%, 2011: 69%, and 2014: 68%, p-value < 0.001). Among HIV-positive men, the percentage of men who were aware of their infection at the time of the interview increased significantly over time (26, 35, and 48%, p-value = 0.002). Among those men, the percentage who reported currently being on antiretroviral therapy also increased significantly over time (46, 69, and 72%, p-value = 0.050). The percentage of men reporting high-risk sexual risk behaviors increased or remained stable. Our findings support the hypothesis that HIV testing and treatment has increased among African American MSM from 2008 to 2014. Additional research is needed to fully explore the population-level impact it has on HIV transmission among women.

Improving the HIV Prevention Landscape to Reduce Disparities for Black MSM in the South

Black men who have sex with men (MSM) in the South have the highest rates of HIV diagnosis in the country adding to the persistent racial disparities in HIV experienced by this population. The current HIV prevention and care landscape is heavily driven by individual-level clinical and biomedical approaches that have shown progress in reducing HIV diagnoses, but yield less than adequate results in reducing the HIV racial disparities for Black MSM in the South. In efforts to enhance focus on reducing the racial HIV disparities and more completely address the needs of Black MSM in the South, we offer insight on comprehensive approaches that can complement our current HIV prevention and care portfolio. There are five domains we discuss which include: (1) leveraging and integrating resources; (2) building upon existing program models designed to reduce disparities; (3) workforce development and cultural sensitivity; (4) social determinants of health data utilization; and 5) policy considerations. We urge public health practitioners and healthcare providers to consider and incorporate the outlined approaches to improve HIV outcomes along the continuum of care and ultimately reduce disparities in HIV affecting the quality of life of Black MSM living in the South.

Sexual Orientation, Religious Coping, and Drug Use in a Sample of HIV-Infected African-American Men Living in the Southern USA

Religiosity and spirituality are associated with reduced drug use in the general population, but it is unclear whether this relationship generalizes to sexual minorities. This study investigated the relationship between religious coping, drug use, and sexual orientation in a sample of HIV-infected African-American men (40 heterosexuals; 64 sexual minorities). Most participants (76%) reported being "moderately" or "very" religious. We found no main effect of religious coping or sexual orientation on frequency of drug use. However, there was an interaction between positive religious coping and sexual orientation. Among heterosexuals, positive religious coping was inversely associated with frequency of drug use. However, this relationship was not significant among sexual minorities. Findings suggest HIV-infected African-American sexual minorities living in the South may need additional coping resources to decrease vulnerability to drug use.

An examination of grit in black men who have sex with men and associations with health and social outcomes

AIMS

This study sought to examine the prevalence and correlates of grit in a sample of Black men who have sex with men (BMSM) in Baltimore, Maryland.

METHODS

A trained research assistant administered the Short-Grit and Center for Epidemiological Studies Depression (CES-D) scales and surveyed participants of a community-based behavioral health intervention for demographic, health, and sexual behaviors.

RESULTS

Of 239 participants, two-thirds scored in the high grit category. A greater proportion of men with high grit demonstrated higher educational attainment, were employed in the prior 6 months, reported very good/excellent health, were human immunodeficiency virus-positive, scored < 16 on the CES-D, and had more friends who were gay. After controlling for other variables, high grit was associated with higher odds of having more friends who are gay and lower odds of alcohol use, unemployment, and a high CES-D score.

CONCLUSIONS

These findings demonstrate that grit could be an important mechanism upon which to focus health and behavioral interventions for BMSM.

Understanding Puberty and Its Measurement: Ideas for Research in a New Generation

The measurement of puberty is an intricate and precise task, requiring a match between participants' developmental age and appropriate techniques to identify and capture variations in maturation. Much of the foundational work on puberty and its psychosocial correlates was conducted several decades ago. In this article, we review the biological foundation of puberty; the operationalization of puberty in statistical analyses; and strategies for considering diversity and social context in research to help researchers align measurement with meaningful conceptual questions. These three areas are particularly important, given new statistical techniques, greater awareness of individual variations in development, and key differences between past cohorts and youth coming of age today.

Methodological considerations for conducting focus groups in HIV prevention research among Black men who have sex with men

INTRODUCTION

Focus groups are an important learning tool in HIV prevention research among U.S. Black men who have sex with men (BMSM), for whom incidence persists. Focus groups are useful in designing interventions, but many have struggled to engage BMSM in research. To optimize the utility of focus group methodology on HIV prevention among BMSM, this paper offers methodological considerations for conducting and managing focus groups with BMSM.

METHODS

Perspectives come from the process of conducting nine focus groups (N = 52) to explore the role of religion and spirituality in the lives of BMSM in Baltimore City and how these concepts could be used to inform local HIV prevention interventions.

RESULTS

Themes from field notes captured important concepts to consider regarding the following: recruitment and retention, recruiting from within the social network, screening for HIV status, focus group stratification, and focus group facilitation.

DISCUSSION

Considerations and recommendations for mitigating the challenges in focus group research and enriching data collection with BMSM are outlined.

Correlates of same-sex behavior disclosure to health care providers among Black MSM in the United States: implications for HIV prevention

Disclosure of same-sex behavior to health care providers (HCPs) by men who have sex with men (MSM) has been argued to be an important aspect of HIV prevention. However, Black MSM are less likely to disclose compared to white MSM. This analysis of data collected in the United States from 2006-2009 identified individual and social network characteristics of Black MSM (n = 226) that are associated with disclosure that may be leveraged to increase disclosure. Over two-thirds (68.1%) of the sample had ever disclosed to HCPs. Part-time employment (AOR = 0.32, 95% CI = 0.11-0.95), bisexual identity (AOR = 0.29, 95% CI = 0.12-0.70), and meeting criteria for alcohol use disorders (AOR = 0.32, 95% CI = 0.14-0.75) were negatively associated with disclosure. Disclosers were more likely to self-report being HIV-positive (AOR = 4.47, 95% CI = 1.54-12.98), having more frequent network socialization (AOR = 2.15, 95% CI = 1.24-3.73), and having a social network where all members knew the participant had sex with men (AOR = 4.94, 95% CI = 2.06-11.86). These associations were not moderated by self-reported HIV status. Future interventions to help MSM identify social network members to safely disclose their same-sex behavior may also help disclosure of same-sex behavior to HCPs among Black MSM.

