Learning from successful interventions: A culturally congruent HIV risk-reduction intervention for African American men who have sex with men and women

Cultural interventions addressing disparities in the HIV prevention and treatment cascade among Black/African Americans: a scoping review

Culture is an important determinant of HIV risk and protective behaviors; yet, we know little about how it is integrated in HIV interventions. This scoping review characterizes the integration of culture in HIV prevention and treatment interventions focused on Black/African Americans. We searched MEDLINE, PsycINFO, CINAHL, and Google Scholar for peer-reviewed manuscripts published between July 1, 2011, and June 28, 2021. Twenty-five interventions were identified, with 96% focused on prevention. Most (40%) targeted men who have sex with men or transgender women. Only three were grounded in cultural theory. Although all interventions were labeled "culturally based," only two explicitly defined culture. Moreover, there was much diversity regarding the ways in which interventions integrated cultural elements, with some conflating race/ethnicity with culture. To improve uptake and HIV-related outcomes, interventions integrating culture are greatly needed. Additionally, HIV interventions purporting to be "culturally based" must include basic information to support rigor and reproducibility.

Reducing Human Immunodeficiency Virus and Sexually Transmitted Infections Risk in African American Women with At-Risk Male Partners: A Randomized Trial

Background: We examined the efficacy of the Females of African American Legacy Empowering Self (FemAALES) intervention in a cohort of 203 publicly insured Black women in Los Angeles. Materials and Methods: Women who reported recent sex with a male partner who was at increased risk for infection by human immunodeficiency virus (HIV) and sexually transmitted infections (STI) were randomized to the six-session FemAALES intervention or to a single client-centered family planning and STI/HIV counseling session. Participants were followed at 3 and 9 months post-intervention. To investigate between-group behavioral changes in condomless sex in the prior 90 days and other HIV/STI risks, we used generalized estimating equations that accounted for repeated observations in individuals. Results: Most participants (mean age 34 ± 11 standard deviation) were low-income and unemployed, despite three-quarters having completed high school or the equivalent. The most common HIV/STI risk factors among recent male partners were incarceration (58.8%) and concurrent sex with other women (72.2%). At 3 months, the FemAALEs group showed a larger increase in the odds of asking their partner to test (adjusted odds ratio = 2.14; 95% confidence interval [CI], 1.02-4.47; p = 0.0431) and in sexual health self-efficacy scores (adjβ = 1.82; 95% CI, 0.02-3.62; p = 0.0471) compared to the control group, although these changes did not hold at 9 months. Both groups showed statistically significant declines in the frequency of several sexual risk factors between baseline and 9 months. Conclusion: Although we did not find evidence that the FemAALES intervention was more efficacious than the less-intensive control condition in reducing sexual risk behaviors, the overall declines in risk behaviors we observed warrant further research. ClinicalTrials.gov (Identifier: NCT02189876).

Work-in-progress: Focus groups evaluate and inform revisions of a socio-behavioral health intervention

African American men and women are disproportionately impacted by HIV/STI risk. Particularly, African American women are more likely to be infected with HIV from heterosexual sex. Yet, much of the intervention research has focused on men who have sex with men. This article describes the development and feasibility study of a six-session socio-behavioral health intervention that utilized sociodrama to reduce substance use and HIV/STI risk among heterosexual, African American men and women who have multiple sex partners. The intervention was developed based on theories and models of critical consciousness, social scripts, and group work practice. Content and delivery were informed by qualitative data collection with a range of stakeholders including service providers and members of the target population. The resulting intervention was six group sessions, delivered by two licensed social workers, with one of the facilitators trained in sociodrama. The results of the qualitative study explored the feasibility of conducting this six-week intervention and evaluated a trial run of the intervention. The data was obtained through focus group interviews and observations. Findings revealed that the intervention could be delivered with fidelity and was acceptable to participants and indicated that the intervention's innovative components of sociodrama and critical consciousness resonated with the participants and has potential to reduce HIV/STI risk and substance use. Reported barriers and suggested revisions need to be examined further and addressed to develop and implement a sustainable program that can be delivered in community-based settings. A future randomized control trial of the revised intervention will evaluate the intervention's efficacy.

A pilot test of a treatment to address intersectional stigma, mental health, and HIV risk among gay and bisexual men of color

We tested the feasibility and acceptability of a group therapy treatment that addresses the intersecting stigma-related stressors theorized to drive elevated mental health risk, sexual health risk, and their co-occurrence among Black and Latino gay, bisexual, and other men who have sex with men (GBM). First, we modified an existing 10-week, one-on-one, cognitive-behavioral treatment addressing co-occurring health risks among GBM to develop a group-based, intersectionally informed treatment for GBM of color. Then, an open pilot was conducted (n = 21, across two cohorts) with young Black and Latino GBM. An evaluation of feasibility metrics (e.g., eligibility-enrollment ratio, session attendance, rate of retention) supported overall treatment feasibility. Qualitative data suggest high acceptability of the treatment length, format, and content-and revealed a powerful theme: The treatment and group composition led participants to feel less alone as GBM of color. To further evaluate acceptability, baseline and 3-month posttreatment assessments and exit interviews were used to examine the treatment's impact on stigma coping, mental health, and sexual health. Expected changes were found for: (a) stigma coping, as demonstrated by decreases in perceived sexual minority stress, racial minority stress, and intersectional stress; (b) mental health, including depression, anxiety, stress, and suicidality, but not alcohol use; and (c) sexual health, including condom use efficacy, sexual compulsivity, and preexposure prophylaxis uptake; with partial support for decreased in human immunodeficiency virus; HIV-transmission risk acts. This study lays the groundwork for a group treatment to address intersectional stigma, mental health, and HIV risk among young Black and Latino GBM in the U.S. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Measuring Gender Role Conflict, Internalized Stigma, and Racial and Sexual Identity in Behaviorally Bisexual Black Men

