Challenging Dogma - Fall 2009

Thursday, December 17, 2009

Saving Face: Failures of HIV Prevention Programs... - KJ

Saving Face: Failures of HIV Prevention Programs for Asian-American/Pacific Islander Men who have Sex with Men to Address Social and Cultural Stigmas of Homosexuality and HIV– KJ

The spread of Human Immunodeficiency Virus (HIV) among Asian-American/Pacific Islander men who have sex with men (AAPI MSM) is a growing public health problem in the United States. Although a number of public health interventions have attempted to address this issue, HIV continues to spread at increasing rates among AAPI MSM (1, 2).
Current interventions to prevent the spread of HIV among AAPI MSM often fail to recognize and adapt to unique aspects of AAPI culture and tradition. Interventions should address the root causes of cultural stigmas towards HIV and homosexuality in order to maximize effectiveness in preventing high-risk sexual practices and HIV transmission. Through utilization of social theory models and research understanding social and cultural values in AAPI communities, we can develop new interventions to create a larger impact in HIV prevention among AAPI MSM.
In the United States, HIV affects men who have sex with men (MSM) at disproportionately high levels and at an increasing annual rate of infection. More than one million people have HIV in the U.S. and MSM account for 48% of this population (3). Furthermore, MSM make up more than two-thirds of all men living with HIV, despite the fact that only 5 – 7% of men in the U.S. reported having sex with other men (4). The annual number of new HIV infections among MSM has been steadily increasing since the early 1990s, compromising 53% of new HIV infections in the U.S. each year. In contrast, new infection rates from 2004-2005 have declined among groups other than MSM, such as heterosexuals (3.5% decrease) and injection drug users (3% decrease) (5).
MSM constitute a particularly high portion of the HIV positive population within the U.S. Asian-American/Pacific Islander (AAPI) demographic: 61.3% of all AAPI with HIV are MSM (1). Furthermore, MSM comprise 72% of the cumulative AIDS cases among the U.S. AAPI population. This is the second highest proportion compared to that in other racial/ethnic groups, following only two percentage points behind the proportion of MSM among White AIDS patients (6).
Several factors help explain the disproportionately high HIV/AIDS infection rates among AAPI MSM. AAPI MSM are significantly less likely than other racial groups to report having been tested for HIV, and routine HIV testing has a demonstrated effect in preventing the spread of HIV (1, 3). Furthermore, AAPI MSM generally engage in riskier behaviors than MSM in other racial/ethnic groups. In a San Francisco study, results indicated that from 1999 to 2002, AAPI MSM rates of unprotected anal intercourse with multiple partners increased steadily each year, starting from 12% in 1999 and rising to 20% in 2002 (7). This 67% increase compares to only a 5% increase among White MSM, although rates were initially higher in the White population. Furthermore, unprotected anal intercourse among AAPI MSM with two or more sex partners of unknown HIV serostatus increased from 6% to 16% compared with an increase from 12% to 14% in White MSM during that same time period (7).
Although the actual prevalence of HIV infection in AAPI MSM is comparatively compared to other groups, recent upward trends in unprotected anal intercourse and incidences of sexually transmitted infections (STIs) suggest a reversal in the relative risk between AAPI MSM and White MSM. For example, incidences of rectal gonorrhea and syphilis among AAPI MSM have significantly increased over the last several years (8). Despite these trends, HIV prevention research and intervention programs often overlook the AAPI subset of MSM (9).
Past HIV prevention programs for MSM, including AAPI MSM, have applied traditional psychosocial models to target the individual’s knowledge, beliefs, norms, and attitudes related to HIV (10). For example, the Gay Asian and Pacific Islander Alliance Community HIV Project adopted three major models of social cognitive theory (Health Belief Model, Theory of Reasoned Action, and Social Learning Theory) to develop safer sex skills and HIV prevention training for AAPI MSM. The intervention consisted of one 3-hour session in small groups that facilitated development of positive self-identity and social support, safer sex education, eroticizing safer sex, and negotiating safer sex (10). To cultivate positive self-identity and social support, the program focused on highlighting personal strengths and sharing negative experiences of being AAPI and homosexual (11). The participants were encouraged to acknowledge personal strengths and to be more open about their personalities and sexual preference. The program’s safer sex education explained modes of HIV transmission and the dangers involved in high-risk sexual behaviors such as one night stands. In sessions that eroticized safer sex, participants shared lists of erotic but safe ways of being intimate with a partner and learned about the correct use of condoms and how to make their usage more sensual. Lastly, participants engaged in role play demonstrations to encourage themselves to not be embarrassed or to feel apologetic about bringing up the topic of safer sex. Equally important, participants were educated on ways to refuse unsafe sex with partners (11). As a result, the project helped to create a 46% reduction in multiple partnerships among participants of all ethnicities in the AAPI group and a greater than 50% reduction in unprotected anal intercourse among Chinese and Filipino participants (10).
