Challenging Dogma - Spring 2008

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

Monday, April 21, 2008

Social and Cultural Stigma Drives Failure of HIV Interventions in MSM – Chris Kim

MSM HIV Infection: What and Who

According to reports from the Center for Disease Control Surveillance Report 2005, men who have sex with men account for the greatest proportion of individuals infected with HIV. 71% of all infections occur in this group even though less than 7% of men identify as being a part of this group (1). Recent data suggest that interventions in the 80’s and 90’s had slowed the rate of infection among men who have sex with men, but those efforts are not permanent as the rate has begun to increase again (1).

In the US, 67% of all new infections are occurring in the men who have sex with men (MSM) group, accounting for approximately 25,000 new infections on a yearly basis. About two thirds of those cases occur in ethnic minorities (1). Among homosexual men infected with HIV, 80% are unaware of their positive status (2). The principle cause of HIV infection is unprotected sexual activity. By the 12th grade, 70% of survey takers responded they have had sex (2). Inadequate sexual education has contributed to greater high-risk sex. Committed partners can be at risk due to prior infection that has yet to manifest itself. Some men may experiment outside of their traditional sexual partners leading to potential infections. The feeling of invulnerability is a large problem, causing many to engage in unsafe sex practices.

The current state of preventing HIV among the MSM populations is limited in scope. Educational campaigns and targeted messages assume that these individuals self-identify as gay or bisexual. The outreach can also mistakenly make young men less aware of the fact they are at risk by providing misleading information (3). When the outreach campaigns are compared to those of general pregnancy and condom-use campaigns, it becomes readily apparent that the messages are being handled in a completely different manner. Successful condom and safe sex practice campaigns have involved provocative images and used advertising theory using mass-market appeal and emotions of approval. These campaigns have had a successful dose-response relationship with exposure to advertising and condom efficacy and use leading to improved personal risk perception and self-efficacy (4).

Counseling and modifications to behavioral patterns for HIV prevention have met with success limited to the short-term. Lack of trust and acceptance leading to reduced participation is the major reason for the failure to reduce HIV infection. The prevailing method of outreach has been education of health effects via the health belief model, and is still viewed as being the most effective method by people in the community—despite suggestions that sexual activity is not always a rational process. Other interventions have used provocative advertising which is not sensitive to the population, potentially offending the general population. Other ideas for interventions have yet to be implemented.

The failure of preventing and ending the spread of HIV infection among men who have sex with men has been due to social stigmas, failing to address drug use, and neglecting cultural groups. Social interventions en masse have failed to address fundamental causes of HIV infections and issues and have relied on the traditional health belief model via education, when social group focused interventions have shown the most promise.

Social stigma and rejection from society

Outreach, as performed by the Montana Gay Men’s Task Force, is often lacking proper social sensitivity and serves to alienate the population they are trying to target. Their message involves using provocative images of scantily clad men embracing each other suggesting they practice safe sex, but homosexuality in general, is sometimes not favorably viewed upon in parts of the country. Voters continue to vote for bans on same-sex marriage, indicating there still exists some resentment towards homosexuality (5). In fact, not only is sexual orientation an important factor in viewing others, fulfilling traditional gender roles continues to play a large part in how favorably a person is viewed among teenagers (6). MSM often struggle with self-identity, self-expression, loneliness, and isolation (7), and this campaign does little to address social acceptance. Because people are often ostracized, the internet has become a tool for rampant sexual behavior to avoid public eye. In a study of 270 young men, 48% had engaged in sexual activity with a person met online while only 53% had used condoms regularly. 47% respondents had partners 4+ years older than himself (8). In another study, of 4,974 men, nearly 82% had looked for sexual partners online, 46% had not been tested for HIV, 6% were HIV positive, and 31% engaged in high-risk unprotected anal sex (9). Another study discovered that young people were much more likely to feel comfortable and engage in sex with internet partners (10). These data are problematic because self-acceptance of gay or bisexual identity was related to less sexual risk-taking behavior (11), and if the general public continues to have a disdainful opinion of MSM, men will continue to avoid identifying as gay or bisexual.