Black men who have sex with men and women (BMSMW) experience pressure to fill hypermasculine ideals and may not identify with "gay" cultural norms. Existing measures of gender role expectations and internalized homophobia are not culturally appropriate for BMSMW. Researchers generally measure categorical identification with race, gender, and sexual orientation groups separately, whereas BMSMW may identify with multiple categories. We modified the Gender Role Conflict Scale to create the M-GRCS and the Internalized Homophobia Scale to include biphobia (Internalized Bi/Homophobia Scale, IBHS). To examine identification at the intersection of race, gender, and sexual orientation, we created 11 Integrated Race and Sexuality Scale (IRSS) items. With data from 429 BMSMW, we conducted exploratory factor analysis of the 59 items using categorical principal axis factoring with unweighted least squares extraction and Promax factor rotation. We created simple-summated multi-item scales and evaluated their construct validity. The rotated solution yielded four factors with 47 items and a simple factor structure: M-GRCS defined two factors (α = .93 for restricted emotionality/affection; .87 for success/power/competition); the IBHS (α = .89) and IRSS (α = .74) each defined a single factor. The IRSS factor was positively correlated with the Lukwago Racial Pride Scale, r(417) = .40. The IBHS factor was negatively correlated with the IRSS factor, r(414) = - .22. The two M-GRCS factors suggest that the construct of hypermasculinity impacts BMSMW. The high IBHS reliability indicates that homophobia and biphobia were positively correlated in this sample. These three scales have potential for future studies with BMSMW.

Evidence for neuropsychological health disparities in Black Americans with HIV disease

OBJECTIVE

Black Americans are at high risk for HIV disease and associated morbidity. The impact and clinical correlates of HIV-associated neurocognitive impairment among Black Americans is not fully understood. The current study uses a full factorial design to examine the independent and combined effects of race and HIV disease on neurocognitive functioning, including its associations with everyday functioning and clinical disease markers in Black and White persons with HIV (PWH).

METHOD

Participants included 40 Black PWH, 83 White PWH, 28 Black HIV- and 64 White HIV- individuals. Neurocognition was measured by raw sample-based z-scores from a clinical battery. Everyday functioning was assessed using self- and clinician-rated measures of cognitive symptoms and activities of daily living. HIV-associated neurocognitive disorders were also classified using demographically adjusted normative standards and the Frascati criteria.

RESULTS

We observed a significant three-way interaction between HIV, race, and domain on raw neurocognitive z-scores. This omnibus effect was driven by medium and large effect size decrements in processing speed and semantic memory, respectively, in Black PWH compared to other study groups. Black PWH also demonstrated higher frequencies of HIV-associated neurocognitive disorders as compared to White PWH. Unexpectedly, global neurocognitive performance was negatively related to everyday functioning impairments for White PWH, but not for Black PWH.

CONCLUSIONS

Systemic disadvantages for Black Americans may combine with HIV disease to compound some neurocognitive impairments in this under-served population. Prospective studies are needed to identify better ways to prevent, measure, diagnose, and manage HIV-associated neurocognitive disorders among Black Americans.

Evaluating Locally Developed Interventions to Promote PrEP Among Racially/Ethnically Diverse Transgender Women in the United States: A Unique CDC Initiative

In the United States, transgender women are disproportionately affected by HIV. However, few evidence-based prevention interventions exist for this key population. We describe two promising, locally developed interventions that are currently being implemented and evaluated through the Centers for Disease Control and Prevention Combination HIV Prevention for Transgender Women Project: (a) ChiCAS, designed to promote the uptake of pre-exposure prophylaxis (PrEP), condom use, and medically supervised hormone therapy among Spanish-speaking transgender Latinas, and (b) TransLife Care, designed to address the structural drivers of HIV risk through access to housing, employment, legal services, and medical services, including HIV preventive care (e.g., PrEP use) among racially/ethnically diverse urban transgender women. If the evaluation trials determine that these interventions are effective, they will be among the first such interventions for use with transgender women incorporating PrEP, thereby contributing to the evidence-based resources that may be used to reduce HIV risk among this population.

Evaluating Locally Developed Interventions to Promote PrEP Among Racially/Ethnically Diverse Transgender Women in the United States: A Unique CDC Initiative

In the United States, transgender women are disproportionately affected by HIV. However, few evidence-based prevention interventions exist for this key population. We describe two promising, locally developed interventions that are currently being implemented and evaluated through the Centers for Disease Control and Prevention Combination HIV Prevention for Transgender Women Project: (a) ChiCAS, designed to promote the uptake of pre-exposure prophylaxis (PrEP), condom use, and medically supervised hormone therapy among Spanish-speaking transgender Latinas, and (b) TransLife Care, designed to address the structural drivers of HIV risk through access to housing, employment, legal services, and medical services, including HIV preventive care (e.g., PrEP use) among racially/ethnically diverse urban transgender women. If the evaluation trials determine that these interventions are effective, they will be among the first such interventions for use with transgender women incorporating PrEP, thereby contributing to the evidence-based resources that may be used to reduce HIV risk among this population.

Increasing HIV Testing and Viral Suppression via Stigma Reduction in a Social Networking Mobile Health Intervention Among Black and Latinx Young Men and Transgender Women Who Have Sex With Men (HealthMpowerment): Protocol for a Randomized Controlled Trial

BACKGROUND

Stigma and discrimination related to sexuality, race, ethnicity, and HIV status negatively impact HIV testing, engagement in care, and consistent viral suppression (VS) among young Black and Latinx men who have sex with men and transgender women who have sex with men (YBLMT). Few interventions address the effects of intersectional stigma among youth living with HIV and those at risk for HIV within the same virtual space.