Despite these positive results, the intervention could be improved in several ways. It did not acknowledge the impact that traditional values within AAPI communities and families have on AAPI MSM and the resulting perceptions that members of this community hold towards their HIV infection susceptibility. The lack of dialogue about sex in the AAPI communities often leads to a poor understanding of HIV and its prevention and treatment. Furthermore, the intervention did not address how the “dual identity” as a gay man and an AAPI impacts high-risk behavior and the spread of HIV. As a result, a culturally competent intervention that addressed the disconnect regarding sex in family dialogue, encouraged HIV testing as a social norm within AAPI MSM communities, and marketed the harmony of identities as a gay man and of AAPI ethnicity could be an effective HIV prevention initiative among AAPI MSM.
The Lack of Dialogue about Sex
The Gay Asian and Pacific Islander Alliance Community HIV Project fails to address the important role that the AAPI community and family unit has on the behaviors and perceptions of AAPI MSM. The intervention fails to sufficiently reach out to peers and elders of MSM within the AAPI community. Encouraging dialogue about sex and homosexuality would ultimately foster a healthier and more understanding environment for AAPI MSM.
In contrast to the individualism typical of Western society, AAPI communities generally place more emphasis on collectivism, group harmony, and the conformation of individuals to promote the happiness of the group and community (12). In AAPI communities, premarital sex is generally disapproved and communication about sex in AAPI families is rarely encouraged. The lack of dialogue about any sex and the strong stigmas associated with homosexuality makes it especially difficult for AAPI MSM to come out to their families regarding their sexuality. Fear of being ostracized or inflicting dishonor to the family are common reasons that AAPI MSM stay closeted. For AAPI MSM, social support in the family system is a powerful safe haven from adversity faced as ethnic minorities in the U.S. and many strive to preserve this bond (6). As a result, if AAPI MSM hide their sexualities, they will be less inclined to attend interventions for HIV prevention due to uncomfortable feelings of acknowledgement of their sexuality or belief that they are not at risk for the disease.
The lack of discussion about sex in the family unit creates an automatic deficit in sexual health knowledge among AAPI MSM, thus contributing to increased chances of high-risk behavior. According to the AIDS Risk Reduction Model (ARRM), an individual passes through three stages in order to adopt behavioral changes to protect him or herself from contracting HIV. The first stage, recognizing and labeling one’s behavior as high-risk, involves knowing the methods of HIV transmission and believing that one is personally susceptible to the disease (13). The next stage involves making a commitment to a behavior change to decrease high-risk activities and promote low-risk activities. Finally, the third stage involves taking action to reduce high-risk behaviors. In a study of sexual behaviors among Asian-American college students, researchers found that a typical Asian-American college student lacked basic information about HIV transmission, risk and prevention (14). In another study by the California Collaborations in HIV Prevention Research Dissemination Project, researchers found that many of their AAPI MSM participants were uncertain about their risk for HIV through oral sex (15). According to the ARRM, the lack of knowledge regarding susceptibility and transmission of HIV does not allow one to pass through the other stages towards behavior change. Furthermore, the stigma associated with outwardly discussing sex can cause AAPI students to be less receptive to safe sex messages in sex education classes provided by most high schools. As a result, AAPI MSM may unknowingly engage in high-risk sexual behavior due to their lack of sexual health knowledge and may lack the impetus to change their behaviors (10).
The resulting oversight in including families of AAPI MSM in the safe sex/HIV prevention initiative creates a deficit in the outreach and success of the initiative. Without encouraging dialogue within families for AAPI youths, families will continue to consider discussions about sex to be taboo, thus contributing to the internalization of sexuality by AAPI MSM and their lack of self-efficacy to advocate for safer sex practices with their partners.
The Taboo Associations with HIV Testing and Perceived Susceptibility to Infection
The Gay Asian and Pacific Islander Alliance Community HIV Project addressed the modes of transmission for HIV and the risks of infection involved in high-risk sexual behaviors. However, the program inadequately addressed the taboo associations with HIV testing and the risk of susceptibility for AAPI in particular. Although the participants gained knowledge about the HIV acquisition and transmission, they have the potential to engage in high-risk sexual behaviors because their specific susceptibility to the disease as AAPI was not emphasized. Furthermore, the intervention did not address social fears among AAPI MSM that are associated with HIV testing, thus increasing the possibility of HIV infection and propagation of the virus to partners because these men are unaware of their infection status (3).