Perceptions of Needs, Assets, and Priorities Among Black Men Who Have Sex With Men With HIV: Community-Driven Actions and Impacts of a Participatory Photovoice Process

Black men who have sex with men (MSM) with HIV experience significant health inequities and poorer health outcomes compared with other persons with HIV. The primary aims of this study were to describe the needs, assets, and priorities of Black MSM with HIV who live in the Southern United States and identify actions to improve their health using photovoice. Photovoice, a participatory, collaborative research methodology that combines documentary photography with group discussion, was conducted with six Black MSM with HIV. From the photographs and discussions, primary themes of discrimination and rejection, lack of mental health services, coping strategies to reduce stress, sources of acceptance and support, and future aspirations emerged. After the photographs were taken and discussed, the participants hosted a photo exhibition and community forum for the public. Here, 37 community attendees and influential advocates collaborated with the participants to identify 12 actions to address the men's identified needs, assets, and priorities. These included making structural changes in the legal and medical systems, encouraging dialogue to eliminate multiple forms of stigma and racism, and advocating for comprehensive care for persons with HIV. As a secondary aim, the impacts of photovoice were assessed. Participants reported enjoying photovoice and found it meaningful. Results suggest that in addition to cultivating rich community-based knowledge, photovoice may result in positive changes for Black MSM with HIV.

Using Partially-Observed Facebook Networks to Develop a Peer-Based HIV Prevention Intervention: Case Study

Background

This is a case study from an HIV prevention project among young black men who have sex with men. Individual-level prevention interventions have had limited success among young black men who have sex with men, a population that is disproportionately affected by HIV; peer network–based interventions are a promising alternative. Facebook is an attractive digital platform because it enables broad characterization of social networks. There are, however, several challenges in using Facebook data for peer interventions, including the large size of Facebook networks, difficulty in assessing appropriate methods to identify candidate peer change agents, boundary specification issues, and partial observation of social network data.

Objective

This study aimed to explore methodological challenges in using social Facebook networks to design peer network–based interventions for HIV prevention and present techniques to overcome these challenges.

Methods

Our sample included 298 uConnect study respondents who answered a bio-behavioral survey in person and whose Facebook friend lists were downloaded (2013-2014). The study participants had over 180,000 total Facebook friends who were not involved in the study (nonrespondents). We did not observe friendships between these nonrespondents. Given the large number of nonrespondents whose networks were partially observed, a relational boundary was specified to select nonrespondents who were well connected to the study respondents and who may be more likely to influence the health behaviors of young black men who have sex with men. A stochastic model-based imputation technique, derived from the exponential random graph models, was applied to simulate 100 networks where unobserved friendships between nonrespondents were imputed. To identify peer change agents, the eigenvector centrality and keyplayer positive algorithms were used; both algorithms are suitable for identifying individuals in key network positions for information diffusion. For both algorithms, we assessed the sensitivity of identified peer change agents to the imputation model, the stability of identified peer change agents across the imputed networks, and the effect of the boundary specification on the identification of peer change agents.

Results

All respondents and 78.9% (183/232) of nonrespondents selected as peer change agents by eigenvector on the imputed networks were also selected as peer change agents on the observed networks. For keyplayer, the agreement was much lower; 42.7% (47/110) and 35.3% (110/312) of respondent and nonrespondent peer change agents, respectively, selected on the imputed networks were also selected on the observed network. Eigenvector also produced a stable set of peer change agents across the 100 imputed networks and was much less sensitive to the specified relational boundary.

Conclusions

Although we do not have a gold standard indicating which algorithm produces the most optimal set of peer change agents, the lower sensitivity of eigenvector centrality to key assumptions leads us to conclude that it may be preferable. The methods we employed to address the challenges in using Facebook networks may prove timely, given the rapidly increasing interest in using online social networks to improve population health.

Internalized Homophobia and Drug Use in a National Cohort of Gay and Bisexual Men: Examining Depression, Sexual Anxiety, and Gay Community Attachment as Mediating Factors

The minority stress process of internalized homophobia (IH) has been associated with a range of adverse health outcomes among gay and bisexual men (GBM). However, evidence is mixed regarding the effect of IH on drug use, suggesting the potential role of multiple mediated pathways. Researchers have linked depression, sexual anxiety, and gay community attachment with IH. Depression, sexual anxiety, and gay community attachment have also been linked with drug use and drug-related problems suggesting potential mediating roles. A U.S. national sample of 1071 HIV-negative GBM completed at-home surveys, including measures of sociodemographic characteristics, IH, depression, sexual anxiety, gay community attachment, and drug use and associated problems. Adjusting for sociodemographic characteristics, depression mediated the association between IH and recent drug use. IH was positively associated with depression, and depression was positively associated with recent drug use. Gay community attachment partially mediated drug-related problems. IH had a positive direct association with drug-related problems and a negative direct association with gay community attachment. Gay community attachment had a positive association with drug-related problems. IH was positively associated with sexual anxiety, but sexual anxiety was not associated with either drug outcome. Efforts to reduce IH among HIV-negative GBM are likely to have a positive impact on mental health problems, as well as reduce risk for drug use and drug-related problems. Gay communities could provide the social support necessary for reducing IH; however, emphasis on community level interventions that address factors that increase risk for drug-related problems remains important.

