Mind the Gap: HIV Prevention Among Young Black Men Who Have Sex with Men.

PURPOSE OF REVIEW: Young Black men who have sex with men (YBMSM) suffer profound health inequities in new HIV diagnoses and clinical outcomes. While the evolution of HIV prevention options has become increasingly biomedical, inequities in access and uptake of these modalities persist. RECENT FINDINGS: Studies suggest that while YBMSM display interest and acceptability of varied HIV prevention options, uptake lags due to the lingering effects of intersectional oppression from racism and sexual prejudice, HIV stigma, institutional and provider bias, and unresolved health policy barriers. Promising avenues to address these barriers have yet to be fully explored. We have the tools to effectively prevent HIV transmission and acquisition among YBMSM, but we have not yet effectively implemented these tools for this priority population. To end the epidemic, we must tailor and adapt HIV prevention strategies to meet the unique intersecting needs, identities, and social contexts of YBMSM.

Pride.

In this narrative medicine essay, an internal medicine physician, invited to speak at an International AIDS Society plenary session about his HIV work, endures a cool response from his parents upon sharing his HIV status but is met with a standing ovation and cheered by his chosen family and friends after the speech.

The Case for Extragenital Screening of Chlamydia trachomatis and Neisseria gonorrhoeae in the College Health Setting.

BACKGROUND: Although the Centers for Disease Control and Prevention does not recommend routine oropharyngeal and anorectal screening for Chlamydia trachomatis and Neisseria gonorrhoeae in the general population, they do recommend it for men who have sex with men. However, risk-based extragenital screening of men may not have been adopted at all college health centers, and existing research has not focused on the college population. METHODS: We examined health records of men at a college health center in a large urban university over 6 years to evaluate effectiveness of C. trachomatis and N. gonorrhoeae screening. We also evaluated the proportion of C. trachomatis and N. gonorrhoeae infections that would have been missed if risk-based extragenital screening were not performed. Decisions to screen at extragenital sites were based on patient-reported risk behavior. RESULTS: For 4093 male college students screened, 7.6% of the screening visits used extragenital screening in response to self-reported risk behaviors. The case positivity rate for C. trachomatis was 3.1% with urogenital-only screening and 3.7% with risk-prompted extragenital screening. The case positivity rate for N. gonorrhoeae was 0.7% with urogenital-only screening and 3.3% with risk-prompted extragenital screening. If the college health center had relied solely on urogenital screening rather than risk-based extragenital screening, 26.4% of C. trachomatis infections and 63.2% of N. gonorrhoeae infections would have been missed. CONCLUSIONS: One out of four C. trachomatis infections and 2 of 3 N. gonorrhoeae infections would have been missed without extragenital screening in this analysis of college men. This study reinforces Centers for Disease Control and Prevention recommendations for risk-based extragenital screening and is the first report to focus on college men. Because guidelines exist only for men, future studies should focus on extragenital screening in college women to build evidence for another group of patients that may benefit from this practice, given the high risk in young adults.

Measuring Black men's police-based discrimination experiences: Development and validation of the Police and Law Enforcement (PLE) Scale.

OBJECTIVES: Although social science research has examined police and law enforcement-perpetrated discrimination against Black men using policing statistics and implicit bias studies, there is little quantitative evidence detailing this phenomenon from the perspective of Black men. Consequently, there is a dearth of research detailing how Black men's perspectives on police and law enforcement-related stress predict negative physiological and psychological health outcomes. This study addresses these gaps with the qualitative development and quantitative test of the Police and Law Enforcement (PLE) Scale. METHOD: In Study 1, we used thematic analysis on transcripts of individual qualitative interviews with 90 Black men to assess key themes and concepts and develop quantitative items. In Study 2, we used 2 focus groups comprised of 5 Black men each (n = 10), intensive cognitive interviewing with a separate sample of Black men (n = 15), and piloting with another sample of Black men (n = 13) to assess the ecological validity of the quantitative items. For Study 3, we analyzed data from a sample of 633 Black men between the ages of 18 and 65 to test the factor structure of the PLE, as we all as its concurrent validity and convergent/discriminant validity. RESULTS: Qualitative analyses and confirmatory factor analyses suggested that a 5-item, 1-factor measure appropriately represented respondents' experiences of police/law enforcement discrimination. As hypothesized, the PLE was positively associated with measures of racial discrimination and depressive symptoms. CONCLUSIONS: Preliminary evidence suggests that the PLE is a reliable and valid measure of Black men's experiences of discrimination with police/law enforcement. (PsycINFO Database Record

Reconciling Epidemiology and Social Justice in the Public Health Discourse Around the Sexual Networks of Black Men Who Have Sex With Men.