OBJECTIVE

Building on the success of the HealthMpowerment (HMP) mobile health (mHealth) intervention (HMP 1.0) and with the input of a youth advisory board, HMP 2.0 is an app-based intervention that promotes user-generated content and social support to reduce intersectional stigma and improve HIV-related outcomes among YBLMT. The primary objective of this study is to test whether participants randomized to HMP 2.0 report improvement in HIV prevention and care continuum outcomes compared with an information-only control arm. We will also explore whether participant engagement, as measured by paradata (data collected as users interact with an mHealth intervention, eg, time spent using the intervention), mediates stigma- and HIV care-related outcomes. Finally, we will assess whether changes in intersectional stigma and improvements in HIV care continuum outcomes vary across different types of social networks formed within the intervention study arms.

METHODS

We will enroll 1050 YBLMT aged 15 to 29 years affected by HIV across the United States. Using an HIV-status stratified, randomized trial design, participants will be randomly assigned to 1 of the 3 app-based conditions (information-only app-based control arm, a researcher-created network arm of HMP 2.0, or a peer-referred network arm of HMP 2.0). Behavioral assessments will occur at baseline, 3, 6, 9, and 12 months. For participants living with HIV, self-collected biomarkers (viral load) are scheduled for baseline, 6, and 12 months. For HIV-negative participants, up to 3 HIV self-testing kits will be available during the study period.

RESULTS

Research activities began in September 2018 and are ongoing. The University of Pennsylvania is the central institutional review board for this study (protocol #829805) with institutional reliance agreements with the University of North Carolina at Chapel Hill, Duke University, and SUNY Downstate Health Sciences University. Study recruitment began on July 20, 2020. A total of 205 participants have been enrolled as of November 20, 2020.

CONCLUSIONS

Among a large sample of US-based YBLMT, this study will assess whether HMP 2.0, an app-based intervention designed to ameliorate stigma and its negative sequelae, can increase routine HIV testing among HIV-negative participants and consistent VS among participants living with HIV. If efficacious and brought to scale, this intervention has the potential to significantly impact the disproportionate burden of HIV among YBLMT in the United States.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03678181; https://clinicaltrials.gov/ct2/show/study/NCT03678181.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/24043.

Development of a Black Caucus within the HIV Prevention Trials Network (HPTN): Representing the Perspectives of Black Men Who Have Sex with Men (MSM)

Black men who have sex with men (MSM) have disproportionate HIV disease burden in the United States. Black MSM have been underrepresented in biomedical research, including HIV clinical trials, due to a myriad of socio-structural, socio-cultural, and psychosocial factors. The HIV Prevention Trials Network (HPTN) 061, a feasibility study of a multi-component HIV prevention intervention for Black MSM in six US cities, incorporated the development and implementation of a Black Caucus as a culturally grounded model for the integration of Black MSM in clinical trials and research in HPTN. Based on a qualitative methodological approach, we describe the formation and implementation of the Black Caucus from the perspective of Black MSM key community stakeholders. Three major themes emerged from the qualitative narratives: (1) the role of the Black Caucus in shaping the HPTN, (2) how the Black Caucus addresses the needs of Black MSM communities pertaining to the influence of race and sexual identity, and (3) socio-cultural needs of Black MSM. These findings have implications for the provision of culturally congruent expertise, community engagement, cultural mistrust, recruitment and retention of Black MSM in HIV clinical trials, culturally-relevant study design and implementation, and the role of developing Black MSM prevention researchers.

Meeting the Sexual Health Needs of Bisexual Men in the Age of Biomedical HIV Prevention: Gaps and Priorities

The field of HIV/STI prevention has primarily focused on gay men (or "men who have sex with men" [MSM] as a broad category) with limited attention to bisexual men in particular. Although bisexual men are also at increased risk for HIV and other STI, they are less likely to utilize HIV/STI prevention services than gay men, and very few interventions have been developed to address their unique needs. Further, while biomedical advances are changing the field of HIV prevention, bisexual men are also less likely to use biomedical HIV prevention strategies (e.g., pre-exposure prophylaxis [PrEP]) than gay men. In an effort to advance research on bisexual men and their sexual health needs, the goals of this commentary are: (1) to review the empirical literature on the prevalence of HIV/STI among bisexual men, the few existing HIV/STI prevention interventions developed for bisexual men, and the use of biomedical HIV prevention among bisexual men; (2) to describe the ways in which the field of HIV/STI prevention has largely overlooked bisexual men as a population in need of targeted services; and (3) to discuss how researchers can better address the sexual health needs of bisexual men in the age of biomedical HIV prevention.

Meeting the Sexual Health Needs of Bisexual Men in the Age of Biomedical HIV Prevention: Gaps and Priorities

The field of HIV/STI prevention has primarily focused on gay men (or "men who have sex with men" [MSM] as a broad category) with limited attention to bisexual men in particular. Although bisexual men are also at increased risk for HIV and other STI, they are less likely to utilize HIV/STI prevention services than gay men, and very few interventions have been developed to address their unique needs. Further, while biomedical advances are changing the field of HIV prevention, bisexual men are also less likely to use biomedical HIV prevention strategies (e.g., pre-exposure prophylaxis [PrEP]) than gay men. In an effort to advance research on bisexual men and their sexual health needs, the goals of this commentary are: (1) to review the empirical literature on the prevalence of HIV/STI among bisexual men, the few existing HIV/STI prevention interventions developed for bisexual men, and the use of biomedical HIV prevention among bisexual men; (2) to describe the ways in which the field of HIV/STI prevention has largely overlooked bisexual men as a population in need of targeted services; and (3) to discuss how researchers can better address the sexual health needs of bisexual men in the age of biomedical HIV prevention.