Efficacy of a Small-Group Intervention for Post-Incarcerated Black Men Who Have Sex with Men and Women (MSMW)

We conducted a randomized controlled trial of a six-session behavioral intervention designed to reduce frequency of condomless sex and numbers of sex partners among recently incarcerated, bisexual Black men. One hundred participants were assigned to the small-group intervention, Men in Life Environments (MILE), and 112 were assigned to the control condition. Among those assigned to MILE, 69% attended at least one session, 88% of whom attended all sessions. At 3-months' follow-up, large reductions in risk behaviors were reported by both groups. Means for episodes of condomless sex in the previous 3 months declined from 27.7 to 8.0 for the intervention and 25.6 to 6.7 for the control group. Reductions were not greater for the intervention than those of the control group. Regression to the mean, respondent burden, and implementation issues, such as moving from office-based to field-based survey administration at follow-up, may have contributed to the large declines reported by both groups.

'Church hurt can be the worst hurt': community stakeholder perceptions of the role of Black churches in HIV prevention among young Black gay and bisexual men

Black gay and bisexual men aged 15-29 are disproportionately represented among new cases of HIV in the USA. Researchers have argued that community-based prevention cannot succeed without the participation of faith-based organisations, particularly given the salience of religion and spirituality in the lives of young Black gay and bisexual men. Yet some Black churches may be hesitant to engage in HIV prevention efforts given their beliefs about same-sex behaviour. It is less clear, however, whether and how public health practitioners in the field of HIV prevention have approached church inclusion. We therefore explored how community stakeholders describe the involvement of Black churches with the HIV continuum of care. We draw on a qualitative dataset of 50 in-depth semi-structured interviews conducted in Detroit, USA. Participants offered multiple perspectives on the response of Black churches to the HIV epidemic, from overt stigma to gradual acceptance and action. Nevertheless, participants agreed that when stigma was present in the pews and the pulpit, young Black gay and bisexual men were at potential risk of social isolation. Furthermore, tensions may exist between Black churches and secular community-based organisations that are attributable to histories of mistrust. These findings have important implications for future community-based intervention strategies among young Black gay and bisexual men.

Psychosocial Functioning and Decisional Balance to Use Condoms in a Racially/Ethnically Diverse Sample of Young Gay/Bisexual Men Who Have Sex with Men

Young gay/bisexual and other men who have sex with men (YGBMSM; ages 18-24) are experiencing an increase in HIV infection rates, particularly if they are Black or Latino. Psychosocial functioning is consistently implicated in HIV risk behaviors; however, less is known about the role of these factors in YGBMSM's decision-making process to use condoms (i.e., decisional balance to use condoms; DBC). We examined whether YGBMSM's psychological functioning was associated differentially with their DBC across racial/ethnic groups. Using data from a cross-sectional web-survey of single YGBMSM (N = 1380; 9.9% Black; 18.6% Latino; 71.5% White), we performed racial/ethnic-specific multivariable regression models to explore the association between DBC and psychological factors (e.g., depression, anxiety), demographics (e.g., age, education, HIV status, prior STI diagnosis), and perceived difficulty implementing safer sex strategies. Black YGBMSM reported lower DBC if they reported higher depression symptoms (β = -.31, p < .05), were HIV-negative (β = -.20, p < .05), and had greater difficulty implementing safer sex strategies (β = -.32, p < .001). Latino participants reported greater DBC to use condoms if they reported greater anxiety symptoms (β = .21, p < .05). White participants reported greater DBC if they were younger (β = -.09, p < .01), did not report a prior STI (β = .10, p < .001), and had fewer difficulties implementing safer sex strategies (β = -.27, p < .001); DBC had no association to psychological well-being among White participants. Psychological factors may be differentially associated with DBC across racial/ethnic group categories. Health promotion initiatives targeting condom use may benefit from culturally tailored interventions that address psychosocial functioning and its role in YGBMSM's condom use decision-making.

Gay Men's Health and Identity: Social Change and the Life Course

Due to significant historical change in the late 20th and early 21st century related to both health and cultural attitudes toward homosexuality, gay men of distinct birth cohorts may diverge considerably in their health and identity development. We argue that research on gay men's health has not adequately considered the significance of membership in distinct generation-cohorts, and we present a life course paradigm to address this problem. Focusing on the U.S. as an exemplar that can be adapted to other cultural contexts, we identify five generations of gay men alive today and review unique issues related to health and identity development for each. Implications for research, practice, and advocacy on gay men's health and development are discussed.

Racial Pride and Condom Use in Post-Incarcerated African-American Men Who Have Sex With Men and Women: Test of a Conceptual Model for the Men in Life Environments Intervention

African-American men who have sex with men and women (MSMW) are among those most heavily impacted by HIV in the United States, and those who have histories of incarceration are at further risk of infection. The Men in Life Environments (MILE) HIV prevention intervention was developed to provide culturally appropriate skills-based education and support for African-American MSMW with recent histories of incarceration. The MILE's conceptual framework was informed by three theories: Theory of Reasoned Action and Planned Behavior, Critical Thinking and Cultural Affirmation Model, and Empowerment Theory. The theory-based framework posits that improving racial pride is crucial in building self-efficacy and intentions that in turn promote health-protective behaviors. Therefore, our study aimed to assess whether baseline associations between racial pride and condom use self-efficacy, intentions, and behaviors among African-American MSMW with histories of incarceration align with our conceptual model. We report data on 212 participants recruited from Los Angeles County Sheriff's Department Men's Central Jail and the local community. Using structural equation modeling, we tested two separate models: one with female sexual partners and one with male sexual partners, while stratifying by participant's HIV status. Only among HIV-negative participants was greater racial pride associated with less condomless intercourse with men. In this group, greater self-efficacy and intentions-but not racial pride-predicted less condomless intercourse with women. Our findings suggest that racial pride is an important factor to address in HIV prevention interventions for post-incarcerated African-American MSMW.