Several studies have implicated the sexual networks of Black men who have sex with men (MSM) as facilitating disproportionally high rates of new HIV infections within this community. Although structural disparities place these networks at heightened risk for infection, HIV prevention science continues to describe networks as the cause for HIV disparities, rather than an effect of structures that pattern infection. We explore the historical relationship between public health and Black MSM, arguing that the current articulation of Black MSM networks is too often incomplete and counterproductive. Public health can offer a counternarrative that reconciles epidemiology with the social justice that informs our discipline, and that is required for an effective response to the epidemic among Black MSM.

Transition to adulthood and antiretroviral adherence among HIV-positive young Black men who have sex with men.

OBJECTIVES: We conducted a qualitative study of HIV-positive young Black men who have sex with men (YBMSM) to explore their experiences of living with HIV and adhering to antiretroviral medications (ARVs) within the developmental context of their transition to adulthood. METHODS: We conducted life history interviews with 20 HIV-positive YBMSM in Atlanta, Georgia, engaged in outpatient HIV care. We addressed these questions: (1) How do YBMSM living with HIV experience the transition to adulthood? and (2) What are the important sociocontextual influences on ARV adherence for YBMSM? RESULTS: Successful transition to adulthood and optimal ARV adherence were inextricably linked. HIV's detrimental impact on development was moderated by the degree of physical illness at diagnosis. Many participants described resilient trajectories while coping with HIV. Adherence problems occurred primarily among participants who were not meeting their developmental goals. CONCLUSIONS: Our findings support the need for early diagnosis and linkage to care, as well as the need to develop holistic, resilience-based interventions focusing on transition to adulthood. These findings have implications for individual clinical outcomes as well as ARV-based prevention efforts among YBMSM.

"I Always Felt I Had to Prove My Manhood": Homosexuality, Masculinity, Gender Role Strain, and HIV Risk Among Young Black Men Who Have Sex With Men.

Objectives. We explored gender role strain (GRS) arising from conflict between homosexuality and cultural conceptions of masculinity among young Black men who have sex with men (MSM). Methods. We conducted a categorical analysis (a qualitative, 3-stage, iterative analysis) of data from studies conducted in 2001 to 2006, which interviewed 35 men aged 18 to 24 years in 3 New York cities and Atlanta, Georgia. Results. Participants described rigid, often antihomosexual expectations of masculinity from their families, peers, and communities. Consistent with GRS, this conflict and pressure to conform to these expectations despite their homosexuality led to psychological distress, efforts to camouflage their homosexuality, and strategies to prove their masculinity. Participants believed this conflict and the associated experience of GRS might increase HIV risk through social isolation, poor self-esteem, reduced access to HIV prevention messages, and limited parental-family involvement in sexuality development and early sexual decision-making. Conclusions. Antihomosexual expectations of masculinity isolate young Black MSM during a developmental stage when interpersonal attachments are critical. GRS may influence sexual risk behavior and HIV risk and be an important target for HIV prevention.

Sexual scripts and sexual risk behaviors among Black heterosexual men: development of the Sexual Scripts Scale.