Because AAPI communities shy away from discussing sex and STIs, AAPI MSM’s lack of knowledge regarding STI transmission puts them at high-risk for infection (12, 14). Researchers observed that the risk of HIV infection is increased when individuals at high-risk perceive themselves to be at low-risk. For example, AAPI MSM who perceived themselves to be at low-risk for acquiring and transmitting HIV were more likely to engage in unprotected anal intercourse (12). As a result, AAPI MSM fall prey to the optimistic bias. The optimistic bias states that individuals feel that they are less likely than other people to fall prey to harmful events in their lives, but more likely to experience beneficial events (16). An HIV testing survey featured by the CDC stated that 90% of AAPIs perceived themselves to be at some risk for HIV infection but only 47% of them had been tested in the past year (2). This indicates that they believe their true susceptibility for HIV to be much lower, thus increasing their likelihood of high-risk sexual behavior.
Stigma due to HIV can alienate AAPI MSM from HIV testing due to cultural beliefs that HIV is acquired through socially unaccepted behaviors such as homosexuality, substance abuse and sexual promiscuity (12). In response to familial and community avoidance of issues surrounding homosexuality, AAPI MSM may be less inclined to obtain information regarding the importance of HIV testing to aid in prevention and spread. Furthermore, AAPI MSM may be motivated by fears of alienation and “bringing shame” to the family if they do test positive for HIV and have to disclose the information to their families. In essence, to save face among their families, AAPI MSM risk their own health.
In developing HIV prevention initiatives for AAPI MSM, it is simply not enough to educate about HIV transmission. The initiative lacked efforts to inform AAPI MSM of their susceptibility to contracting the virus and to encourage HIV testing as a means of prevention. As a result, the intervention is not fully effective in decreasing the risk for situations of HIV infection among AAPI MSM.
The Dual Identity Dilemma
The intervention conducted by the Gay Asian and Pacific Islander Alliance Community HIV Project was individual-focused, and attempted to instill a sense of self-efficacy and empowerment among AAPI MSM to be more vocal about safe sex practices. Although the intervention discusses the negative struggles of being both AAPI and homosexual, it does not give inspiration on how these two “dual identities” within AAPI MSM can coexist and where one can find resources to strengthen these characteristics into one core identity.
AAPI families stress the importance of family roles and obligations. For men, this often means marrying a woman and passing on the family name with a son. However, for AAPI MSM, their sexual preference for men contends with the possibility of fulfilling these familial expectations, thus causing strong feelings of guilt and anxiety regarding sexual identity and behavior (9). Furthermore, AAPI MSM confront homophobia within their AAPI social networks and racism in their gay social networks. As a result, AAPI MSM contend with the dual identity of being ethnically AAPI and a homosexual man, and often have trouble feeling comfortable in either group. Consequently, these social pressures cause them to prioritize between these two identities, creating internal personality tension. Some adopt a “don’t ask, don’t tell” policy within their AAPI social networks to avoid “bringing shame” and discomfort to their families (9). Others who perceive racism and prejudice towards AAPIs within the gay community adopt feelings of unstable social identities, alienation and estrangement from the gay community (9). With no “safe haven” social network, these men downplay their personal vulnerability towards HIV and in turn practice unsafe sex (11).
Furthermore, alienation from the gay community makes them more socially vulnerable and inexperienced in talking about and suggesting safe sex practices among their partners. Studies show that AAPI MSM perceive stereotypes in the gay community that depict them as submissive and non-confrontational (9). According to the Theory of Planned Behavior, an individual balances the expectations that they have for doing a particular behavior (e.g. practicing safe sex) with the perceptions of the behavior among individuals they interact with. The behavior is also influenced by their self-efficacy, or belief that they are capable of doing a particular behavior. For AAPI MSM, being subjected to familial alienation as a homosexual man as well as being discriminated within the gay community as a submissive, non-confrontational individual may result in a lack of self-confidence to advocate for a use of a condom in sexual situations. This action is assured by previous evidence showing that AAPI MSM believe that they are at lower risk for HIV. Therefore, their expectations of not using a condom may not include contracting HIV. As a result, AAPI MSM prioritize their partner’s comfort and pleasure over their own health.
