Special Considerations for HIV Risk Prevention with Gay Men

1. Special Considerations for HIV Risk Prevention with Gay Men Jeremy T. Goldbach, LMSW Street Outreach Workers Conference June 15, 2011

2. Framing HIV Risk… • What factors influence HIV risk? • Personal? • Family? • School? • Community? • Society? • Internationally?

3. Importance of Phenomena • HIV is a critical public health issue • Gay men were the primary cohort of people associated with HIV since its beginning in the U.S. • Gay men remain the highest affected group (50% of cases) • Programs are most effective when culturally relevant • History, Politics and Social Forces have a significant affect on risk practices in gay men.

4. Scope of the Problem • Worldwide, 33 million people are infected with HIV and 2.7 million new infections annually (UNAIDS, 2008). • The United states finds a rate of 56,300 new cases annually (CDC, 2009). • Three times as many cases in men as in women • Male to male sexual contact approximately 50% of all new infection (CDC, 2008) • Rate remains 44x that of all other risk groups (CDC, 2008).

5. Historical Background • Gay Rights movement • Stonewall, 1969 • Revolution of the 1970’s • Bathhouses begin (Binson, et.al., 2001) • Financial impact of Bathhouses • “Gay Cancer” (1978) becomes GRID (1980) becomes HIV (1981) • Closely associated with gay men • 37% of public had “worsened opinions” (Gallup, 1985)

6. HIV Policy Development and Gay Men • Policy plays a significant role • Policy took years to develop (1985) • “No threat to the public” (CDC, 1983) • Shaping of policy • “Just Say No!” • Clash of sexual liberation with moral values • Abstinence vs. Harm Reduction

7. Key Concept: Culture • Established patterns of human behavior that include thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups (NASW, 2001) • Includes interpersonal social settings (Hopson, 2006; Holleran & Hopson, 2006), low income housing (MacLoed, 2004), centers for GLBTQ health promotion (Welle, 2003), age, substance use patterns (Marshall, et.al., 2008), socio-sexual settings (Frankis & Flowers, 2005).

8. Key Concept: MSM or Gay Men • Young and Meyer argued that the term “MSM… [implies] absence of community, social networks, and relationships in which same-gender pairing is shared and supported” (p. 1145). • Halkitis (2010) charged that reducing intimate exchanges between gay men to merely behaviors dehumanizes them, adding “gay men are more than vessels for the transmission of pathogens” (p. 753)

9. Conceptualizing Culture • Personally owned but socially mediated (Tajfel & Turner, 1979) • “Gay identity” has different connotations for individuals • Sub-cultural assignments • Barebacker (Halkitis, et.al., 2005) • “down low” (Millet, et.al., 2005) • Not dichotomous • multi-risk group membership

10. Some Empirical Links • Age • Race • Substance Use • Social Settings and Normative Behaviors • Culminative Nature of HIV Risk

11. Age and HIV Risk • Little research exists • Young men at higher risk (Celentano,et.al., 2006) • Less concerned with HIV risk (Webster, et.al., 2003) • Theoretically and Historically linked • Clinically linked • Survivors Guild (Agnos, 1990; Odets, 1994) • The PTSD-like symptoms occurred, as Agnos (1990) states, from the “simple fact that by 1990, more San Franciscans had died of AIDS than died in the four wars of the 20th century, combined and tripled.”

12. Racial Inequities and Culture in Gay Men • HIV and Hispanic Men • 2.6x the rate of Caucasian men (CDC, 2009) • Competing cultures • Within group homophobia (Jarama,et.al., 2008) • Machismo, Familism (Diaz, 1996; 2001) • HIV and African American Men • 7.6x the rate of Caucasian men (CDC, 2009) • Increased risk for violence, poverty, homelessness (Fullilove, et.al., 1990) • “Down Low” Controversy (Icard, 2008) • Cultural considerations (Boykin, 2005)

13. Substance Use and Culture • High Prevalence (Marshal, et.al., 2008) • 3x the rate of heterosexual peers (Russel, et.al., 2002) • Initiation of Drug Use • Cultural elements such as groups, setting and permissiveness (Grov, et.al., 2008; Kubicek, et.al., 2007) • Usually in sexually charged social situations (Bauermeister, 2007; Halkitis & Jerome, 2008; Frosch, et.al., 1996) • Methamphetamine and Gay Culture • 56% of gay men who use meth also engage in unprotected sex (CDC, 2001; NIDA, 2006) • 3x as likely to become HIV positive (Gordon, 2005)

14. Social Setting and Norming of HIV Risk Taking • Why is Social Setting important? • Permissiveness (Halkitis, et.al., 2008; Frankis & Flowers, 2005) • Bath houses • Victimless crime? (Woods, et.al., 2003) • Don’t Ask, Don’t Tell (Vicioso, et.al., 2005) • Escape from the reality of risk? (Binson, 2001) • Sex Parties • Hidden, difficult to research • Unsafe sex often accepted AND promoted (Bauermeister, et.al., 2009 • Internet – 50% having unsafe sex (Bolding,et.al., 2005)

15. The Culminative Nature of Risk • How does it all come together? • Synergistic impact of risk • Substance abuse, sexual risk-taking and social setting taken together (Halkitis et al., 2005; Kubicek, McDavitt, Carpineto, Weiss, Iverson, & Kipke, 2007; Vicioso, Parsons, Nanin, Purcell, & Woods, 2005) • Identity expression (Reback, 1997) • Lowered rates of condom use (Semple, et.al., 2002)

16. Limitations to Evidence-Based Practice with MSM • Reliance on convenience sampling • Difficult to reach populations • Difficult to define boundaries of population • Most at need are often most represented in sampling frames • Significant data on prevalence; lack of data on determinants

17. Clinical and Practical Thoughts • Culture, Decision-making and Behavior • Translation of evidence to practice (Collins, et.al., 2006) • Current models mostly focus on Information-Motivation-Behavior-Skills (Fisher & Fisher, 2000). • Does not account for social motivators • Transactional nature of decision-making • Failure of programs can be traced to lack of cultural sensitivity (Holleran Steiker, 2008; Marsiglia, et.al., 2000)

18. Culture and Clinical Considerations • Theories of Culture and Risk • Social Identity Theory • Human behavior can be understood through an individual’s interaction with their social environment (Tajfel & Turner, 1979) • Not an “active” theory • Transtheoretical Model of Change • Stages of change (Prochaska & DiClemente, 1984) • An “Action only” theory • Theory of Reasoned Action (Fishbein & Ajzen, 1980) • Attitude + norms = behavioral intention  behavior

19. Implications • Practice • Interventions are more effective when culturally informed (Holleran Steiker, 2008) including in gay communities (Hughes & Eliason, 2002) • Clear understanding of behavioral “triggers” • Match clients where they are at • Understand in non-judgmental ways the many factors that push and pull men into decision-making • Policy • Reduce moralistic, social policy and outside goal-seeking activities that are mismatched with affected communities (Gonsiorek & Shernoff, 1991)

20. Implications, Continued • Research • Reducing limitations to research (Binson, et.al., 2007; Hershberger, et.al., 1997) • More research on age as a risk factor • More focus on • determinants of behavior • Protective factors • Intervention approaches • Youth and adolescent approaches

21. Questions? Thoughts? Jeremy T. Goldbach, LMSW (832) 244-5437 Email: jeremy.goldbach@gmail.com