Even free HIV testing provided by groups such as the Montana Task Force haven’t increased testing because there is a fear surrounding HIV, and individuals sometime do not want to know his own serostatus. Men that did not get tested frequently, 45% believed themselves at low risk of infection, 41% said they feared finding the results, and 21% listed a fear of needles as reason for not getting tested more often (12). These data seem to indicate that there is still an underlying fear of HIV infection, and people are willing to engage in poor behavior choices rather than being identified as having HIV knowing they are potential vectors of disease. The outreach has done little to alleviate fears about HIV as they don’t provide robust resources for an individual if he is to become infected. Others men have a fear or mistrust of going to a doctor, leading to a failure of getting proper treatment for the disease and potentially infecting others. Men who do not regularly get tested for HIV and other STDs often are the same men that participate in risky sexual behaviors not using condoms—18% of men in the study by Valleroy et al (13) did not know they were HIV-positive. In another study, 41% had engaged in unprotected anal sex, 37% of them did not know of their HIV-positive status. Even among young gay monogamous couples that engage in sex, 42% did not know the status of himself or his boyfriend, despite the fact they had regular unprotected anal sex (14). By not knowing one’s own serostatus, there is no burden of knowing he might become sick one day. He also might believe himself to be free of moral guilt of potentially infecting others with the virus. HIV positive individuals have been ostracized in the past, like many other minorities, and thus may choose not to get tested.

Heavy drug use: a conduit for risky behavior groups and activities

Successful interventions such as the Mpowerment project, though generally considered a success because it uses social networking theory rather than the health belief model, fails to address alcohol and drug use. These substances are associated with increased sexual activity and greater risk taking (15). Marijuana use was associated with non-condom use, and alcohol had a strong influence on risky sex behavior in first-time sexual encounters. About 18% of adolescents had their first sexual encounter while under the influence and a large number of these individuals did not use condoms or other means of protecting themselves to HIV transmission (16). Also, injection drug use is a high risk factor for HIV infection because men engaging in MSM are much more likely to be injection drug users (17). Injection drug use is a direct risk for becoming infected with HIV because needle sharing with an infected person can lead to infection. For Hispanics, over 40% of cases of infection occur due to injection drug use, despite the existence of needle exchange programs. Also, Hispanics are less likely to participate in needle exchange programs if the exchange site is public for fear of being labeled a drug user (16), although this phenomenon is not likely isolated to Hispanics. The reason for reduced use of these programs is due to social stigmas in some cultures that reflect poorly upon individuals that use drugs and seek help for addiction. These programs need to be available confidentially so that people can feel secure in utilizing the services.

Mpowerment tries to create its own ‘safe sex networks’, but does nothing to combat existing sex and drug networks leading to risky behavior choices. Methamphetamine usage has become an increasingly popular drug leading to unsafe sexual behavior among MSM. In particular, circuit parties, bathhouses, urban centers, and sex clubs have strongly been linked to usage. Men will use the drug and engage in sexual activity with multiple partners (5+), often unprotected, with other men. Among this cohort, struggles with isolation drive methamphetamine use and a search for venues of sexual expression, indicating that many individuals may utilize these networks as a coping tactic (7). Sex networks have seen a dramatic increase in drug use. Between a crack using group and a non-using comparison group, 63% of crack users engaged in at least one of sexual intercourse under influence, had 5+ partners in one year (43%), exchanged sexual favors for drugs (29%), or had unprotected sexual encounters (75%). Most striking is that crack use is highest among friends and relatives (19). This suggests initiation to sex and drug circles is likely to happen in familiar social networks, which is where interventions need to be targeted since they are a doubly risky group due to social isolation and drug use.

The power of socioeconomic status, social groups, and networking

No major HIV intervention campaigns have tried to use culturally sensitive messages. Culturally sensitive interventions suggested in 1991 by Martinez et al. (20) through 2003 with Barbara Marin’s ideas (21) have yet to be implemented. Efforts are often lost because they lack cultural sensitivity, can offend some cultures, and reinforce existing discrimination against MSM minorities increasing social isolation. This can lead to a breakdown of community support and potentially promote social networks that facilitate promiscuity and HIV transmission (22). Because communities are not established for promoting protection from HIV, self-efficacy of protecting oneself is decreased as individuals feel fated to become infected with HIV and/or accept HIV positivity as normal (23). This is particularly problematic in minority communities that are stricken with poverty where campaigns frequently fail to reach. Increased development of culturally sensitive HIV prevention services and improved access to testing and care early in the course of disease is needed to further reduce HIV-related morbidity in racial/ethnic minority MSM, as men in these communities may not be as socially accepted into their own communities compared to whites in strong gay communities such as San Francisco (23).