Without careful consideration of the inner struggles that AAPI MSM face in their relationships in both the gay and AAPI communities and the ways to resolve these struggles, the intervention fails to change the core reasons for high-risk sexual behavior among AAPI MSM.
A Culturally Competent Alternative Intervention
Through consideration of the deficits in the Gay Asian and Pacific Islander Alliance Community HIV Project to prevent HIV transmission and high-risk sexual behavior among AAPI MSM, new and improved interventions can be developed. Behaviors among AAPI and AAPI MSM suggest that a culturally competent intervention that (1) addressed the disconnect regarding sex in family dialogue, (2) encouraged HIV testing as a social norm within AAPI MSM communities, and (3) marketed the harmony of identities as a gay man and of AAPI ethnicity would be an effective HIV prevention initiative. To achieve these tasks, the intervention can effectively utilize social theory models such as social expectations theory to encourage dialogue among families, or social marketing theory to instill positive values of self-worth and self-esteem in AAPI MSM.
Through utilization of social expectations theory, establishing dialogue about sex and STIs as a standard among AAPI families can encourage feelings of acceptance and practices of safe sex among AAPI MSM. Social expectations theory states that individuals adjust their behaviors to conform to the expectations of others and the existing social norms. If families are encouraged to establish dialogue about sex and different sexual orientations in order to promote the health of their family members, this dialogue can eventually be established as a social norm among the AAPI culture. As a result, AAPI MSM will be more inclined to be open about their sexual preference, with a decreased fear of alienation among their families and cultural community. Furthermore, increased dialogue generates a better understanding within the AAPI MSM population about HIV transmission and their susceptibility to the disease. Local community leaders can begin dialogue among families and encourage discussion in safe spaces for the families and community (such as neighborhood centers or churches/temples). The incentive for discussion can be the knowledge that they are helping to keep their future generations healthy through preventing the spread of HIV. This increase in HIV transmission knowledge allows AAPI MSM to move forward through the AIDS Risk Reduction Model, thus increasing the potential for behavior change to safe sex practices.
Finally, open discussion between family members of AAPI MSM will generate higher probabilities that this population will be inclined to attend interventions and adopt suggestions for safe sex practice. Therefore, interventions for AAPI MSM which include their family and community members can begin to break the root of the cultural stigmas regarding homosexuality and HIV. This increasingly open community and dialogue can in turn increase self-efficacy among AAPI MSM for safe sex behaviors, thus reducing their risk for HIV infection.
It is also important for an effective HIV prevention and safe sex campaign to encourage HIV testing and to educate about the realistic probabilities of infection. Utilizing principles of social expectations theory, an intervention can establish HIV testing as a social norm within the AAPI MSM community. Thus, more people will be inclined to get tested. Furthermore, interventions can analyze the conditions and locations in which AAPI MSM are comfortable to undergo testing. By providing a comfortable location for AAPI MSM to undergo testing, HIV testing practices can be increased (17). Studies have found that the comfortable location should include culturally sensitive testing procedures with appropriate linguistic translators for AAPI MSM in which English is not their primary language. Also, the type of testing technology available should be made aware, especially in the case of AAPI MSM who may cite a fear of needles as a barrier to testing (17).
Improved interventions should also inform AAPI MSM of the realistic risk that men of their community face with regard to HIV infection. Interventions need to stress the fact that AAPI MSM, like other ethnic groups, are susceptible to the disease and should take the proper precautions to prevent against infection (18). These precautions would include safe sex practices as well as regular STI testing.
Finally, prevention initiatives that supported the dual identity of AAPI MSM and helped them integrate their AAPI ethnicity with their sexual preference would encourage safe sex practices and increased awareness about HIV susceptibility and testing. One way this can be accomplished is through social marketing theory. Social marketing theory utilizes core concepts from commercial marketing to plan and implement programs for social change and action. The theory appeals to people’s core values and, as a result, “sells” behavior to the targeted group. By increasing the representation of AAPI MSM in mainstream media targeted for MSM of all ethnicities, AAPI MSM would not feel as alienated and discriminated by their MSM peers. This could increase their self-esteem and self-efficacy with regard to safe sex practices. Furthermore, social marketing initiatives for HIV prevention among AAPI MSM could appeal to their core values by depicting AAPI MSM as strong, capable individuals, characteristics valued within the AAPI communities. These messages can be transmitted via specific outreach by AAPI MSM peer leaders and through media targeted for MSM. As a result, this portrayal would serve to trump feelings of submissiveness and emasculation imposed by peers of AAPI MSM, thus further contributing to their self-efficacy. Also, these positive portrayals of AAPI MSM would debunk expectations of submissiveness and non-confrontational behavior by MSM of other ethnicities, thus encouraging more positive, respectful partnerships.
