Challenging Dogma - Spring 2008

...Using social sciences to improve the practice of public health

Wednesday, April 23, 2008

HIV/AIDS Prevention Efforts Have Failed African-American Men – Megan Coffman

African-American men in the U.S. are at a greater risk of being infected with HIV/AIDS than other portions of the population because prevention efforts do not address the specific risks present in this community. African-Americans make up approximately twelve percent of the U.S. population; however, they represent nearly fifty percent of known AIDS cases and AIDS is the fourth leading cause of death among African-American men (1). The Centers for Disease Control and Prevention (CDC) estimates that almost 500,000 African-Americans are infected with HIV, which is almost 2% of the African-American population (1). This is nearly eight times the infection rate of Caucasians in the United States (2).
HIV/AIDS prevention efforts must be more directly targeted towards the African-American male community and conducted in a culturally appropriate manner. Since the HIV/AIDS epidemic first emerged a quarter century ago, the focus of HIV prevention has focused on white gay men. Not enough focus has been put on the specific needs of the African-American male community, and as a result, this population has been especially hard hit. The HIV/AIDS epidemic should be framed as a public health crisis that affects all communities, but that has a disproportionate impact on the African-American community. Public health and government officials must work together to reduce HIV/AIDS infections in African-American men and to inform all levels of government about the impact HIV/AIDS is having on it and the nation as a whole. The United States cannot effectively tackle the HIV/AIDS epidemic without dramatically reducing the number of HIV/AIDS infections in African-American men.

A Message that Resonates
Current prevention messages fail to promote a healthy, self-sufficient and HIV negative lifestyle as a realistic option for African-American men. The failure to represent African-American men in this manner is just one of the reasons HIV prevention messages have not gotten through to African-American men. Recently, there are have been efforts to reach African-American men through public health campaigns via local public health agencies and television companies. Some of these ads are smart, creative, and inspiring, but they have not been effective in reducing the number of African-American males with HIV nationwide. They lack essential elements of Communications Theory that would insure their message would be heard. Communications theory is quite simple: a sender packages a message, the message is sent to the recipient, and the recipient analyzes or distills the message. At present HIV/AIDS prevention efforts have not been packaged in a way African-American men want to analyze or decode.
The Rap-It-Up campaign is one of the most recognized HIV/AIDS prevention campaigns directed at African-Americans. The Kaiser Family Foundation and BET (Black Entertainment Television) are co-sponsors of the national Rap-it-Up campaign. According to Kaiser, the Rap-It-Up campaign is directed at all African-Americans of all age groups (3). However, many of the Rap-it-Up ads feature young, straight African-Americans. Some ads feature young men in school or hanging out with friends in the community. Others include young women texting one another about getting tested or heterosexual couples in a relationship discussing sexually transmitted infections and condom use. This leaves several particularly at-risk groups of African-American men unrepresented in prevention materials. None of the ads address men that have sex with men, men who have sex with multiple partners, or men over thirty. The campaign fails to reach all members of the African-American community because the message is only meant for a specific audience and does not resonate with the entire population. Being able to decode the messages that are being shared by any sender is a key element of Communications Theory. (4) If messages are not accessible to a variety of sub-groups within the African-American male population only small portion of the recipients will identify with the message.
Not only are the TV ads not representative of the broad spectrum of African-American men, they can be simply offensive. One Rap-It-Up print ad tells readers “Making smart decisions is easier than you might think”(5). As if making a smart decision is not an easy task. This message implies that African-American do not typically make smart decisions.
Another ad asks the audience to “Assume that everyone is positive” (5). Messaging like this may lead to negative assumptions about themselves and their communities and leaves them without hope that they are negative. If one assumes that everyone is positive, why bother trying to protect one self because if they are not already infected now, they will be soon. If one just assumes that their partner is positive, then they may not make an effort to have a healthy discussion about pregnancy, preventing other sexually transmitted infections, or the status of their relationship with their partner.
When Kaiser surveyed a small group of African-Americans over 18, the respondents listed HIV/AIDS as the most urgent health issue facing the country today. However, when they asked members of the survey group if they had ever discussed HIV/AIDS with any partner, nearly 40 percent responded no (6). This demonstrates a serious failure of these campaigns and illustrates why they have not been successful in sufficiently reducing the number of new infections within the African-American community.
The federal governments’ attempts to address HIV/AIDS in African-American men do not even try to tailor the message to African-American men. The CDC uses the same message to address HIV/AIDS among African-Americans as they with other demographics. Prevention advice listed on the CDC website for African-Americans includes: “Don’t have sex when you are taking drugs or drinking alcohol”, “Use only clean needles and syringes” when injecting drugs, and “Abstain from sex until you are in a relationship with only one person (7)”. These messages are exactly the same for other demographics and make no effort to incorporate African- American culture or beliefs in the message. Not to mention, these messages infer that message recipients are not leading a healthy lifestyle.
In addition to its generic messaging, the CDC is late in addressing the challenges facing men who have sex with men, but do not consider themselves gay. African-American men have been especially hard hit by the lack of prevention efforts directed towards men who have sex with men. There are increased cultural barriers facing men who have sex with men in the African- American community based on faith, family expectations, and tradition (8). The CDC addresses this specific group of men as particularly at risk, but does not present any specific ways in which to prevent HIV within this demographic (7).