What's In an Identity Label? Correlates of Sociodemographics, Psychosocial Characteristics, and Sexual Behavior Among African American Men Who Have Sex With Men

African American men who have sex with men (AAMSM) are vastly overrepresented among people with HIV/AIDS. Using data from 595 AAMSM in Philadelphia, we explored differences in sociodemographics, psychosocial characteristics related to beliefs about ethnicity, sexuality and masculinity, and sexual behavior with men and women by self-reported sexual identity (gay, bisexual, down low, straight). Roughly equivalent numbers identified as gay (40.6 %) and bisexual (41.3 %), while fewer identified as straight (7.6 %) or down low (10.5 %), with significant differences in age, income, history of incarceration, HIV status, alcohol and drug problems, childhood sexual abuse, and connection to the gay community evident among these groups. Analysis of psychosocial characteristics theorized to be related to identity and sexual behavior indicated significant differences in masculinity, homophobia, and outness as MSM. Gay and straight men appeared to be poles on a continuum of frequency of sexual behavior, with bisexual and down low men being sometimes more similar to gay men and sometimes more similar to straight men. The percentage of men having total intercourse of any kind was highest among down low and lowest among gay men. Gay men had less intercourse with women, but more receptive anal intercourse with men than the other identities. There were no significant differences by identity in frequency of condomless insertive anal intercourse with men, but gay men had significantly more condomless receptive anal intercourse. There were significant differences by identity for condomless vaginal and anal intercourse with women. This study demonstrates the importance of exploring differences in types of sex behavior for AAMSM by considering sexual identity.

Enhancing PrEP Access for Black and Latino Men Who Have Sex With Men

OBJECTIVE

Implementation of HIV pre-exposure prophylaxis (PrEP) programs for populations with highest incidence is critical to reducing new infections in the United States. Black and Latino men who have sex with men (BLMSM) are disproportionately burdened by HIV. We examined differences in perceived barriers and facilitators to PrEP access for BLMSM compared with other men who have sex with men (MSM).

METHOD

MSM who met the Centers for Disease Control and Prevention criteria for PrEP (n = 491) completed measures of barriers and facilitators to PrEP at the systems, provider, and individual levels. Multivariate analyses examined differences by race/ethnicity, adjusting for other sociodemographic factors.

RESULTS

Compared with other MSM, BLMSM (56% of the sample) were more likely to have public insurance and to access health care via public clinics [adjusted odds ratio(aOR) 3.2, P < 0.001; aOR 2.4, P < 0.01]. BLMSM were more likely to regard having to talk to their doctor about their sex life as a barrier to PrEP (aOR 3.7, P < 0.001) and were less likely to endorse agency in medical decision making (aOR 0.58, P < 0.001). BLMSM were more likely to report PrEP stigma (aOR 2.3, P < 0.001) and concerns regarding PrEP efficacy (aOR 1.6, P < 0.05). BLMSM were more likely to consider access to free sexual health care (aOR 2.1, P < 0.01) and additional supportive services, eg, counseling (aOR 3.1, P < 0.001) or text-based support (aOR 2.9, P < 0.001) to be significant facilitators of PrEP use.

CONCLUSIONS

Findings suggest specific points of multilevel intervention to increase PrEP access for BLMSM and increase representation of BLMSM along the PrEP continuum of care.

Criminal justice involvement history is associated with better HIV care continuum metrics among a population-based sample of young black MSM

OBJECTIVE

To examine how history of criminal justice involvement (CJI) is related to HIV care continuum metrics among young black MSM 16-29 years of age.

DESIGN

Population-based survey.

METHODS

From 2013 to 2014, a representative sample of young black MSM was generated using respondent-driven sampling (RDS) in Chicago (n = 618). HIV antibody/antigen and RNA testing were performed using dry blood spots. Factors assessed in the care continuum included HIV testing, HIV diagnosis, linkage to care within 6 months, retention in care, adherence to antiretrovirals, and viral suppression. RDS-weighted regression models examined the associations between history of CJI, including frequency of CJI and durations of stay and each of the continuum metrics.

RESULTS

A final analytic sample of 618 participants was generated through RDS chains of up to 13 waves in length and with a mean of 2.1 recruits per participant. At enrollment, 40.8% had prior history of CJI and 34.6% were HIV seropositive. Of persons reporting HIV seropositive status, 58.4% were linked to care, 40.2% were retained in care, 32.2% were adherent to antiretrovirals, and 24.3% were virally suppressed. Any CJI history was associated with the overall care continuum (adjusted odds ratio = 2.35; 95% confidence interval 1.13-4.88) and was most associated with increased retention in care [adjusted odds ratio = 3.72 (1.77-7.84)]. Having one CJI experience and detention for only 1 day was associated with better retention in care compared with no or more frequent CJI.

CONCLUSION

Those with a previous history of CJI were more successful in achieving most HIV care continuum metrics. Frequent and cycling CJI, however, was detrimental to HIV care.

Opportunities for HIV Prevention Communication During Sexual Encounters with Black Men Who Have Sex with Men

Conversations about HIV prevention before engaging in sex may result in safer sex practices and decreased HIV transmission. However, partner communication for HIV prevention has been understudied among black/African American men who have sex with men (BMSM), a group that is disproportionately affected by HIV. We explored and described encounters and perceptions about HIV prevention conversations among BMSM and their sex partner(s) in New York City. We conducted an inductive thematic analysis of semi-structured interviews with BMSM who reported sex with a man in the previous 3 months. Interviews were professionally transcribed; Nvivo was used for data analysis. Twenty-two BMSM were included in this analysis; median age = 29.1 years; 71.4% self-identified as MSM; 85.7% were ever HIV tested; and 52.6% reported no disclosure or discussion about HIV status with their previous sex partner. The main themes were: (1) missed opportunities for HIV prevention conversations (e.g., no HIV prevention conversations or HIV prevention conversations after sex had occurred); (2) barriers to HIV prevention conversations (e.g., being in the moment; not wanting to pause); (3) emotional thoughts after sex (e.g., feeling worried about possible HIV exposure); and (4) rethinking relationships and sexual health (e.g., changed sex practices by asking partners' HIV status before sex; started using condoms). These findings offer insight into HIV prevention conversations by BMSM around the time of or during sexual encounters and may inform and strengthen partner-level HIV prevention communication interventions for BMSM.