HIV and Sexuality Stigma Reduction Through Engagement in Online Forums: Results from the HealthMPowerment Intervention

HIV and sexuality stigma impede HIV prevention and care efforts. HealthMpowerment.org (HMP) is an interactive mobile phone- and web-based HIV prevention and care intervention for young Black men who have sex with men (YBMSM; ages 18-30) in the United States. HMP included three forums where participants could share their experiences. In this study, we explored whether engaging in stigma-related discussions was associated with changes in YBMSM's stigma-related scores throughout the trial. YBMSM (ages 18-30; N = 238) participating in HMP completed surveys at baseline, and 3 and 6 month follow-ups that included a series of scales focused on HIV and sexuality (internalized homophobia; sexual prejudice) stigma. Sixty-two participants contributed to the forums (1497 posts). We coded instances where YBMSM's conversations were stigma related (915 posts, 61.1%), including discussions of anticipated (74/915, 8.1%), experienced (125/915, 13.7%), internalized (410/915, 44.8%), and/or challenged (639/915, 69.8%) stigma regarding sexuality and HIV. Using a mixed methods approach, we examined whether changes in YBMSM's stigma scores were associated with stigma-related discussions within the forum. We controlled for age, HIV status, income, and educational attainment in these multivariable models. YBMSM who discussed experiencing HIV stigma in the forums reported decreases in perceived HIV stigma over time (b = - 0.37, p ≤ 0.05). YBMSM whose forum posts indicated anticipated HIV stigma reported increases in HIV stigma over time (b = 0.46, p ≤ 0.01). Participants who challenged sexuality-related stigma in forums had lower internalized homophobia (b = - 0.68, p ≤ 0.01) at baseline. YBMSM whose discussions focused on experiencing sexuality-related stigma reported increases in internalized homophobia (b = 0.39, p ≤ 0.01) and sexual prejudice (b = 0.87, p ≤ 0.05) over time. Developing strategies to combat stigma remains a key priority. HMP created an online space where YBMSM could discuss HIV and sexuality stigma. Although a limited number of HMP participants authored the majority of these forum discussions, the discussions were associated with changes in the sample's stigma scores over time. Online interventions (e.g., social media, apps) should consider the inclusion of forums to address stigma and test the efficacy of forums to improve YBMSM's HIV prevention and care continuum outcomes.

Pre-exposure prophylaxis initiation and adherence among Black men who have sex with men (MSM) in three US cities: results from the HPTN 073 study

INTRODUCTION

Randomized clinical trials have demonstrated the efficacy of antiretroviral pre-exposure prophylaxis (PrEP) in preventing HIV acquisition among men who have sex with men (MSM). However, limited research has examined initiation and adherence to PrEP among Black MSM (BMSM) in the United States (US) who are disproportionately represented among newly HIV infected and late to care individuals. This research reports on the HIV Prevention Trials Network 073 (HPTN 073) study aimed to examine PrEP initiation, utilization and adherence among Black MSM utilizing the theoretically principled, culturally informed and client-centered care coordination (C4) model.

METHODS

The HPTN 073 study enrolled and followed 226 HIV-uninfected Black MSM in three US cities (Los Angeles, CA; Washington DC; and Chapel Hill, NC) from February 2013 through September 2015. Study participants were offered once daily oral emtricitabine/tenofovir (FTC/TDF) PrEP combined with C4 and followed up for 52 weeks. Participants received HIV testing, risk reduction education and clinical monitoring.

RESULTS

Of the 226 men enrolled, 178 participants initiated PrEP (79%), and of these 64% demonstrated PrEP utilization at week 26 (mid-point of the study) based on pharmacokinetic testing. Condomless anal sex with an HIV-infected or unknown status casual male partner was statistically significantly associated with a greater likelihood of PrEP initiation (adjusted odds ratio (OR) 4.4, 95% confidence interval (CI) 1.7, 11.7). Greater age (≥25 vs. <25, OR 2.95, 95% CI 1.37 -6.37), perception of having enough money (OR 3.6, 95% CI 1.7 to 7.7) and knowledge of male partner taking PrEP before sex (OR 2.22, 95% CI 1.03 to 4.79) were statistically significantly associated with increased likelihood of PrEP adherence at week 26. Annualized HIV incidence was 2.9 (95% CI 1.2 to 7.9) among those who initiated PrEP, compared to 7.7 (95% CI 2.5 to 24.1) among those who did not initiate PrEP (p = 0.18).

CONCLUSIONS

Results suggest a high level of PrEP initiation among at-risk Black MSM, a group historically characterized as hard to reach. The data support the importance of addressing contextual factors that affect PrEP initiation and adherence, and of additional research on the ultimate benefit of PrEP in HIV prevention among Black MSM.

Latent Classes of Sexual Risk Among Black Men Who Have Sex with Men and Women

Black men who have sex with men and women (BMSMW) are at high risk for HIV and other sexually transmitted infections (STIs). Despite knowing that HIV/STI risk varies by sexual positioning practices, limited data have characterized the risk profiles of BSMW. This study utilized latent class analysis (LCA) to explore BMSMW's sexual risk profiles regarding condomless sexual positioning practices. Participants were BMSMW in intervention studies in Los Angeles, Chicago, and Philadelphia. LCA was used to characterize their sexual risk profiles. Age, study location, HIV status, social support, and internalized homophobia were used as covariates in a multinomial regression model predicting the likelihood of class membership. Among the 546 participants, three latent classes of risk were identified: Seropositive Serosorters, Seronegative/unknown Serosorters, and Main Partners Only. All groups had the greatest probabilities of condomless sex with main partners. Seropositive Serosorters had the highest probabilities of condomless sex with HIV-positive partners. Seronegative/unknown Serosorters had the highest probabilities of condomless sex with HIV-negative or unknown status partners. HIV-positive BMSMW had 87% lower odds of being classified as Seronegative/unknown Serosorters than Seropositive Serosorters than HIV-negative/unknown status BMSMW (AOR = 0.13, 95% CI 0.06, 0.28). HIV-positive BMSMW had 71% lower odds of being classified as Main Partners Only than Seropositive Serosorters than HIV-negative/unknown status BMSMW (AOR = 0.29, 95% CI 0.16, 0.51). Findings highlight opportunities for clinicians to promote condom use and risk reduction among BMSMW with differing sexual risk profiles. Increased understanding of sexual positioning practices among BMSMW might help address HIV/STIs among this group.