Ethnic groups are a source of camaraderie and these communities need to be a source of networking to promote healthier interventions (24). The only prominent effort was the ‘Brothers y Hermanos’ collaboration to assess current efforts. This study published in 2007, is one of the first to elucidate the behaviors of Hispanics in America that discovered creating trust among Hispanics was negatively associated with HIV infection. As of yet, specific interventions are unimplemented (25). Among several interventions targeted at Hispanics, the majority are individual level counseling sessions or small-group activities that have been derived from predominantly white, homosexual identifying groups (26). These types of interventions may not necessarily be successful because of cultural differences in acceptance of homosexuality. Supervision of adolescents is seen as a community effort rather than an individual family’s responsibility in traditional Hispanic communities, but in American society, these community norms have not persisted (16). Because many gay men are being rejected by families as being unacceptable and detestable, these men are seeking alternative avenues for social needs such as the sex clubs and shooting galleries.

Where to go from here?

The current trend of HIV infection among MSM is increasing which was preceded by a decrease in the rate of infection during the 80’s and 90’s. The reason rates have continued to increase is the lack of intervening at a fundamental level of acceptance of MSMs into the general population, resulting in social stigmas and underground sexual networks. These networks are often accompanied by drugs and alcohol, which can lead to riskier behaviors, leading to further infection. Not addressing culturally sensitive messages is a mistake because the communities are a potential source of positive support for MSM.

Interventions that are successful have been those based on peer norms and utilized social networking theory as a basis for outreach and this is where interventions should be headed. Peer norms were associated with greater condom use among MSMs and this could be a future target of interventions (18). An intervention at the community level (especially among the gay community in areas of the country where homosexuality is not readily accepted) would be beneficial as suggested by Hays et al. (14). Of the few interventions that have worked, social networking theory has shown in its infancy that groups can influence individual behavior and positive trends of condom use (27). In group interventions that attempted to intervene within groups of individuals with similar interests, studies indicated a 23% reduction in the proportion of men engaging in unprotected sex compared to individual-based interventions. When these interventions were targeted at men in their 20’s, the overall response from the group was positive and accepting (28).

There is hope. Social groups are a place to target interventions as people feel tied to communities and that is a place where trust can be built. These communities need to be made aware of the risks of HIV. The first order is to create outreach programs and campaigns that are culturally sensitive to MSMs, so that they don’t feel they are being ostracized for being a part of that cohort. They must be able to identify the risks that press their group. If acknowledging the presence of a problem fails, all other efforts will fail because the community will continue to be ostracized. There could be an effective use of social marketing theory to address where some short comings are and provide the products and ads that are needed to be effective tools. For instance, Fenway Community Health ran a campaign in 2007 trying to reach out to the MSM community to make them aware of the potential of certain STD infections through flyers and advertisements on the subways that portrayed two men casually sitting together without any depiction of the stereotypical ‘being gay’ images that the Montana group depicted. The Fenway ad appealed to a core value of family and love, and it sent a message of acceptance and normality to all those that viewed it. Using the Fenway campaign as a stepping stone, a combination of social expectations theory with social networking theory to create an even broader and applicable campaign directed at making seeking treatment and prevention of HIV less taboo, targeting risk behaviors can become a reality.


1.) Center for Disease Control and Prevention. HIV/AIDS surveillance report 2005. Atlanta, GA. Center for Disease Control and Prevention.

2.) Futterman, DC. 2005. HIV in adolescents and young adults: half of all new infections in the United States. Top HIV Med. 13(3): 101-105.

3.) Advocates for Youth. 2008. HIV/STD Prevention and Young Men Who Have Sex with Men. Washington, DC.: Advocates for Youth.

4.) Agha, S. 2003. The impact of a mass media campaign on personal risk perception, perceived self-efficacy and on other behavioural predictors. AIDS Care. 15(6): 749-762

5.) CNN. Key Ballot Measures. Atlanta, GA: Turner Broadcasting Company.