Real Talk: Developing a Computer-Delivered Sexual Health Program for Black Men Who Have Sex With Men

HIV disproportionately affects Black men who have sex with men (MSM), yet there are few evidence-based programs that respond to the diverse realities of Black MSM communities. This article examines the development of Real Talk, a new harm reduction-based, sexual health intervention for Black MSM. We first analyze the key themes from our formative research: (1) stigma, discrimination, and intersectionalities in the lives of Black MSM, (2) the importance of safe spaces and community provided by health promotion programs, and (3) moving beyond condoms in sexual health messaging. We then describe our agile design product development process and present an overview of the intervention's components and how they respond to the issues identified in the formative research. In conclusion, we discuss dissemination opportunities and challenges in an age of decreased prevention funding, pre-exposure prophylaxis (PrEP), and the increased use of e-health promotion modalities.

A mixed methods study of health and social disparities among substance-using African American/Black men who have sex with men

African American/Black men who have sex with men (MSM) in the U.S. experience health and social disparities at greater rates than MSM of other races/ethnicities, including HIV infection and substance use. This mixed methods paper presents: 1) a quantitative examination of health and social disparities among a sample of substance-using African American/Black MSM (N=108), compared to Caucasian/White MSM (N=250), and 2) in-depth qualitative data from a subsample of African American/Black MSM (N=21) in order to contextualize the quantitative data. Findings indicate that compared to Caucasian/White MSM, African American/Black MSM experienced a wide range of health and social disparities including: substance use and dependence; buying, trading or selling sex; educational attainment; employment; homelessness; identifying as gay; HIV status; arrest history; social support; and satisfaction with one's living situation. Qualitative data suggests that structural interventions that address homophobia and the social environment would be likely to mitigate many of the health and social disparities experienced by African American/Black MSM.

Sexual and Gender Diversity within the Black Men who have Sex with Men HIV Epidemiological Category

Epidemiological categories not only reflect existing frameworks for public health, but reify how subpopulations are defined, understood, and targeted for interventions. The sweeping categorization of Black men who have sex with men (BMSM) used in HIV research and intervention work is one such example. The current paper builds upon previous critiques of the "MSM" nomenclature by delineating the sexual and gender diversity embedded in the term as it pertains specifically to Black peoples. The emphasis is on developing greater specificity about the sociocultural and structural factors that may be shared among these subgroups, such as racism and poverty, and the factors that are likely to distinguish the groups, such as levels of sexual minority identification, access to lesbian, gay, bisexual, and transgender (LGBT) services and community, and experiences with anti-bisexual or anti-transgender bias. The aim then is to provide a framework for HIV health policy work for Black sexual minority cisgender men (SMCM) and gender minorities (GM).

Examining the Relationships Between Religiosity, Spirituality, Internalized Homonegativity, and Condom Use Among African American Men Who Have Sex With Men in the Deep South

The Sexual Health in Faith Traditions Study evaluated the relationships between religiosity, spirituality, internalized homonegativity, and sexual risk behaviors among a sample of African American men who have sex with men living in the Deep South. Participants were recruited primarily from Black Gay Pride celebrations to complete a self-administered, paper-and-pencil survey. Structural equation modeling was used to determine relationships between key constructs and condom use for insertive ( n = 285) and receptive ( n = 263) anal intercourse in the past 3 months. Almost half of respondents reported using condoms "every time" when engaging in insertive (48.3%) or receptive (45.1%) anal intercourse. Religiosity and spirituality were differentially associated with dimensions of internalized homonegativity. While no significant direct relationships were reported between either religiosity or spirituality and condom use, dimensions of internalized homonegativity mediated significant indirect relationships. Findings suggest that religiosity and spirituality influence African American men who have sex with men's internalized homonegativity and, subsequently, engagement in safer sex behaviors.

Contributions of Qualitative Research in Informing HIV/AIDS Interventions Targeting Black MSM in the United States

This article presents a systematic review of qualitative studies focusing on human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS) among Black men who have sex with men (BMSM) in the United States. We reviewed studies that were published between 1980 and 2014. Qualitative methods employed in the studies reviewed include in-depth interviews, focus groups, participant observation, and ethnography. We searched several databases (PubMed, PsychINFO, JSTOR, ERIC, Sociological Abstracts, and Google Scholar) for relevant articles using the following broad terms: "Black men" "Black gay/bisexual" or "Black men who have sex with men," and "qualitative" and/or "ethnography." We include 70 studies in this review. The key themes observed across studies were (1) heterogeneity, (2) layered stigma and intersectionality, (3) risk behaviors, (4) mental health, (5) resilience, and (6) community engagement. The review suggests that sexual behavior and HIV-status disclosure, sexual risk taking, substance use, and psychological well-being were contextually situated. Interventions occurring at multiple levels and within multiple contexts are needed to reduce stigma within the Black community. Similarly, structural interventions targeting religious groups, schools, and health care systems are needed to improve the health outcomes among BMSM. Community engagement and using community-based participatory research methods may facilitate the development and implementation of culturally appropriate HIV/AIDS interventions targeting BMSM.

Social support, psychological vulnerability, and HIV risk among African American men who have sex with men

Previous research has suggested a need to understand the social-psychological factors contributing to HIV risk among African American men who have sex with men (MSM). We conducted individual in-depth interviews with 34 adult African American MSM to examine their personal experiences about: (i) sources of social support, (ii) psychological responses to the presence or absence of social support and (iii) influences of social support on sexual behaviours. The majority of participants described limited positive encouragement and lack of emotional support from family, as well as few meaningful personal relationships. Feelings of isolation and mistrust about personal relationships led many participants to avoid emotional intimacy and seek physical intimacy through sexual encounters. Findings highlight a need for multilevel interventions that enhance social support networks and address the social-psychological, emotional and interpersonal factors that contribute to HIV risk among African American MSM.