Addressing HIV in Zambia through traditional games

There has been a proliferation of organizations in Zambia touting the mobilization of traditional games as a tool to prevent HIV. However, there is a dearth of evidence on how culturally important activities like traditional games are being incorporated into programing. The purpose of this study was to explore how traditional games are used as a strategy to prevent HIV in Zambia. This qualitative study generated data from 17 case studies of HIV programs operating in Lusaka, Zambia. Observations of the programs were conducted and 44 interviews with program staff were completed. Participants believed that traditional games can engage youth while helping them learn about HIV. However, when traditional games were implemented, they were oversimplified and taught via regimented practices that did not foster critical thinking. This kind of implementation comes at the expense of the development of skills needed to retain and act on information essential for HIV prevention. The results of the study also reveal that due to the increase in cultural pride that has welcomed the revival of traditional games, there are opportunities to encourage government and political support for their systematic integration to address HIV in Zambia.

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.

HIV Acquisition and Transmission Potential Among African American Men Who Have Sex with Men and Women in Three U.S. Cities

Black men who have sex with men and women (BMSMW) are at increased HIV risk, but few efficacious interventions meet their unique needs. Three HIV prevention interventions were evaluated with a common protocol. Baseline data were pooled to describe sexual behavior involving transmission risk with male, female, and male-to-female transgender partners and identify factors associated with transmission risk. BMSMW from Los Angeles, Philadelphia, and Chicago who reported sexual risk and bisexual behavior in the past year were recruited via modified chain referral sampling and community recruitment. Baseline assessments were conducted via audio computer-assisted interview and sexual behaviors assessed over the past 3 months. From December 2010 to November 2012, 584 BMSMW were enrolled across the three cities. More than half (55%) were recruited by other participants. Overall, the mean age was 43 years. Seventy-five percent reported an annual income <$10,000 and selling sex was prevalent (31%). Three-quarters identified as bisexual. Thirty-nine percent were HIV-positive. Among HIV-positive participants, 46% reported sex without condoms with HIV-negative or unknown male partners and 45% with HIV-negative or unknown female partners. Overall, factors associated with sex without condoms included network size, education, income, sexual orientation identification, HIV status, exchange sex, homonegativity, and social support. Findings support the need for enhanced HIV prevention efforts for this population. Future studies should examine contextual factors in addition to individual risk behaviors to inform the development and implementation of promising strategies to prevent HIV and promote the overall health and wellness of BMSMW and their sexual partners.

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.

Effects of a Laboratory Health Information Exchange Intervention on Antiretroviral Therapy Use, Viral Suppression, and Racial/Ethnic Disparities

BACKGROUND

Although antiretroviral therapy (ART) is available to treat HIV+ persons and prevent transmission, ineffective delivery of care may delay ART use, impede viral suppression (VS), and contribute to racial/ethnic disparities along the continuum of care. This study tested the effects of a bi-directional laboratory health information exchange (LHIE) intervention on each of these outcomes.

METHODS

We used a quasi-experimental, interrupted time-series design to examine whether the LHIE intervention improved ART use and VS, and reduced racial/ethnic disparities in these outcomes among HIV+ patients (N = 1181) in a comprehensive HIV/AIDS clinic in Southern California. Main outcome measures were ART pharmacy fill and HIV viral load laboratory data extracted from the medical records over 3 years. Race/ethnicity and an indicator for the intervention (after vs. before) were the main predictors. The analysis involved 3-stage, multivariable logistic regression with generalized estimating equations.

RESULTS

Overall, the intervention predicted greater odds of ART use (odds ratio [OR] = 2.50; 95% confidence interval: 2.29 to 2.73; P < 0.001) and VS (OR = 1.12; 95% confidence interval: 1.04 to 1.21; P < 0.05) in the final models that included sociodemographic, behavioral, and clinical covariates. Before the intervention, there were significant black/white disparities in ART use OR = 0.75 (0.58-0.98; P = 0.04) and VS OR = 0.75 (0.61-0.92; P = 0.001). After the intervention, the black/white disparities decreased after adjusting for sociodemographics and the number of HIV care visits, and Latinos had greater odds than whites of ART use and VS, adjusting for covariates.

CONCLUSIONS

The intervention improved overall ART treatment and VS, and reduced black/white disparities. LHIE interventions may hold promise if implemented among similar patients.

Selection and Evaluation of Media for Behavioral Health Interventions Employing Critical Media Analysis

Although a growing number of psychosocial health promotion interventions use the critical analysis of media to facilitate behavior change, no specific guidelines exist to assist researchers and practitioners in the selection and evaluation of culturally relevant media stimuli for intervention development. Mobilizing Our Voices for Empowerment is a critical consciousness-based health enhancement intervention for HIV-positive Black young gay/bisexual men that employs the critical analysis of popular media. In the process of developing and testing this intervention, feedback on media stimuli was collected from youth advisory board members (n = 8), focus group participants (n = 19), intervention participants (n = 40), and intervention facilitators (n = 6). A thematic analysis of qualitative data resulted in the identification of four key attributes of media stimuli and participants' responses to media stimuli that are important to consider when selecting and evaluating media stimuli for use in behavioral health interventions employing the critical analysis of media: comprehension, relevance, emotionality, and action. These four attributes are defined and presented as a framework for evaluating media, and adaptable tools are provided based on this framework to guide researchers and practitioners in the selection and evaluation of media for similar interventions.

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).

