Help Us, Save Us! HIV/STI Risk Reduction for Black Men Who Have Sex With Men

HIV/AIDS has had a devastating impact on African American MSM. Although African Americans represent only 13% of the US population, 49% of AIDS diagnoses in 2004 were in African Americans. That HIV/AIDS has taken an increasing toll on African American injection drug users and heterosexuals during the last decade is well documented. Nevertheless, MSM continue to account for the largest number of African Americans with HIV/AIDS. Through 2004, the MSM exposure category accounted for 37% of the cumulative AIDS cases in African American men, whereas injection drug use accounted for 31% and heterosexual transmission accounted for 10%. Consonant with these figures on HIV/AIDS cases, the HIV infection rates in several studies the Centers for Disease Control and Prevention (CDC) conducted on African American MSM have rivaled those found in many sub-Saharan African nations. For instance, a CDC 5-city study found that of the African American MSM who were tested for HIV, two-thirds were unaware of their status and 46% were HIV positive. Similarly, the 7-city CDC Young Men's Survey found an HIV prevalence rate of 32% in African American MSM. Interestingly, although African American MSM have relatively high HIV infection rates, evidence does not suggest that they engage in riskier sexual practices than do other MSM. This may mean that African American MSM are drawing their sexual partners from pools of people where HIV prevalence is relatively high, which underscores the urgency of targeting interventions to this population.

Quite apart from risk of HIV, African American MSM are at high risk for other STIs. The CDC MSM Prevalence Monitoring Project conducted in 9 US cities, in 1999 through 2004 found that the rates of gonorrhea and chlamydia were high in MSM, but especially high in African American MSM. In 2004, urethral gonorrhea positivity was 16% in African Americans, as compared with 11% in Whites, and 9% in Hispanics. The median urethral chlamydia positivity was 6% overall, but 9% in African Americans. To curb the HIV epidemic and the high rates of other STIs in African American MSM now, prevention efforts must be urgently undertaken.

Although several researchers have stressed the need for culturally appropriate prevention interventions targeting African American MSM, scant progress has been made toward the identification of such interventions. Ample evidence indicates that theory-based interventions can decrease sexual risk behavior among MSM. A meta-analysis 40 controlled studies of HIV prevention behavioral interventions for MSM found that the interventions reduced the amount of reported unprotected sex by as much as 27%, but revealed that the MSM populations at the highest risk, including African American MSM, have been underserved by intervention research. Consider, for example, Project EXPLORE, a large-scale multi-site controlled trial (RCT) that enrolled over 4,200 MSM and followed them for up to 4 years. Fewer than 7% of participants were African American, eligible African Americans were less likely to enroll in the trial than were eligible Whites, and African Americans were more likely to drop out. Another meta-analysis found that, of 33 HIV sexual risk reduction intervention trials on MSM, only 6 employed a sample that was at least a 10% African American. The insufficient number of rigorous intervention trials directed at African American MSM has hindered the ability to make definitive conclusions about how to combat men's attitudes and beliefs concerning sexual risk behavior and ultimately determine the effectiveness of HIV prevention strategies targeting African American MSM.

Reaching African American MSM may be particularly challenging because many African American MSM do not use traditional resources and organizations that serve gay men because they do not identify with White gay culture. In addition, African American MSM may also be difficult to reach within African American communities because they are often closeted and isolated due to real and perceived homophobia. That isolation, in turn, contributes to internalized repression of gay sexual identity, which may further isolate them from resources available to gay men. The investigators' approach to addressing the problem of reaching African American MSM is to develop an intervention that can be used by community-based organizations (CBOs) that already serve African American MSM. The investigators will create a Community Advisory Board that includes representatives of CBOs that serve African American MSM and representatives of the study population to advise them on the intervention design and other aspects of the trial. In addition, the investigators have held a focus group with representatives of CBOs that serve African Americans and have frequently consulted with them regarding their approach.

Reviews of the literature have suggested that there have been 3 basic approaches to the design of HIV/STI risk reduction programs aimed at MSM. One approach is to seek to reduce risk through the implementation of small group or workshop interventions. The second approach is through the use of community-level interventions. A third approach is the individual one-on-one intervention. All three approaches have merit and have reduced risk behavior among men in controlled trials. An advantage of the one-on-one is that it avoids the problem of men having to risk revealing that they have sex with other men in order to participate in the prevention program. There are added benefits of the one-on-one approach. It permits tailoring the intervention to the specific needs of the man. A recent meta-analysis has identified characteristics of effective HIV behavioral interventions for MSM. Efficacy was associated with interventions having more than one session, duration of 4 or more hours, and a time span of at least 3 weeks.