6.) Horn, S. 2007. Adolescents’ Acceptance of Same-Sex Peers Based on Sexual Orientation and Gender Expression. Journal of Youth and Adolescence. 36(3): 363-371

7.) Garofalo, R.; Mustanski, BS.; McKirnan, DJ.; Herrick, A.; Donenberg, GR. 2007. Methamphetamine and young men who have sex with men. Arch Pediatr Adolesc Med. 161(6): 591-596

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11.) Waldo, CR; McFarland, W; Katz, MH; MacKellar, D; Valleroy, LA. 2000. Very young gay and bisexual men are at risk for HIV infection: the San Francisco Bay Area Young Men's Survey II. Journal of Acquir Immune Defic Syndr. 24(2): 168-174

12.) MMWR. 2002. Unrecognized HIV Infection, Risk Behaviors, and Perceptions of Risk Among Young Black Men Who Have Sex with Men --- Six U.S. Cities, 1994—1998. MMWR CDC Weekly. 51(33): 733-736

13.) Valleroy, LA.; MacKellar, DA.; Karon, JM, et al. 2000. HIV prevalence and associated risks in young men who have sex with men. JAMA 284(2):198-204.

14.) Hays, RB.; Kegeles, SM.; Coates, TJ. 1997. Unprotected sex and HIV risk taking among young gay men within boyfriend relationships. AIDS Educ Prev. 9(4): 314-329

15.) Busen, NH.; Marcus, MT.; Sternberg, KL. 2006. What African-American middle school youth report about risk-taking behaviors. Journal of Pediatric Health Care. 20(6): 393-400

16.) Prado, G.; Schwartz, SJ.; Pattatucci-Aragon, A.; Clatts, M.; Pantin, H.; Fernandez, MI.; Lopez, B.; Briones, E.; Amaro, H.; Szapocznik, J. 2006. Drug and Alcohol Dependence: The prevention of HIV transmission in Hispanic adolescents. Drug and Alcohol Dependence. 84(S1): S43-S53

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18.) Maslow, CB.; Friedman, SR; Perlis, TE; Rockwell, R; Des Jarlais, DC. 2002. Changes in HIV Seroprevalence and Related Behaviors Among Male Injection Drug Users Who Do and Do Not Have Sex With Men: New York City, 1990–1999. Am J Public Health. 92(3): 382-384

19.) Fullilove, MT.; Golden, E.; Fullilove, RE.; Lennon, R.; Porterfield, D.; Schwarcz, S.; Bolan, G. 1993. Crack cocaine use and high-risk behaviors among sexually active black adolescents. J Adolesc Health. 14(4): 295-300

20.) Martinez, C; Weiner, M; Johnson, D; Reyes, M; Garza, M; Catala, S. 1991. Hispanic HIV negative gay men and culturally sensitive intervention. Int Conf AIDS. 7: 297

21.) Marin, BV. 2003. HIV Prevention in the Hispanic Community: Sex, Culture, and Empowerment. Journal of Transcultural Nursing, 14(3): 186-192.

22.) Adimora, AA.; Schoenbach, VJ. 2005. Social context, social networks, and racial disparities in rates of sexually transmitted infections. The Journal of Infectious Diseases. 191: S115-S122

23.) Blair JM, Fleming PL, Karon JM. Trends in AIDS incidence and survival among racial/ethnic minority men who have sex with men, United States, 1990-1999. 2002. J Acquir Immune Defic Syndr. 31(3):339-47.

24.) Health Resources and Services Administration. HIV/AIDS Work Group on Health Care Access Issues for Gay and Bisexual Men of Color. Washington, DC: US Department of Health and Human Services, 1995:33.

25.) Los Angeles County Public Health. The Public’s Health. Los Angeles, CA: Los Angeles County Public Health.

26.) Center for Disease Control and Prevention. HIV/AIDS Among Hispanics/Latinos. Atlanta, GA: CDC HIV/AIDS Resources.

27.) Amirkhanian, YA.; Kelly, JA; Kabakchieva, E.; McAuliffe, TL.; Vassileva, S. 2003. Evaluation of a Social Network HIV Prevention Intervention Program for Young Men Who Have Sex with Men in Russia and Bulgaria. AIDS Education and Prev. 15(3): 205-220

28.) Johnson, WD; Hedges, LV; Diaz, RM. 2003. Interventions to modify sexual risk behaviors for preventing HIV infection in men who have sex with men. Cochrane Database Syst Rev. (1): CD001230

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