Adaptation of a Couple-Based HIV/STI Prevention Intervention for Latino Men Who Have Sex With Men in New York City

Predominantly Spanish-speaking Latino men who have sex with men (MSM) and their same-sex partners continue to be at high risk for HIV and STIs. Behavioral research has identified how relationship dynamics for male couples are associated with sexual risk behavior. Connect 'n Unite (CNU), an evidence-based HIV/STI prevention intervention originally created for Black MSM and their same-sex partners, was adapted for predominantly Spanish-speaking Latino MSM and their same-sex partners on the assumption that its key elements would be translatable while its efficacy would be retained. A systematic adaptation process utilizing qualitative methods was used, including intervention adaptation sessions with 20 predominantly Spanish-speaking Latino gay couples and 10 health service providers. The process included five steps: (1) engaging community stakeholders, (2) capturing the lived experiences of Latino gay couples, (3) identifying intervention priorities, (4) integrating the original intervention's social cognitive theory into a relationship-oriented, ecological framework for Latino gay couples, and (5) adapting intervention activities and materials. The adapted intervention, which we called Latinos en Pareja or Latinos in a Relationship, incorporates elements that effective HIV prevention interventions share, including: a solid theoretical foundation; emphasis on increasing risk reduction norms, sexual communication skills and social support for protection; and guidance on how to utilize available, culturally and linguistically appropriate services. The systematic adaptation approach used for a couples-based HIV prevention intervention also can be employed by other researchers and community stakeholders to adapt evidence-based interventions that promote wellness, linkage to care, and disease prevention for populations not originally targeted.

Childhood Exposure to Religions With High Prevalence of Members Who Discourage Homosexuality Is Associated With Adult HIV Risk Behaviors and HIV Infection in Black Men Who Have Sex With Men

Exposure to childhood religious affiliations where the majority of members discourage homosexuality may have negative psychological impacts for Black men who have sex with men. This study tested the hypothesis that exposures to these environments during childhood were associated with adulthood human immunodeficiency virus (HIV)/sexually transmitted infection (STI) behavioral risk and HIV infection, because these exposures influenced HIV/STI risk by undermining race/sexual identity congruence and increasing internalized homophobia and interpersonal anxiety. Structural equation modeling as well as logistic and Poisson regressions were performed using baseline data from HIV Prevention Trials Network 061 ( N = 1,553). Childhood religion affiliations that were more discouraging of homosexuality were associated with increased likelihood of HIV infection; however, the association was no longer significant after adjusting for age, income, and education. Having a childhood religion affiliation with high prevalence of beliefs discouraging homosexuality was associated with increased numbers of sexual partners (adjusted odds ratio = 4.31; 95% confidence interval [3.76, 4.94], p < .01). The hypothesized path model was largely supported and accounted for 37% of the variance in HIV infection; however, interpersonal anxiety was not associated with HIV/STI risk behaviors. Structural interventions are needed that focus on developing affirming theologies in religious institutions with Black men who have sex with men congregants.

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.

Beyond the bisexual bridge: sexual health among U.S. men who have sex with men and women

CONTEXT

Men who have sex with both men and women (MSMW) experience health problems in ways that distinguish them from men who only have sex with men (MSM) and men who only have sex with women (MSW). Historically, an undue focus on MSMW's potential role in transmitting HIV to women has resulted in limited understanding of these men's unique sexual health needs. This article discusses the sexual health of MSMW in the U.S.

EVIDENCE ACQUISITION

The author searched PubMed, Sociological Abstracts, PsycINFO, and GoogleScholar to acquire peer-reviewed studies pertaining to MSMW that were published during January 2008 and December 2013. Reference lists for these studies provided additional studies not acquired through this search.

EVIDENCE SYNTHESIS

MSMW are more likely than MSW to be infected with HIV. MSMW may be at increased risk for some other sexually transmitted infections (STIs) compared with both MSW and MSM. Some factors that affect their sexual health include unprotected sex, early sexual debut, forced sexual encounters, increased numbers of sexual partners, substance use, exchange sex, risk behaviors of their male and female partners, and pregnancy-related considerations. These factors uniquely shape MSMW's vulnerability to HIV/STIs and other sexual health problems. Anti-bisexual sentiment, socioeconomic marginalization, culturally specific masculine ideologies, and sexual identity can negatively influence their sexual partnerships and likelihood of disease acquisition.

CONCLUSIONS

Risk-reduction interventions alone are likely insufficient to improve MSMW's sexual health. Efforts should also address the social contexts affecting MSMW in order to decrease HIV/STI vulnerability and mitigate other barriers to MSMW's sexual health.

Concomitant socioeconomic, behavioral, and biological factors associated with the disproportionate HIV infection burden among Black men who have sex with men in 6 U.S. cities

BACKGROUND

American Black men who have sex with men (MSM) are disproportionately affected by HIV, but the factors associated with this concentrated epidemic are not fully understood.

METHODS

Black MSM were enrolled in 6 US cities to evaluate a multi-component prevention intervention, with the current analysis focusing on the correlates of being newly diagnosed with HIV compared to being HIV-uninfected or previously diagnosed with HIV.

RESULTS

HPTN 061 enrolled 1553 Black MSM whose median age was 40; 30% self-identified exclusively as gay or homosexual, 29% exclusively as bisexual, and 3% as transgender. About 1/6(th) (16.2%) were previously diagnosed with HIV (PD); of 1263 participants without a prior HIV diagnosis 7.6% were newly diagnosed (ND). Compared to PD, ND Black MSM were younger (p<0.001); less likely to be living with a primary partner (p<0.001); more likely to be diagnosed with syphilis (p<0.001), rectal gonorrhea (p = 0.011) or chlamydia (p = 0.020). Compared to HIV-uninfected Black MSM, ND were more likely to report unprotected receptive anal intercourse (URAI) with a male partner in the last 6 months (p<0.001); and to be diagnosed with syphilis (p<0.001), rectal gonorrhea (p = 0.004), and urethral (p = 0.025) or rectal chlamydia (p<0.001). They were less likely to report female (p = 0.002) or transgender partners (p = 0.018). Multivariate logistic regression analyses found that ND Black MSM were significantly more likely than HIV-uninfected peers to be unemployed; have STIs, and engage in URAI. Almost half the men in each group were poor, had depressive symptoms, and expressed internalized homophobia.