The Right Frame
Early in the history of the epidemic, public health officials and political leaders framed the AIDS epidemic as a disease that only affected gay white men, and have failed to frame the HIV/AIDS epidemic as a threat to African-American men. Successful use of Framing Theory involves the ability of invested individuals to frame an issue in a specific way. Based on how the issue is framed determines how people will respond to the issue. Simplified: it is all in the presentation (9). Unfortunately, this mis-framing of HIV/AIDS as a disease of gay white men led other communities, especially African-Americans, to believe they were not at risk of HIV/AIDS infection and therefore did not need to take the necessary precautions. This association between HIV/AIDS and homosexuality hit the African-American community especially hard. The impact has been two-fold. Heterosexual men do not see HIV/AIDS as a risk, and therefore are not taking the necessary precautions to stop the spread of HIV.
The other component relates to widespread negative attitudes towards homosexuality within African-American communities (10), which see homosexuality as a taboo subject. It goes against gender role expectations, definitions of masculinity, community norms relating to sexuality, and is perceived as sinful and unnatural. Because of these community expectations, African-American men are less likely than Caucasian men to identify as being gay. Fear of being labeled gay prevents some heterosexual men from discussing condom use. This is because they are concerned that their female partner will think they are gay or bi-sexual, that they are having sex outside of the relationship, or that they have a sexually transmitted infection. This social stigma contributes to low rates of participation in HIV prevention services by gay, bi-sexual and straight men of color (10). All of these fears and expectations negatively impact the African-American community in their efforts to prevent the spread of HIV. If the HIV/AIDS crisis had been framed in a way that affected all people, African-American men would not be paying such a heavy price now.

Setting the Record Straight
The media, public health officials and political leaders have failed to identify HIV/AIDS among African-American men as a crucial part of public health efforts. The responsibility to raise this issue falls squarely on political leaders, public health officials, and the media. Without their concern and influence African-American men will continue to be infected with HIV at rate 8 times that of their Caucasian counterparts. The United States has made fighting HIV/AIDS in the developing world a priority, and now it must do the same at home. President Bush hopes to spend $30 billion on fighting HIV/AIDS in Africa over the next five years. The president should be commended for these efforts abroad, but he and other leaders are missing the crisis right here at home (11).
All over the country individuals are trying to spread the word of the crisis with in the African-American community. Paula Silvestone, the Executive Director of AIDS Rochester, believes that “We need people on the streets, mass media campaigns, black leaders, black ministers who step up to the plate and talk about this (12).” Her call is being echoed in communities across America. Members of the National Medical Association, a professional association of African-American physicians, have called on the President to take action now to create a national plan to prevent HIV/AIDS in the United States before the crisis spirals further out of control (13). Unfortunately, the public health community and government officials have failed to heed this call and exert their influence to utilize agenda setting theory in informing and educating the public on this health crisis. The application of agenda-setting theory influences mass-news media to determine what stories will be told or what information the media will share (4). As of yet the media has not deemed the HIV/AIDS crisis in African-American men as important and relevant to the public as a whole. Failure to appropriately influence the media on the severity if HIV/AIDS in African-American men being especially hard.
In addition to raising the issue of HIV/AIDS prevention, the public health community must address the fear and skepticism that many African-American men feel towards the U.S. government and pubic health clinics. Misconceptions about the epidemic and a general mistrust of the public heath and political establishment contribute to the lack of effective communication and testing efforts. Common myths about HIV among the African-American community include: a cure exists, but the government refuses to share it with the poor; like syphilis, HIV was engineered in a lab and is part of a larger strategy to kill African-Americans and destabilize the community. Those that believe strongly in the HIV/AIDS conspiracy theories are less likely to utilize condoms consistently (14). African-American men continue to be reluctant to have their blood drawn and tested in public clinics for fear of being exploited (14). Until the public health community can frame their efforts as a way of helping African-American men instead of exploiting them they will continue to see limited progress in HIV/AIDS prevention efforts (15).
Public health practitioners and local leaders have failed to gain a better understanding of how the HIV/AIDS epidemic is affecting their community. More often than not, the solutions are within the community, but they need some of the resources to support their ideas. A number of common community solutions that have proven successful in other contexts, but that local leaders have still failed to utilize, include partnering with schools, clubs, sports teams, churches and mosques, community organizers, and radio stations at the local level to incorporate community driven efforts (14); encouraging community members to write Op-ed pieces in the paper or on-line, contact local news outlets, and tell their own story regarding the need for more resources in the fight against HIV/AIDS; putting pressure on elected officials.