Exploring Service Provider Perceptions of Treatment Barriers Facing Black, Non-Gay-Identified MSMW

Non-gay-identified men who have sex with men and women and who use alcohol and other drugs are a vulnerable population. Little is known about health and medical service provider interaction with these underserved clients. This article presents a thematic analysis of two focus groups undertaken with social and medical service providers regarding the needs of non-gay-identified men who have sex with men and women. Four emergent themes (labeling, constructions of masculinity, HIV/AIDS awareness, and treatment success) illustrate perceived barriers to HIV/AIDS prevention and treatment, as well as treatment success. Implications for policy, practice, and future research are discussed.

Experiences of Antihomosexual Attitudes and Young Black Men Who Have Sex with Men in the South: A Need for Community-Based Interventions

PURPOSE

In 2012, Jackson, Mississippi, had the third highest incidence rate of human immunodeficiency virus (HIV) among young Black men who have sex with men (MSM). The goal of this qualitative study (the initial phase of an HIV prevention clinical trial) was to explore how cultural norms regarding antihomosexual attitudes interfere with the safe sex practices and relationship norms of young Black MSM in Mississippi.

METHODS

Nine focus groups (N = 54) were conducted with young Black MSM aged 18-29. Participants were recruited through medical providers at local sexually transmitted infection clinics and through community organizers at local LGBT outreach programs. The data were analyzed through the use of grounded theory, multiple coders for consistency and intercoder reliability, and a qualitative data analysis software.

RESULTS

Three major themes were identified during the analysis: (1) resiliency and condom use, (2) inconsistent condom use among closeted young Black MSM, and (3) intimate partner violence (IPV) among closeted young Black MSM. Black MSM in Mississippi continue to be highly stigmatized within their social networks (i.e., families, sexual partners, and community).

CONCLUSIONS

The findings suggest that cultural and community norms regarding antihomosexual attitudes may be a barrier to the practices of safe sex and a contributing factor to IPV among young Black MSM. There is a need for tailored interventions that address these cultural norms and establish social and community support for young Black MSM in Mississippi.

A qualitative analysis of emerging adult black men's sexual decision-making behavior and substance use

Emerging adult Black men and substance users may have an increased risk for compromised sexual health. This study qualitatively investigated how substance use affects the sexual decision-making of emerging adult Black men. Nineteen Black men in college (18-24 years) completed a semi-structured interview about their sexual attitudes, behaviors, and perceptions and their substance use. Results show that substance use may not independently affect sexual risk behavior among emerging adult Black men. Findings highlight the importance of using approaches that incorporate structural and sociocultural factors when framing research and interventions related to substance use, sexual decision making, and Black men.

The Development of a Counseling-Based HIV Prevention Intervention for African American Men Who Have Sex With Men and Women: The Bruthas Project

African American men who have sex with both men and women (AAMSMW) are at high risk for acquiring and transmitting HIV, yet few interventions exist to address their unique prevention needs. We conducted 3 focus groups, 21 in-depth interviews, and a pilot test of our intervention with = 61 AAMSMW, which showed significant reductions in sexual risk behavior after 6 months. The intervention is currently being tested in a randomized controlled trial (RCT). We discuss the development of a culturally tailored, theoretically grounded counseling intervention for AAMSMW, presenting findings from our formative research, intervention development process, pilot study, and the implementation of our RCT. We describe the content of each session, our protocol for merging Bruthas with HIV testing, and best practices for recruiting AAMSMW. If Bruthas is found to be efficacious, the intervention will reach a vulnerable population to encourage uptake of regular HIV testing and reduced sexual risk taking.

Correlates of Sexual HIV Risk Among African American Men Who Have Sex With Men

OBJECTIVES

We examined correlates of condomless anal intercourse with nonmain sexual partners among African American men who have sex with men (MSM).

METHODS

We recruited social networks composed of 445 Black MSM from 2012 to 2014 in Milwaukee, Wisconsin; Cleveland, Ohio; and Miami Beach, Florida. Participants reported past-3-month sexual behavior, substance use, and background, psychosocial, and HIV-related characteristics.

RESULTS

Condomless anal intercourse outside main concordant partnerships, reported by 34.4% of MSM, was less likely in the case of no alcohol and marijuana use in the past 30 days, and higher risk-reduction behavioral intentions. High frequency of condomless anal intercourse acts with nonmain partners was associated with high gay community participation, weak risk-reduction intentions, safer sex not being perceived as a peer norm, low condom-use self-efficacy, and longer time since most recent HIV testing.

CONCLUSIONS

Condomless anal intercourse with nonmain partners among Black MSM was primarily associated with gay community participation, alcohol and marijuana use, and risk-reduction behavioral intentions.

Correlates of requesting home HIV self-testing kits on online social networks among African-American and Latino men who have sex with men

High levels of HIV stigma are one of the main difficulties in engaging African-American and Latino men who have sex with men (MSM) in HIV testing. The availability of home HIV test and the possibility of self-testing in private may improve uptake and counteract stigma. This paper sought to determine the correlates of requesting home HIV test kits among a sample of MSM social media users. The odds of participants requesting a test kit were significantly associated with using social networks to seek sexual partners (aOR: 2.47, 95% CI: 1.07-6.06) and thinking it is easier to use social networks for seeking sexual partners (1.87, 1.2-3.12), uncertain HIV status (4.29, 1.37-14.4), and having sex under the influence of alcohol (2.46, 1.06-5.77). Participants who had not been tested for more than 6 months were more likely to request a test kit than those who were tested in the past 6 months (2.53, 1.02-6.37). Participants who frequently talked to others about having sex with men online were less likely to request a test kit (0.73, 0.56-0.92). By reaching people over social media and offering them access to test kits, we were able to reach at-risk individuals who were uncertain about their HIV status and had not been regularly tested. The findings of the study will help to inform future HIV testing interventions.

