Challenging Dogma - Fall 2009

Monday, December 21, 2009

Health Belief Model and HIV Prevention Programs: A Failure to reach Black Men Who Have Sex With Men

-- Beatrice C. Martin


HIV/AIDS has become one of the major public health problems during the twentieth century. Because of the high Incidence of HIV infection in the gay community, much effort to reduce risky sexual behaviors has been targeted at gay men. Nearly half of the people living with HIV in the United States are MSM (10). Moreover, MSM are the only group in the United States in which HIV infection is steadily increasing every year, they account for more than half of new HIV infection each year (10). Public health intervention efforts to educate gay men about safer sex practices have been proven quite successful at the beginning. Gay men reported to have been engaging in sex with fewer partners and have been using condoms more frequently during sex (8).

Despite many public health HIV prevention programs targeting the gay community, there is a concern of the reemergence of the epidemic. Evidence suggests that although rates of new HIV infections declined between the years of mid- 1980 to mid-1990, rates of HIV infections are starting to increase (5). Moreover, black MSM are disproportionally hit by the epidemic compared to any other race and ethnicity. According to Wolitski et al., in 1999 the AIDS incidence rates among African American were more than five times that of the white MSM. Recent trends indicate that black MSM are at greater risk of contracting HIV infection compared to white MSM. Between the years of 1990 and 1995, black MSM AIDS cases increased among African American MSM by 45%, while AIDS cases decreased by 2% among white MSM(5).

One theory widely used to guide HIV prevention interventions is the health belief model. The health belief model is applied in the development of prevention programs to modify health behavior. It elucidates the relationship between individual health beliefs associated with a disease and the likelihood of engaging in preventive health actions (1). A number of studies of AIDS-preventive behavior have been based, in part, on the health belief model (1). The main components of the health belief model to HIV prevention are as follow: AIDS preventive behavior is a function of perceived vulnerability to HIV infection, perceived severity of HIV infection, perceived costs and benefits of HIV/AIDS preventive behavior, and cues to action (1) and self- efficacy, which is defined as the conviction that one can successfully execute the behavior required to produce the outcomes (12). HIV-preventive programs based on theoretical frameworks like the health belief model has not proved to be effective among the black MSM as the rise of HIV incidence rate is higher than the white MSM population. The efforts of HIV risk reduction strategies were not effective in decreasing the rate of HIV infection among the African American Population (11). The health belief model is an individual-focused model that has limitations in addressing the historical, social context of black MSM living in African American communities.

Failure to address the historical context of Black MSM as African Americans in the country

A limitation of the health belief model is the implication that people exist in similar cultures and have similar degrees of control over their environment (12). As an individual -focused model, the health belief model fails to address the historical and social context of HIV/AIDS among the black MSM communities. The experience of African American in this country is unique due to their history of racism and slavery. A lack of mistrust in the government makes it more challenging for public health messages to effectively reach African Americans. According to Bogart et al. article, a handful of studies shows evidence that a significant group of African American hold conspiracy beliefs that HIV/AIDS is a form of black genocide. Hereck and Glunt conducted a national telephone survey in which they found that two third of blacks (67%) agreed that the government is not telling the truth about AIDS, and another national telephone survey conducted by Hereck and Capotino found that twenty percent of black Americans believe in the statement that the government in using AIDS as a way of killing minority groups (7). The revelation of the Tuskegee Syphilis study confirms long held beliefs among the black communities that the government should not be trusted. After the study has been exposed, charges surfaced that the experiment was part of a governmental plot to exterminate black people (3). Thomas and Quinn argued that the legacy of this experiment with its failure to educate the study participants and treat them adequately, laid the path for today’s pervasive sense of the black distrust of public health authorities (3). The belief of genocide and the distrust of the health authorities are foundation for opposition to many strategies that will directly reduce transmission of HIV. Intervention programs framed by the health belief model to modify the individual’s health behavior will not be effective if the targeted black MSM hold beliefs of genocide and if they mistrust health authorities. They will not take into consideration information and messages they receive about AIDS. This mistrust will get in the way of AIDS education strategies that use theoretical framework like the health belief model to target black MSM within the black communities.

Failure to approach Homophobia in black communities

The HBM model views the individual as devoid of emotion and has the capacity think rationally (1). However, the interaction of the individual and the social environment may bring about situational and emotional difficulties that affect HIV risk behaviors (1). In the United States, HIV- related stigma and discrimination are closely related to negative thoughts surrounding homosexuality (9). African American communities often condemn homosexual behavior, and being homosexual is seen as weakness and embarrassment. As a result, African American men who have sex with men are more “closeted” than white men who have sex with men (9). Research shows that African American gay men and MSM are likely to experience prejudice, discrimination and even threats of physical violence based both on their status as gay and MSM in the black community (9). Therefore, Black MSM who fear discriminations and who do not want to be perceived as weak homosexuals in their community hide their sexual orientation. They stay “in the closet” in order to avoid prejudice and threats of physical violence. They tend to identify themselves as heterosexuals, while secretly having sex with other men. Black MSM who hide their sexual orientation are more likely to engage in risky sexual behavior.

