Latinos and HIV/AIDS: Deconstructing Risk Factors, Cultural Norms, and Resiliency

1. Latinos and HIV/AIDS: Deconstructing Risk Factors, Cultural Norms, and Resiliency Creciendo Juntos HIV/AIDS Services Group Virginia HIV/AIDS Resource Consultation Group Thursday, November 13, 2008 Charlottesville, VA

2. Introductions Objectives Epidemiologic profile and survey data Analyzing risk factors Cultural norms that oppress Structural racism as a barrier to HIV prevention Resiliency for change Community organizing for health justice PRESENTATION OUTLINE

3. LEARNING OBJECTIVES • Upon completion of the session, participants will be able to: • Identify trends for HIV/AIDS rates within the Latino community. • Understand risk taking behavior identified at a local level. • Determine the extent that culture, context, structural barriers and resiliency impact risk taking behavior. • Discuss what can be organized locally.

4. NATIONAL TRENDS

5. HIV/AIDS EPIDEMIC • Although Latinos/as represent approximately 15% of the US population, they account for 19% of the AIDS cases diagnosed in 2006 (CDC). • Latinos account for 17% of new HIV infections (9,700 of 56,300 total new infections). • Among women, Latinas account for 16% of new HIV infections and their HIV incidence rate is nearly four times the rate for white women (CDC, 2008).

6. HIV/AIDS EPIDEMIC • HIV was the sixth leading cause of death for Latinos ages 25-44 in 2006. • In 2006, 54 percent of Latinos reported having been tested for HIV, higher than the overall population (45%) (Kaiser, 2006). • Latinos born in the US account for 34% of estimated AIDS cases among Latinos in 2006, followed by Latinos born in Puerto Rico (17%) and Mexico (17%) (CDC, 2008).

7. HIV/AIDS TRENDS • Estimated AIDS prevalence among Latinos is clustered in a handful of states, with ten states accounting for 90 percent of Latinos estimated to be living with AIDS. • During the early 1990s, important new advances were made in the treatment of the HIV disease . The number of new AIDS cases and deaths declined among all racial groups, but not at the same rate.

8. HIV/AIDS TRENDS • AIDS cases among Latinos declined by 56 percent between 1993 and 2001, compared to a 73 percent decline among whites. • Estimated deaths among Latinos with AIDS declined by 63 percent between 1993 and 2001 compared to an 80 percent drop for whites.

9. HIV/AIDS TRENDS • Studies indicate that Latinos may be more likely to be tested for HIV late in their illness-that is, to be diagnosed with AIDS at the time of their first HIV test or to develop AIDS within one year of testing positive (42%). • Nearly a quarter of Latinos named HIV as the most urgent health problem facing the nation and many believe (39%) that the US is making progress against the epidemic (Kaiser, 2006).

10. HIV/AIDS TRENDS • Of those who self-identified as HIV positive, nearly half were unconnected to medical care. • Four main reasons given for not receiving medical care, regardless of HIV status, were they can’t afford care (27%), they do not need medical services (17%), they can’t get transportation (6%), and not knowing where to go (5%). (HCSUS, 2000). • Latinos with HIV/AIDS more likely to be uninsured or be publicly insured (50% on Medicaid).

11. HIV/AIDS EpidemiologicProfile Conclusions • Diagnosed AIDS cases by year show a decreasing trend for the last eight years. • The number of newly diagnosed HIV/AIDS cases stayed the same for the last four years. • There is still a significant disparity among ethnic groups related to class, access to health care, and testing practices. • Women are playing a more important role in the profile, although men still lead the epidemic.

12. LOCAL EPIDEMIC

13. RURAL REALITY:A CASE STUDY IN VIRGINIA • The Latino population tripled between 1990 and 2006. • Latinos represent 6% of the population but 8% of the HIV/AIDS cases. • The rate of AIDS diagnosis was higher (30 in 100,000) than the national average (24 in 100,000). • Sixty-two percent of the reported HIV/AIDS Latino cases are in Northern Virginia (VDH, 2006).