CONCLUSIONS

ND HIV-infected Black MSM were more likely to be unemployed, have bacterial STIs and engage in URAI than other Black MSM. Culturally-tailored programs that address economic disenfranchisement, increase engagement in care, screen for STIs, in conjunction with safer sex prevention interventions, may help to decrease further transmission in this heavily affected community.

Feasibility, acceptability, and preliminary efficacy of an online HIV prevention program for diverse young men who have sex with men: the keep it up! intervention

Young men who have sex with men (YMSM) are disproportionately infected with HIV/AIDS and there are few prevention programs with published efficacy for this population. This study evaluated the feasibility, acceptability, and preliminary efficacy of an online, interactive, and highly engaging HIV prevention program called Keep It Up! The intervention was designed to be delivered to diverse YMSM upon receiving an HIV negative text result, with the goal for them to "Keep It Up" and stay negative. In a randomized clinical trial, the intervention was compared to an online didactic HIV knowledge condition. The study sample included 102 sexually active YMSM. Participants reported completing online modules in settings that were private and not distracting. Mixed methods data showed intervention participants felt the program was valuable and acceptable. Compared to the control condition, participants in the intervention arm had a 44 % lower rate of unprotected anal sex acts at the 12-week follow-up (p < 0.05).

Efficacy of a culturally congruent HIV risk-reduction intervention for behaviorally bisexual black men: results of a randomized trial

OBJECTIVES

Black men who have sex with men and women (MSMW) experience high HIV rates and may not respond to interventions targeting gay-identified men. We tested the efficacy of the Men of African American Legacy Empowering Self (MAALES), a multisession, small-group holistically framed intervention designed to build skills, address sociocultural issues, and reduce risk behaviors in black MSMW.

DESIGN

From 2007 to 2011, we enrolled 437 black MSMW into a parallel randomized controlled trial that compared MAALES to the control condition, a single, individualized HIV risk-reduction session.

METHODS

Participants completed surveys at baseline, 3 months, and 6 months postintervention. We used multiple regressions to compare risk behaviors at follow-up between the intervention and control groups while adjusting for baseline risk behaviors, time between assessments, other covariates, and clustering. We used inverse probability weighting (IPW) to adjust for loss-to-follow-up while carrying out these regressions with the 291 (76.4%) randomized participants who completed at least one follow-up.

RESULTS

Participants were largely low-income (55% reported monthly incomes <$1000); nearly half had previously tested HIV positive. At 6 months of follow-up, unadjusted within-group analyses demonstrated reduced risk behaviors for the MAALES but not the control group. Adjusted results indicated significant intervention-associated reductions in the numbers of total anal or vaginal sex acts [risk ratio = 0.61; 95% confidence interval (CI) 0.49–0.76], unprotected sex acts with women (risk ratio = 0.50; 95% CI 0.37–0.66), and female partners (risk ratio = 0.56; 95% CI 0.44–0.72). Near significant reductions were observed for number of male intercourse partners.

CONCLUSION

The MAALES intervention was efficacious at reducing HIV risk behaviors in black MSMW.

A systematic review of HIV interventions for black men who have sex with men (MSM)

Background

Black men who have sex with men (MSM) are disproportionately burdened by HIV/AIDS. Despite this burden there has been a shortage of research on HIV interventions for black MSM. This article provides a comprehensive review of the literature on interventions for black MSM to identify effective HIV prevention intervention strategies for black MSM.

Methods

We searched 3 databases: Pubmed, Scopus, and Google Scholar to identify peer-reviewed articles and used the following search terms: African American or black; MSM or men who have sex with men and women (MSMW); HIV; program or intervention; and evaluation or intervention science or implementation research. We included research articles that assessed interventions for black men who have sex with men. We included studies that used an experimental, quasi-experimental, or pre-post test design as well as formative research studies. We also searched the CDC and NIH websites to identify planned and on-going intervention studies. We identified a total of 23 studies to include in the review.

Results

We identified 12 completed studies of interventions for black MSM. Eight of these 12 interventions aimed to reduce HIV risk behaviors and 5 found a significant reduction in HIV risk behavior over time. We identified 4 health service intervention studies for young black MSM.

Conclusions

Behavior change interventions are effective at reducing HIV risk behaviors among black MSM. However, relying only on behavioral interventions that aim to reduce HIV risk behavior will most likely not have a population-level effect on HIV infection among black MSM. There is a compelling and urgent need to develop and test comprehensive HIV testing, linkage to care, retention in care and adherence interventions for black MSM.

Counseling to reduce high-risk sexual behavior in HIV care: a multi-center, direct observation study

A key opportunity to reduce HIV transmission lies with healthcare providers counseling HIV-infected patients about safer sex. We audio-recorded and transcribed clinical encounters between 45 healthcare providers and 417 of their HIV-infected patients at four outpatient sites in the United States. We used logistic regressions to evaluate associations between patient and provider characteristics, and the occurrence of discussion (any talk about sex) and counseling (advice about safer sex). Of the 417 encounters, discussion of sex occurred in 187 (45% of encounters, 95% CI: 40-50%). Counseling occurred for 49% (95% CI: 35-63%) of patients reporting unsafe sex. Discussion of sex was more likely with younger or less-educated patients and with less cultural difference between patient and provider, while counseling was associated with greater provider mindfulness and lower provider empathy. These findings suggest targets to improve communication regarding sexual risk reduction in HIV care.