Neighborhood-level associations with HIV infection among young men who have sex with men in Chicago

The rising incidence of HIV infection among young men who have sex with men (YMSM) is a substantial public health concern. Traditional research on HIV among YMSM has focused largely on individual-level predictors and infrequently accounts for contextual or neighborhood-level factors such as ethnic composition and socioeconomic status. This study used neighborhood-level data from the US Census and other public sources, and individual-level data from a longitudinal cohort of YMSM in Chicago (Crew 450). Of the original 450 YMSM in the cohort, 376 reported living in Chicago (83.6 %) and were included in the analytic sample. A clustering approach was used to group the 77 community areas together by common characteristics, resulting in the identification of 11 distinct clusters. An unconditional model of individual HIV status indicated a significant amount of variance existed between neighborhood clusters (χ (2) = 21.66; p = 0.006). When individual-level variables were added to the model, only having an HIV-positive sex partner (OR = 6.41; CI 2.40, 17.1) and engaging in exchange sex in the past 6 months (OR = 3.25; 95 % CI 1.33, 7.93) were significant predictors of HIV status. Clusters with higher Walk Scores were less likely to contain HIV-positive individuals (OR = 0.94; 95 % CI 0.90, 0.98). Conversely, clusters with a larger proportion of vacant buildings were more likely to contain HIV-positive individuals (OR = 1.19; 95 % CI 1.07, 1.33). Future research among YMSM needs to investigate the mechanisms by which neighborhood of residence might influence engagement in risk behaviors or acquisition of HIV.

Assessing the role of masculinity in the transmission of HIV: a systematic review to inform HIV risk reduction counseling interventions for men who have sex with men

HIV affects over 1.2 million people in the United States; a substantial number are men who have sex with men (MSM). Despite an abundance of literature evaluating numerous social/structural and individual risk factors associated with HIV for this population, relatively little is known regarding the individual-level role of masculinity in community-level HIV transmission risk. To address this gap, the current analysis systematically reviewed the masculinity and HIV literature for MSM. The findings of 31 sources were included. Seven themes were identified: (1) number of partners, (2) attitudes toward condoms, (3) drug use, (4) sexual positioning, (5) condom decision-making, (6) attitudes toward testing, and (7) treatment compliance. These factors, representing the enactment of masculine norms, potentiate the spread of HIV. The current article aligns these factors into a masculinity model of community HIV transmission. Opportunities for counseling interventions include identifying how masculinity informs a client's cognitions, emotions, and behaviors as well as adapting gender-transformative interventions to help create new conceptualizations of masculinity for MSM clients. This approach could reduce community-level HIV incidence.

The Relationship Between Online Social Network Use, Sexual Risk Behaviors, and HIV Sero-Status Among a Sample of Predominately African American and Latino Men Who have Sex with Men (MSM) Social Media Users

Social networking technologies have emerged as potential platforms to reach HIV(+) MSM in HIV interventions. This study sought to compare use of online social networking sites (SNSs) and sexual risk behaviors between HIV(+) and HIV(-) individuals among a sample of predominately African American and Latino SNS-using MSM. A total of 112 MSM Facebook users were recruited online and offline and completed an online survey. We performed regression models to assess the association between HIV status, SNS use, and sexual risk behaviors. After adjusting for age, race, and employment status, being HIV positive was significantly associated with a greater number of sexual partners (ARR = 2.84, p = 0.0017) and lower comfort levels of discussing HIV/STI status on SNSs (AOR: 0.23, p = 0.011). Findings suggest that HIV status is associated with sexual risk behaviors and SNS use among SNS-using MSM. We discuss the implications for online HIV prevention.

Correlates of internalized homonegativity among black men who have sex with men

Black men who have sex with men (MSM) carry a disproportionate burden of HIV in the United States. Such disparities cannot be attributed to individual behavioral risk factors alone, prompting the exploration of social and contextual factors experienced by minority MSM. Societal homonegativity and the internalization of those attitudes by Black MSM may play an important role in understanding racial and ethnic disparities in HIV incidence and prevalence. This study explores the correlates of internalized homonegativity in a large multi-site sample of Black MSM. Findings reveal a number of significant contextual and psychosocial factors related to internalized homonegativity including religiosity, resilience, and gay community acculturation, which have important implications for HIV risk, HIV testing, and social and psychological wellbeing for Black MSM.

Attitudes Toward HIV Voluntary Counseling and Testing (VCT) Among African American Men Who Have Sex With Men: Concerns Underlying Reluctance to Test

Contemporary antiretroviral therapy (ART) can produce viral suppression of HIV, maintain health, and prevent onward HIV transmission from infected persons to their sexual partners, giving rise to the concept of treatment as prevention. Successful implementation of test-and-treat strategies rests on the early detection of HIV infection through voluntary counseling and testing (VCT) followed by entry and retention in care, ART initiation and adherence, and subsequent viral suppression. In the United States, African American men who have sex with men (MSM) bear a disproportionate burden of HIV and have high rates of undetected and untreated HIV infection. However, little research has examined racial minority MSM's views about HIV testing. In this study, in-depth interviews were conducted with 96 key informants knowledgeable about racial minority MSM as well as 100 African American MSM community members in Milwaukee, Cleveland, and Miami. Most men in the sample were aware of the availability of testing and knew testing locations, but many voiced great personal ambivalence about being tested, feared knowing their HIV status, expressed concern about stigma and loss of confidentiality, and held beliefs indicative of medical mistrust. Participants did not spontaneously cite benefits of being tested, risk reduction behavior changes made as a consequence of testing, nor the benefits of testing to get early medical care for HIV infection. There is a gap between the public health field's perception of testing benefits and the beliefs about testing held by racial minority MSM in this sample. To increase the desired outcomes from VCT for minority MSM, VCT promotion should address the concerns of African American MSM and underscore the benefits of early entry into medical care.