Sexual scripts are widely shared gender and culture-specific guides for sexual behavior with important implications for HIV prevention. Although several qualitative studies document how sexual scripts may influence sexual risk behaviors, quantitative investigations of sexual scripts in the context of sexual risk are rare. This mixed methods study involved the qualitative development and quantitative testing of the Sexual Scripts Scale (SSS). Study 1 included qualitative semi-structured interviews with 30 Black heterosexual men about sexual experiences with main and casual sex partners to develop the SSS. Study 2 included a quantitative test of the SSS with 526 predominantly low-income Black heterosexual men. A factor analysis of the SSS resulted in a 34-item, seven-factor solution that explained 68% of the variance. The subscales and coefficient alphas were: Romantic Intimacy Scripts (α = .86), Condom Scripts (α = .82), Alcohol Scripts (α = .83), Sexual Initiation Scripts (α = .79), Media Sexual Socialization Scripts (α = .84), Marijuana Scripts (α = .85), and Sexual Experimentation Scripts (α = .84). Among men who reported a main partner (n = 401), higher Alcohol Scripts, Media Sexual Socialization Scripts, and Marijuana Scripts scores, and lower Condom Scripts scores were related to more sexual risk behavior. Among men who reported at least one casual partner (n = 238), higher Romantic Intimacy Scripts, Sexual Initiation Scripts, and Media Sexual Socialization Scripts, and lower Condom Scripts scores were related to higher sexual risk. The SSS may have considerable utility for future research on Black heterosexual men's HIV risk.

Sexual self-identification among behaviorally bisexual men in the midwestern United States.

Previous social and behavioral research on identity among bisexual men, when not subsumed within the category of men who have sex with men (MSM), has primarily focused on samples of self-identified bisexual men. Little is known about sexual self-identification among men who are behaviorally bisexual, regardless of sexual identity. Using qualitative data from 77 in-depth interviews with a diverse sample of behaviorally bisexual men (i.e., men who have had sex with at least one woman and at least one man in the past six months) from a large city in the Midwestern United States, we analyzed responses from a domain focusing on sexual self-identity and related issues. Overall, participants' sexual self-identification was exceptionally diverse. Three primary themes emerged: (1) a resistance to, or rejection of, using sexual self-identity labels; (2) concurrent use of multiple identity categories and the strategic deployment of multiple sexual identity labels; and (3) a variety of trajectories to current sexual self-identification. Based on our findings, we offer insights into the unique lived experiences of behaviorally bisexual men, as well as broader considerations for the study of men's sexuality. We also explore identity-related information useful for the design of HIV/STI prevention and other sexual health programs directed toward behaviorally bisexual men, which will ideally be variable and flexible in accordance with the wide range of diversity found in this population.

Neighborhood context and Black heterosexual men's sexual HIV risk behaviors.

The effects of neighborhood context on sexual risk behavior are understudied, particularly for Black heterosexual men who do not inject drugs or report heavy drug use. Evidence of a generalized HIV epidemic (>1 %) among Black heterosexuals in low-income urban U.S. communities underscores the importance of examining the effects of neighborhood context on Black heterosexual men's sexual risk, however. We used structural equation modeling to test the pathways between neighborhood context (neighborhood disorder, personal violence, neighborhood threats), depression, substance use, and sexual risk behavior. Participants were 526 self-identified Black heterosexual men, ages 18-45, recruited via randomized venue-based probability sampling in Philadelphia, PA. Analyses of model fit statistics from Mplus indicated statistically significant direct pathways between neighborhood context, depression, substance use, and sexual risk behavior. The total indirect effect of neighborhood context on sexual risk behavior through substance use was also significant. The study's results highlight a need for more research on neighborhood context and sexual HIV risk, and for multilevel interventions to address the effects of negative neighborhood context on Black heterosexual men's sexual HIV risk.

Racial discrimination and posttraumatic stress symptoms as pathways to sexual HIV risk behaviors among urban Black heterosexual men.

In light of evidence that racial discrimination and posttraumatic stress symptoms (PTSS) are neither rare nor extraordinary for many Black urban men, we examined the relationship between everyday racial discrimination and sexual HIV risk behaviors in a predominantly low-income sample of 526 urban Black heterosexually identified men; 64% of whom were unemployed and 55% of whom reported a history of incarceration. We tested the hypothesis that PTSS would mediate the relationship between everyday racial discrimination and sexual risk. Participants in the predominantly low-income urban sample ranged in age from 18 to 45 (M = 28.80, SD = 7.57). Three multiple regression models were used to test the study's mediational model. As hypothesized, PTSS mediated the relationship between everyday racial discrimination and sexual risk behaviors. Most participants (97%) reported experiences with everyday racial discrimination. Results empirically support the notion of racial discrimination-based traumatic stress as a pathway to Black heterosexual men's increased sexual risk behaviors. Results also highlighted key demographic differences with older men reporting fewer PTSS and sexual risk behaviors compared with younger men. Incarceration was related to both PTSS and sexual risk, underscoring the role that incarceration may play in Black heterosexual men's adverse health outcomes. Our study highlights the need for more qualitative and quantitative research to understand the nature of PTSS in Black heterosexual men and mechanisms such as substance use that may link traumatic experiences and sexual risk. Future research could also assess experiences with childhood sexual abuse, violence, and incarceration to gain a more in-depth understanding of the sources of traumatic stress in Black heterosexual men's lives. We advocate for the development of community-based individual and structural-level interventions to help Black heterosexual men in urban areas develop effective strategies to cope with racial discrimination-based traumatic stress to reduce sexual HIV risk behaviors in Black communities.