Building on principles of social marketing theory, empowerment theory can also be used to help develop initiatives to address the dual identities experienced by AAPI MSM. Empowerment theory depicts the process by which individuals gain the power, resources and ability to achieve their highest potential and goals. Among AAPI MSM, one goal would be to be accepted by both the AAPI community as a homosexual and by the gay community as an equal. Using the strengths of empowerment theory, individuals can be motivated to develop the self-esteem needed to be open with their families and encourage dialogue about their sexuality. Furthermore, they can be encouraged to take part in active dialogue with their MSM peers and advocate for protection of their own health in sexual encounters. As a result, AAPI MSM can create synergy between their identities as a gay man and an AAPI, thus facilitating higher self esteem and increased advocacy for safe sex.
Lastly, we can use diffusion theory to help mesh the dual identities present within AAPI MSM to produce more awareness and practices of safe sex for HIV prevention. Diffusion theory states that community members are most likely to adopt new ideas and behavior changes when the ideas are communicated by relatable “leaders” within their natural networks. By creating peer-run support groups among AAPI MSM and using peer-designated leaders, the division between ethnic and sexual identity can be decreased and the incorporation of safe sex practices for HIV prevention can be increased. A designated, relatable AAPI MSM peer leader can serve as the impetus to encouraging dialogue among their AAPI and gay communities, thus bridging the gap between identities. Furthermore, the peer leaders can encourage the adoption of safer sex practices. A 1996 study by Kegeles, Hays and Coates demonstrated the effects of diffusion theory to increase safe sex practices among MSM. A community received a peer-designated and peer-run community-based HIV risk reduction initiative that lasted for 8 months. The initiative consisted of peer outreach in locations frequented by young MSM and social events created to promote safe sex, among other activities. As a result, researchers saw a significant decrease in unprotected anal intercourse after the intervention (19). Through incorporation of social theories to bridge the gap between AAPI and gay identities in AAPI MSM, we can encourage safe sex practice for HIV prevention.
Although social theory models and current research support the inclusion and establishment of these goals in HIV prevention initiatives for AAPI MSM, there are still potential barriers to implementation. For example, there is potential for strong opposition towards incorporating dialogues about sex and STIs in families. Years of cultural thought regarding topics of sex and STIs as socially taboo will be hard to overcome. However, the use of community leaders as well as facilitation of dialogues in safe spaces may make families more inclined to participate in these discussions. There are also barriers to establishing HIV testing as a social norm within the AAPI and AAPI MSM communities. Due to the current lack of dialogue regarding STIs and lack of perceived susceptibility to the disease among these communities, it is difficult to establish a trend for STI awareness and testing. This barrier may be overcome by debunking the myths of reduced susceptibility to the disease within AAPI populations and framing the practice of STI testing as a responsibility to the well-being and function of the collective community rather than just to one’s own health. Lastly, the persistence of the mainstream derogatory stereotypes of AAPI men can also serve as a barrier towards improving the self-esteem and self-efficacy of AAPI MSM. While the stereotypes may persist, AAPI MSM can be discouraged from falling prey to “labels” through reinforcement of their positive self-worth and potential by peer-acknowledged leaders in their AAPI MSM community. Although there are barriers to implementing new goals in interventions for AAPI MSM, there are also methods to overcome these barriers. In the end, we can create new, effective and targeted interventions to reduce the prevalence and spread of HIV among AAPI MSM.
Current interventions for AAPI MSM are incomplete in accommodating the most important reasons for high-risk sexual behavior among the group. For example, the Gay Asian and Pacific Islander Alliance Community HIV Project fails to account for the social and cultural impacts in sexual behaviors of AAPI MSM. Furthermore, the initiative does not focus on encouraging HIV testing among AAPI MSM and bridging the divide in identities faced by AAPI MSM within the AAPI and gay communities. AAPIs are one of the fastest growing ethnic groups in the United States, so it is essential that we pay more attention to promoting the health of MSM in their communities (18). By creating a culturally competent initiative that addresses the disconnect regarding sex in family dialogue, encourages HIV testing as a social norm within AAPI MSM communities, and markets the harmony of identities as a gay man and of AAPI ethnicity, we could encourage safer sex practices and effective HIV prevention among AAPI MSM.

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