14. VCU STUDY • Between 1999 to 2000, the Survey and Evaluation Research Laboratory conducted a study on HIV and AIDS with Latino men in rural areas of Virginia on behalf of the HIV Community Planning Committee. • Collection of data occurred over 18 months with 291 Latino MSM living in rural areas. Research team: S.L. Jarama, D. Kennamer, J. Honnold, S. Kennedy, and J. Bradford.

15. VCU STUDY • Most Latino MSM (85%) had at least graduated from high school. About 30 percent had attended some college. • Despite the fairly high educational level of this group, about half the sample earned less than $1,500 per month. • About 77 percent of the sample had been tested.

16. VCU STUDY • Most Latino gay men who came out to a parent experienced a negative reaction from their mother (60%) and their father (64%). Only 32 percent reported coming out to their medical provider. • About seven out of ten of Latino MSM drank alcohol during sex while one third used drugs during sex.

17. VCU STUDY • A significant proportion (43%) of the sample did not know the HIV status of their last sexual partner. • Condom use during anal sex with casual partners is inconsistent among Latino MSM (30% = never, or sometimes) • Many of the men tend to have multiple sexual partners (62%) and reported machista attitudes.

18. MACHISMO AS DETERMINANT • The VCU study found a statistically significant relationship between machismo and HIV/STD sexual risk behaviors. • Latino MSM with high machismo values were over five times more likely to engage in HIV/STD sexual risk behaviors compared to those with low machismo values. • In contrast, HIV/STD sexual risk behaviors were not significantly associated with acculturation, discrimination, or homophobia.

19. VCU STUDY CONCLUSIONS • High machismo values are a significant risk factor for HIV and STD sexual risk behaviors in Latino MSM. • Culturally competent messaging and appropriate skill building opportunities addressing machismo values should be incorporated into HIV and STD prevention programs that target Latino MSM.

20. A COMPARISON Nuestras Voces Study: • Study of gay and bisexual men in three urban settings: Los Angeles, New York, and Miami conducted by Rafael Diaz. • Survey questions developed from focus groups conducted with diverse MSM communities. • Challenged theoretical assumptions about individual behavior vs. socio-cultural factors.

21. NATIONAL STUDY OF LATINO GAY AND BISEXUAL MEN

22. Internalized Psychocultural Factors • Machismo • Homophobia • Family Loyalty • Sexual Silence • Poverty • Racism Not personal deficits, rather logical outcomes of socialization process of Latino gay and bisexual men.

23. 912 men recruited in 35 gay bars 309 (NYC), 302 (Miami), 301 (LA) 50% less than 30 years of age 82% self-identified as gay 55% college educated 27% unemployed 73% immigrant descent 41% had Latino partners 19% HIV positive Survey Participant Profile

24. Critical Thinking about Homophobia • Were you ever hit as a child for being thought of as gay. • As a child did you hear that being gay is abnormal? • As a gay man did you ever pretend to be heterosexual? • As a gay/bisexual man did you ever have to separate yourself from your family?

25. Survey Results: Homophobia Indicators • 18% were hit as a child • 71% as children heard that gays remained alone at old age • 91% heard that being gay is abnormal • 64% had to pretend to be heterosexual • 29% separated themselves from their families.

26. Racism • Have you experienced discrimination in the workplace? • Have you felt sexually objectified? • Have you experienced police brutality? • Have you felt uncomfortable in gay white environments?

27. Survey Results: Racism Indicators • 15% experienced workplace discrimination • 62% have felt like the target of sexual objectification • 22% experienced police brutality • 26% have felt uncomfortable in gay white environments.

28. COMPARISON OF RESEARCH • Both studies suggest culturally-bound determinants that impact HIV/AIDS risk taking behavior. • HIV prevention interventions should integrate messages about racism and hegemonic masculinity (machismo). • Interventions can’t be reduced to individual behaviors alone without considering larger social/cultural context.

29. DEVELOPING A HEALTH JUSTICE MODEL FOR HIV PREVENTION

30. DEFINING HEALTH JUSTICE • Definition: Health justice is the proactive reinforcement of policies, practices, attitudes and actions (praxis) that produce equitable power, access, opportunities, treatment, impacts, and outcomes for all. • Indicators: Equitable impacts and outcomes across race is the key indicator of health justice.