A qualitative analysis of father-son relationships among HIV-positive young black men who have sex with men.

Young black men who have sex with men (YBMSM) are experiencing high and rising rates of HIV infection, more than any other age-risk group category in the USA. Contributors to HIV risk in this group remain incompletely elucidated. We conducted exploratory qualitative interviews with 20 HIV-positive YBMSM aged 17-24 and found that father-son relationships were perceived to be important sociocontextual influences in participants' lives. Participants discussed the degree of their fathers' involvement in their lives, emotional qualities of the father-son relationship, communication about sex, and masculine socialization. Participants also described pathways linking father-son relationships to HIV risk, which were mediated by psychological and situational risk scenarios. Our thematic analysis suggests that father-son relationships are important to the psychosocial development of YBMSM, with the potential to either exacerbate or attenuate sexual risk for HIV. Interventions designed to strengthen father-son relationships may provide a promising direction for future health promotion efforts in this population.

Gender matters: condom use and nonuse among behaviorally bisexual men.

Although frequently cited as being at high risk for HIV/STI transmission, little is known about behaviorally bisexual men's patterns and experiences of condom use and nonuse with male and female sexual partners. Using a variety of recruitment techniques informed by a Community Advisory Committee, a total of 77 behaviorally bisexual men were recruited from Indianapolis, Indiana to participate in semi-structured interviews focused on sexual health. Qualitative data were collected containing detailed information on their patterns and experiences of condom use and nonuse with both male and female partners. Participants described numerous commonly reported barriers for consistent condom use, as well as distinct bisexual-specific barriers. The majority reported consistent condom use with male and female casual partners, but many who did not use condoms described doing so in the context of ongoing relationships. In addition, participants provided reasons for condom use and nonuse that varied based on the gender of the partner and the type of relationship with the partner. Future interventions focused on increasing condom use among behaviorally bisexual men should take into account the unique complexities of gender and relationship configurations in this distinct population.

Common roots: a contextual review of HIV epidemics in black men who have sex with men across the African diaspora.

Pooled estimates from across the African diaspora show that black men who have sex with men (MSM) are 15 times more likely to be HIV positive compared with general populations and 8·5 times more likely compared with black populations. Disparities in the prevalence of HIV infection are greater in African and Caribbean countries that criminalise homosexual activity than in those that do not criminalise such behaviour. With the exception of US and African epidemiological studies, most studies of black MSM mainly focus on outcomes associated with HIV behavioural risk rather than on prevalence, incidence, or undiagnosed infection. Nevertheless, black MSM across the African diaspora share common experiences such as discrimination, cultural norms valuing masculinity, concerns about confidentiality during HIV testing or treatment, low access to HIV drugs, threats of violence or incarceration, and few targeted HIV prevention resources.

Racial discrimination, social support, and sexual HIV risk among Black heterosexual men.

Numerous studies document the adverse impact of racial discrimination on African Americans' health outcomes, but few have focused on HIV risk. We examined the relationship between racial discrimination and sexual risk in a sample of 526 Black heterosexual men and tested the hypothesis that social support would moderate this relationship. Participants in the predominantly low-income urban sample ranged in age from 18 to 45. High social support had a buffering impact on the relationship between racial discrimination and sexual risk. Among men reporting high racial discrimination, those with more social support reported less sexual risk than men with low social support. Men who reported high racial discrimination and low social support reported more sexual risk than men in any of the other groups. The study highlights social support as an important but understudied protective factor that may reduce sexual risk for Black heterosexual men who report high levels of racial discrimination.