Fear of being perceived as gay in their communities may cause Black MSM to avoid expressing any concerns about the HIV epidemic and discussing condom use. This group is less exposed to HIV prevention messages targeting the gay community. They are not aware of the risk factors associated to HIV transmission and how they can reduce their risk of getting infecting. Relative to white men who have sex with men, African American men has less accurate knowledge about HIV risk reduction steps (6). Moreover, AIDS education campaigns targeting the gay community have not successfully reached black MSM who are not open about their sexual orientation (6).

Failure to approach poverty and HIV risk behavior

From an ecological perspective, understanding HIV risk behaviors means understanding how the environment shapes the choices and opportunities available to the individual (12.). The rational presumption that individuals have resources to make preventive HIV risk decisions and that they have control over their environment to change their risk behavior can be challenged. The health belief model does not address the interaction of individuals and their environment. Individuals living in poor neighborhoods have limited resources and are mostly under stressed. When African American men have a prolonged exposure to stress, it may result in individuals denying the threats of a stressful situation or refusing to think about it. African American males denying their risk of contracting HIV may engage in higher risky sexual behavior; they may also deny the realty of HIV/AIDS in the African American community (12). Black MSM living in poor neighborhoods are more likely to have sex with men in exchange for money or drugs. A study found that homosexual and bisexual men with low income who had been paid to have sex with men are less likely to use condoms (11).

An effective approach to HIV prevention among black MSM: Community-Level Intervention.

Research potentially helpful to African Americans has been severely limited because of the exclusion or underrepresentation of this specific group in prevention intervention research or the lack of focus on African Americans at higher risk for HIV infection like the MSM (12). Effective intervention programs to HIV prevention among black MSM should take into account the cultural, historical and socio-economic factors of that group. Public health efforts to change black MSM sexual risky behaviors should promote positive views and acceptance of homosexuality among the black community. Moreover, the messages of HIV prevention programs that target black MSM population should be culturally sensitive in order to successfully reach that community.

Community- level interventions to HIV prevention can be an effective approach to decrease HIV-risk behavior among the black MSM community. Community-level interventions are those that target communities often defined by sex, geography, sexual orientation, risky behaviors and sexual orientations rather than a specific individual. This intervention includes the involvement of community members in the actual design and delivery of the intervention. Community-level intervention aims to change community norms about high risk behaviors. An important aspect of this intervention is the involvement of the target population in formal or informal activities, programs, group discussions, to come up with planned improvement and change in community life, resources(4).

This intervention approach to HIV prevention among black MSM can be effective in addressing the experience of African Americans in this country with discrimination, racism and the mistrust that they hold against public health professionals. The intervention should first choose one or more black MSM leaders within a black community. The involvement of black gay men in the design and study of the intervention may have more positive response to HIV prevention messages targeting black MSM. Black MSM may listen and trust one of their peer leaders rather that a white counterpart. Kelley and colleagues recruited opinion leaders from communities of gay men, trained them in HIV prevention messages and message delivery, and asked them to take these messages back to their communities. Controlled studies showed that these interventions changed community norms, and self-reported risky sexual behaviors among these communities (6). CDC study’s findings provide evidence that HIV prevention endorsement messages, modeled and delivered in outreach fashions by members belonging to the same social group can reduce risk behavior levels in community population (2).

Community-level intervention is mostly founded in the effort to influence individual behavior by changing the social context of communities. In this view, widespread and enduring reduction in risky sexual behaviors among black MSM will not be achieved without new norms governing condoms, and an increased tolerance of homosexuality by African American communities and organizations (4). With an increased acceptance of homosexuality in the black community and changing community norms about HIV-related stigma, black MSM may be able to be open about their sexuality and seek HIV prevention messages. An important factor of the community level in reducing risk behavior among black MSM is the involvement of black gay men members who are conveying the message of condom and promotion of safe sex within their communities. Social theory tells us that peers are important behavioral role models who can establish and redefine population norms, including those of condom use (2). Unemployment may encourage some black MSM to have sex in exchange for money. This situation increases risk behavior because this group has no control over the use of condoms. Community-level interventions find the need for communities to pursue economic and political development, to help men in their community find jobs (4). Trained MSM leaders or peers can work in African American neighborhoods to address common problems such as unemployment and drug abuse.


As shown, the health belief model approach to HIV prevention among black MSM fails to address the social, economic and historical context in which individuals interact. Moreover it assumes that individuals control over their behavior. However, individuals with low social economic status have no control over choosing to use condoms if they engage in sex for money. The community-level approach to HIV prevention addresses the social context of individuals by trying to change the community norms and decreasing homophobia in the black community. Community- level HIV prevention interventions must grow from and be owned by the target population one wants to reach in order to be successful.


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