Bringing the Message Home
Creating effective HIV/AIDS prevention outreach campaigns, appropriately framing the HIV/AIDS crisis in America, and setting the agenda on a local, state, and national level will help to reduce the number of African-Americans infected with HIV/AIDS. The failure to do so has led to an HIV/AIDS crisis among African-American men. Going forward, more HIV prevention messaging must be utilized that resonates with all members of the African-American male community, and does not stigmatize men who have sex with men, utilize drugs, have been imprisoned, or feel like an outsider. African-American men must be represented as being healthy, self-sufficient, and HIV-negative in order for prevention efforts to be effective going forward. It is important that public health practitioners recognize some of these barriers to change within the African-American community and frame their message appropriately. Public health advocates must remember to consider their target audience and how they present their case has an impact of how their audience will respond. Who do they want to make a change? What is the desired outcome of the message? How will individuals benefit from the change? What is needed to convince members of the community that they will benefit? How will the message be dispersed (16)?

1.“Fact Sheet: Black Americans and HIV/AIDS” Kaiser Family Foundation. March 2008.
2. “Out of Control: AIDS in Black America.” ABC August 23, 2006.
3. Kaiser Family Foundation website: Entertainment media Partnership. Rap-It-Up.
4. Edberg, Mark. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Boston. Jones and Bartlett. 2007.
5. Kaiser Family Foundation: Entertainment Partnerships Site. 2007. Kaiser Family Foundation. 15 April 2008.
6. “Assessing Public Education Programming on HIV/AIDS: National Survey of African Americans.” March 2004.
7. “What can African-Americans Do?” Centers for Disease Control and Prevention. March 8, 2007.
8. Bogart, Laura and Sheryl Thorburn, “Relationship of African Americans’ Sociodemographic Characteristics to Belief in Conspiracies about HIV/AIDS and Birth Control” Journal of the National Medical Association. Vol 98, NO 7 July 2006.
9. Siegel, Michael. Social & Behavioral Sciences in Public Health. School of Public Health, Boston University. Boston, MA. 14 February 2008.
10. Brooks, Ronald A., PhD., and Mark A. Etzel, M.P.P., Ernesto Hinjos, M.P.H., Charles Henry, and Mario Perez. “Preventing HIV Among Latino and African American Gay and Bisexual Men in a Context of HIV- Related Stigma, Discrimination, and Homophobia: Perspectives of Providers.” AIDS Patient Care and STDs. Volume 19, Number 11, 2005.
11. Bolton, Warren. “Blacks silent as HIV/AIDS attack through their communities.” The State, Columbia, S.C. 6 March 2008.
12. Wang, Justina. “Lack of voice gives life to persistent killer.” Rochester Democrat and Chronicle, Rochester, N.Y. 1 April 2008.
13. Adams, Nelson L., and Mohammad N. Akhter. “Op-Ed: Fight AIDS here at home.” Appeal- Democrat, Marysville, CA. 1 March 2008
14. King, William. “Examining African Americans’ Mistrust of the Health care System: Expanding the Research Question.” Public Health Reports. Volume 118, July-August 2003.
15. Healthy People 2010. U.S. Department of Health and Human Services. 15 April 2008.
16. Siegel, Michael and Lynne Doner. Marketing Public Health. Sudbury: Jones and Barlett, 2004.

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