Gender role conflict among African American men who have sex with men and women: associations with mental health and sexual risk and disclosure behaviors

OBJECTIVES

We investigated whether high gender role conflict (GRC; internal conflict with traditional gender-role stereotypes and an individual's perceived need to comply with these roles) is associated with psychological distress and HIV-related risk behaviors in a sample of African American men who have sex with men and women (MSMW).

METHODS

We analyzed baseline data collected from questionnaires completed by 400 MSMW participating in the Men of African American Legacy Empowering Self project in Los Angeles, California, in 2007 to 2010 for associations between participants' GRC and experiences of poor mental health and HIV risk outcomes.

RESULTS

MSMW who reported higher levels of GRC than other participants also reported more psychological distress, lower self-esteem, greater internalized homophobia, less HIV knowledge, lower risk reduction skills, less disclosure of same-sex behaviors to others, and more unprotected vaginal or anal intercourse with female partners.

CONCLUSIONS

Future research should consider how high GRC affects African American MSMW's lives and identify specific approaches to help alleviate the psychological distress and other negative behavioral outcomes associated with internal conflict caused by rigid gender role socialization.

Straight talk: HIV prevention for African-American heterosexual men: theoretical bases and intervention design

In the United States, racial disparities in HIV/AIDS are stark. Although African Americans comprise an estimated 14% of the U.S. population, they made up 52% of new HIV cases among adults and adolescents diagnosed in 2009. Heterosexual transmission is now the second leading cause of HIV in the United States. African Americans made up a full two-thirds of all heterosexually acquired HIV/AIDS cases between 2005 and 2008. Few demonstrated efficacious HIV prevention interventions designed specifically for adult, African-American heterosexual men exist. Here, we describe the process used to design a theory-based HIV prevention intervention to increase condom use, reduce concurrent partnering, and increase HIV testing among heterosexually active African-American men living in high HIV prevalence areas of New York City. The intervention integrated empowerment, social identity, and rational choices theories and focused on four major content areas: HIV/AIDS testing and education; condom skills training; key relational and behavioral turning points; and masculinity and fatherhood.

A randomized controlled trial of a culturally congruent intervention to increase condom use and HIV testing among heterosexually active immigrant Latino men

This randomized controlled trial tested the efficacy of an HIV prevention intervention to increase condom use and HIV testing among Spanish-speaking, heterosexually active immigrant Latino men. A community-based participatory research partnership developed the intervention and selected the study design. Following baseline data collection, 142 immigrant Latino men were randomized to the HIV prevention intervention or the cancer education intervention. Three-month follow-up data were collected from 139 participants, for a 98% retention rate. Mean age of participants was 31.6 years and 60% reported being from Mexico. Adjusting for baseline behaviors, relative to their peers in the cancer education comparison, participants in the HIV prevention intervention were more likely to report consistent condom use and receiving an HIV test. Community-based interventions for immigrant Latino men that are built on state of the art prevention science and developed in partnership with community members can greatly enhance preventive behaviors and may reduce HIV infection.

Secondary prevention of HIV in the United States: past, current, and future perspectives

To provide a synopsis of past, current, and potential next-generation approaches to prevention for positives (PfP) interventions in the United States. For a variety of reasons, PfP interventions, with the goals of limiting HIV transmission from people living with HIV/AIDS (PLWHA) to others and protecting the health of PLWHA, did not appear with any frequency in the United States until about 2000. Even today, the number and breadth of evidence-based PfP interventions is very limited. Nevertheless, meta-analytic evidence demonstrates that such interventions can be effective, perhaps even more so than interventions targeting HIV-uninfected individuals. We review early and more recent PfP interventions and suggest that next-generation PfP interventions must involve behavioral and biologic components and target any element that affects HIV risk behavior and/or infectivity. Next-generation PfP interventions should include increased HIV testing to identify additional PLWHA, components to initiate and maintain HIV care, to initiate antiretroviral therapy and promote adherence, and to reduce sexual and injection drug use risk behavior, as well as ancillary treatments and referrals to services. Comprehensive next-generation PfP interventions, including all of these elements and effective linkages among them, are discussed.

The four Cs of HIV prevention with African Americans: crisis, condoms, culture, and community

HIV/AIDS continues to be a devastating epidemic with African American communities carrying the brunt of the impact. Despite extensive biobehavioral research, current strategies have not resulted in significantly decreasing HIV/AIDS cases among African Americans. The next generation of HIV prevention and risk reduction interventions must move beyond basic sex education and condom use and availability. Successful interventions targeting African Americans must optimize strategies that integrate socio-cultural factors and address institutional and historical barriers that hinder or support HIV risk reduction behaviors. Community-based participatory research to decrease the HIV/AIDS disparity by building community capacity and infrastructure and advocating for and distributing equitably, power and resources, must be promoted. Recommendations for paradigm shifts in using innovative theories and conceptual frameworks and for training researchers, clinicians, grant and journal reviewers, and community members are made so that culturally congruent interventions may be tested and implemented at the community level.

HIV/AIDS disparities: the mounting epidemic plaguing US blacks

The human immunodeficiency virus (HIV)/AIDS epidemic presents a formidable challenge for the black community. Blacks, although a small proportion of the US population, are overrepresented, not only in the number of people living with HIV, but also in the categories of new diagnoses and AIDS-related deaths. Fortunately, national initiatives are in place to slow and ultimately reverse these racial inequities. While these disparities may be widely recognized, their causes are not clearly understood. A variety of underlying issues exist for blacks in the United States that may also contribute to these growing disparities. These include transmission risk factors, socioeconomic factors, underrecognition, delayed presentation, and other comorbid conditions. We present a review of the literature regarding the potential causes of racial disparities and how they may contribute to health outcomes for blacks with HIV/AIDS in the United States. We also identify possible gaps in knowledge and offer future directions for research of HIV/AIDS racial disparities.