31. HEALTH INEQUITY • Health is more than healthcare • Health is tied to the distribution of resources • Racism and hegemonic masculinity impose an added health burden • Inequality—economic and political—is bad for your health • Social policy is health policy • We all pay the price of poor health* *Adapted from Office of Minority Health & Public Health Policy

32. DEFINING STRUCTURAL RACISM • Structural racism is the US is the normalization and legitimization of an array of dynamics—historical, cultural, institutional, and interpersonal—that routinely advantage dominant culture while producing cumulative and chronic adverse outcomes for people of color. • It is a system of hierarchy and inequity, primarily characterized by —the preferential treatment, privilege, and power of dominant culture at the expense of Black, Latino, Asian, Pacific Islander, Native American, Haitian, Arab, and other racially oppressed people. *Based on report by Aspen Institute

33. STRUCTURAL RACISM • Indicators/Manifestations: The key indicators of structural racism are inequalities in power, access, opportunities, treatment, and policy impact and outcomes, whether they are intentional or not. • Structural racism is more difficult to locate in a particular institution because it involves the reinforcing effects of multiple institutions and cultural norms, past, and present, continually reproducing old, and producing new forms of racism.

34. STRUCTURAL RACISM • Impact: Structural racism condemns millions of people of color to poverty, inadequate health care, substandard jobs, violence, and other conditions of oppression. • Scope: Structural racism encompasses the entire system of a dominant culture, diffused and infused in all aspects of society, including our history, culture, politics, economics, and entire social fabric.

35. DIFFERENT LEVELS OF RACISM MICRO LEVEL MACRO LEVEL

36. Assets for Healthier Practices inLatino MSM Communities • Family acceptance • Social and sexual satisfaction • Social interaction and political activism • Having a positive gay role model as a young person

37. Sociocultural Predictors of High-Risk SituationsSignificant Paths (standardized coefficients) -.22 Resiliency .27 Social Isolation & Low Self-Esteem .11 High-Risk Situations .34 Poverty .24 Racism .18 .23 Homophobia Variance Explained Isolation/Self-Esteem, R = .29 Risky Situations, R = .16 Test of Model Fit x 2 = 0.24 p = .89

38. WHAT CAN YOU DO? • Challenge homophobia and HIV stigma that is based on assumptions about hegemonic masculinity. • Promote a serostatus approach for HIV prevention with linkages to peer lead interventions that shift power through mobilization efforts. • Mobilize Latinos to understand intersections of inequities in health, political, and social conditions. • Don’t only focus on disparities without addressing root cause of racism and hegemonic masculinity. • Support community level and structural prevention interventions that integrate elements of health justice with economic opportunities.

39. EXPLORING ONE STRATEGY • Implementing stigma reduction strategies through social marketing strategies • AIDS-related stigma refers to prejudice, discounting, discrediting, and discrimination directed at people perceived to have AIDS or HIV and at the individuals, groups, and communities with which they are associated

40. CHALLENGING STIGMA • Primary and secondary AIDS stigma • How do you distinguish between internalized and externalized stigma for HIV prevention and care services? • Delays in testing and treatment • Adverse response to results • Media coverage • Abstinence only legislation • Blame behavior • Risk group discourse

41. CHALLENGING STIGMA • Instrumental stigma is expressed through an individual's concern about his or her risks of contracting HIV through casual contact with people living with HIV/AIDS. • Symbolic stigma is a vehicle for expressing religious, political, or other attitudes and values through one's perception of people living with HIV/AIDS.

42. CHALLENGING STIGMA • Social marketing efforts • Do personal responsibility messages perpetuate blame on people living with HIV/AIDS? • How do normalization messages impact a public’s sense of compassion and exigency for action? • Social marketing strategies • Should name root cause • Tie into medical, employment, and housing rights

43. CLOSING THOUGHTS • Create a mechanism for getting updates about population and epidemic shifts • Plan for regular listening sessions with community stakeholders • Consider health justice framework for HIV intervention design • Challenge stigma as a means of achieving health equity

44. THANK YOU FOR YOUR ATTENTION! J. Carlos Velázquez, MA MLAC Co-Chair ◊ Director of Multicultural Marketing HMA Associates cvelazquez@hmaassociates.com (202) 342-0676