The role of stigma and medical mistrust in the routine health care engagement of black men who have sex with men

Objectives: We assessed how health care-related stigma, global medical mistrust, and personal trust in one's health care provider relate to engaging in medical care among Black men who have sex with men (MSM).

METHODS

In 2012, we surveyed 544 Black MSM attending a community event. We completed generalized linear modeling and mediation analyses in 2013.

RESULTS

Twenty-nine percent of participants reported experiencing racial and sexual orientation stigma from heath care providers and 48% reported mistrust of medical establishments. We found that, among HIV-negative Black MSM, those who experienced greater stigma and global medical mistrust had longer gaps in time since their last medical exam. Furthermore, global medical mistrust mediated the relationship between stigma and engagement in care. Among HIV-positive Black MSM, experiencing stigma from health care providers was associated with longer gaps in time since last HIV care appointment.

CONCLUSIONS

Interventions focusing on health care settings that support the development of greater awareness of stigma and mistrust are urgently needed. Failure to address psychosocial deterrents will stymie progress in biomedical prevention and cripple the ability to implement effective prevention and treatment strategies.

The Role of Resilience and Anti-Resilience Behaviors in the Romantic Lives of Black Same Gender Loving (sgl) Men

This study examines the role of resilience in the romantic lives of Black same gender loving romantic male couples in the nyc metropolitan area. Twenty in-depth interviews (N=40) were conducted, ranging in age from 18 to 67, and were predominately low income and moderately educated. Research questions were: 1) What strategies do Black sgl couples use to preserve and improve their relationships and (2) What are the potential problems or barriers your relationship experiences? The data from interviews were aggregated and three major themes emerged: direct communication strategies, relationship support, and intentional and thoughtful decision making. Additional themes identified as anti-resilient to Black sgl couples were relationship discord, hostile neighborhood climate, poor communication, and lack of support. Findings show that additional research Black gay couples is needed to identify the contextual factors that influence their romantic relationships and the resilient strategies that they uses to support their romantic relationships.

The Social Environmental Elements of Resilience among Vulnerable African American/Black Men Who Have Sex with Men

Resilience theory has been suggested as a strong framework for research on HIV prevention among men who have sex with men (MSM). Among this population, literature indicates that African American/Black MSM are particularly vulnerable to health and social disparities associated with HIV transmission risk. Conceptualizing resilience as a part of one's social environment, this qualitative study investigates the specific elements of resilience, and the associated contexts and relationships, among a sample of 21 substance-using African American/Black MSM. Data indicate that: 1) elements contributing to resilience are multiple and co-occurring, including inner strengths, social relationships, diversity of experience, religion/spirituality, altruism, and creativity; 2) as an element of resilience, social support was experienced differently among men who did and did not have supportive relationships with other gay and bisexual men, which has implications for social service provision and intervention approaches; and 3) diversity of experiences and relationships is an important influencing factor on expressions of resilience. Social services or interventions that facilitate the development of these elements of resilience will likely be especially beneficial for vulnerable African American/Black MSM.

Recruiting Black Men Who Have Sex with Men and Women (BMSMW) in an Urban Setting for HIV Prevention Research

OBJECTIVES

Concerns related to stigma and confidentiality limit HIV-related study recruitment and retention of Black men who have sex with men and women (MSMW). This paper examines lessons learned from recruitment strategies utilized in enrolling 437 participants between 2007 and 2011 for a randomized controlled trial to test a culturally specific HIV risk-reduction intervention for Black MSMW.

METHODS

Interested respondents completed a brief screener and participants completed surveys at baseline and at post, 3 and 6 months follow-up. Recruitment patterns were assessed by examining the source of study information reported when respondents were asked how they learned about the study. Chi-square tests were then conducted to examine differences in the distribution of participants by self-reported HIV status, age group and socio-economic status (SES) for each type of study information source.

RESULTS

Regardless of HIV or SES, study respondents were more likely to have received information about the study through a service agency than from other sources. Participants ages 30-49 and 50+ years were most likely to have learned about the study from an agency (34.9% and 27.0%, respectively) or another participant/friend (20.1%, 23.1%) and least likely to have found out from bus (0.8%, 0.0%) or radio (1.3%, 0.0%) advertisements; whereas younger participants were more likely to have heard about the study through a friend/participant (23.4%) than an agency (15.4%). Although, 14.1% of participants' ages less than 30 years reported the Internet as their source of study information, this compared to just 2.7% and 4.8% for participants in the 30-49 and 50-plus age groups.

CONCLUSIONS

While agencies and referrals from personal networks appear to be the most significant recruitment source for potential HIV research participants, there is evidence that Internet based tools may enhance recruitment, particularly among younger Black MSMW.

Using syndemic theory to understand vulnerability to HIV infection among Black and Latino men in New York City

HIV is a public health crisis that disproportionately affects Black and Latino men. To understand this crisis, syndemic theory, which takes into account multiple interrelated epidemics, should be used. A syndemic is "two or more afflictions, interacting synergistically, contributing to excess burden of disease in a population." Vulnerability to HIV among Black and Latino men is increased as structural, social, and biological factors interact in the context of social marginalization. In New York City, Black and Latino men experience a syndemic of HIV/AIDS, substance abuse, trauma, incarceration, and poverty; however, current research has yet to fully identify the mechanisms of resilience that may reduce the negative impact of a syndemic or explore the potential adaptive functions of individual-level risk behaviors. To understand HIV risk as part of a syndemic and address HIV prevention in Black and Latino men, we propose the following: (1) the use of complex systems analysis, ethnography, and other mixed-methods approaches to observe changes in relations among social conditions and disease; (2) multidisciplinary and inter-institution collaboration; and (3) involvement of public health practitioners and researchers from diverse and underrepresented backgrounds.