“Boys Must be Men, and Men Must Have Sex with Women”: A Qualitative CBPR Study to Explore Sexual Risk among African American, Latino, and White Gay Men and MSM

Abstract

Men who have sex with men (MSM) continue to be disproportionately impacted by HIV and sexually transmitted diseases (STD). This study was designed to explore sexual risk among MSM using community-based participatory research (CBPR). An academic-community partnership conducted nine focus groups with 88 MSM. Participants self-identified as African American/Black (n=28), Hispanic/Latino (n=33), white (n=21), and bi-racial/ethnic (n=6). Mean age was 27 (range 18–60) years. Grounded theory was used. Twelve themes related to HIV risk emerged, including low HIV and STD knowledge particularly among Latino MSM and MSM who use the Internet for sexual networking; stereotyping of African American MSM as sexually “dominant” and Latino MSM as less likely to be HIV infected; and the eroticization of “barebacking.” Twelve intervention approaches also were identified, including developing culturally congruent programming using community-identified assets; harnessing social media used by informal networks of MSM; and promoting protection within the context of intimate relationships. A community forum was held to develop recommendations and move these themes to action.

Introduction

Although gay communities in the United States (US) are credited with making major reductions in, and sustaining relatively low levels of, sexual behavior that put them at risk for HIV during the 1980s and into the early 1990s, HIV and sexually transmitted disease (STD) incidence has been increasing among men who have sex with men (MSM) in the US since the mid-1990s (Nanin, et al., 2009; Naughton & Rhodes, 2009; Wolitski, Valdiserri, Denning, & Levine, 2001). In fact, since 2001, MSM across all racial and ethnic groups have been the only transmission group with significant increases in HIV diagnosis, and the majority of all new AIDS cases among all MSM are diagnosed in racial/ethnic-minority men (Centers for Disease Control and Prevention [CDC], 2001a, 2008a). In a 2005 study of 5 large US cities, 46% of African American/black MSM were HIV-positive, compared to 21% of white MSM. In 2001, the AIDS case rate for Hispanic/Latino men was triple that of white men, and Hispanic/Latino MSM aged 23–29 years have twice the rate of HIV infection of their white peers (CDC, 2005).

In 2008, new subpopulation analysis reinforced the severity of the HIV epidemic in MSM of all races and ethnicities. The new analysis utilized HIV surveillance data, testing and treatment history, and the serologic testing algorithm for recent HIV seroconversion (STARHS) results to estimate HIV incidence using a stratified extrapolation approach. The analysis indicated that, in 2006, 72% of new infections among males occurred from male-to-male sexual contact, including 81% of new infections among whites, 63% among African American/blacks, and 72% among Latinos. Hispanic/Latino and African American/black MSM had two and five times the rate of HIV infection of white MSM (115.7 and 43.1 per 100,000 vs. 19.6 per 100,000), respectively. Most new infections were identified in racial/ethnic-minority MSM who were younger (13–29 years old) compared to white MSM (30–39 years old; CDC, 2008b).

HIV and STDs in the US Southeast

Although the southeastern US is experiencing disproportionate HIV infection rates, has higher numbers of AIDS cases, has higher proportions of African Americans/blacks, and is experiencing the most rapid growth rate of Hispanic/Latinos in the country, little is known about the HIV epidemic, and innovative intervention approaches that are likely to be successful, in this part of the country (Reif, Geonnotti, & Whetten, 2006; Rhodes, Hergenrather, Wilkin, & Jolly, 2008; Rhodes, Yee, & Hergenrather, 2006). Most of what is currently documented for MSM is based on early epicenters of the epidemic (e.g., Los Angeles, San Francisco, Chicago, and New York). Furthermore, rates of some STDs are rapidly increasing throughout southeastern US states (Lieb, et al., 2009). For example, cases of syphilis have doubled between 2007 and 2008 in North Carolina (NC; NC Department of Health and Human Services, 2008).

Thus, this study was designed by a community-based participatory research (CBPR) partnership to qualitatively explore sexual risk and identify potentially effective intervention approaches to reduce risk among MSM. CBPR was used because its authentic approach to research can increase the validity of findings and their interpretation, and thus, the meaningfulness and impact of subsequent interventions (Cashman et al., 2008).

Methods

The CBPR Partnership

This study was conducted by a CBPR partnership of over 50 members who are mainly located in northwest and central NC. Members represent the lay community, including African American/black, Latino, and white gay men, organizational representatives, and academic researchers. Membership is open to anyone committed to the partnership’s mission: “meeting HIV/AIDS prevention and care needs in NC through education, research, advocacy and support.” The partnership, which continues to evolve and reflects demographic trends, has existed for more than 8 years and has numerous studies designed to explore and/or reduce HIV risk among heterosexual Latino men, Latina women, and gay men. Partnership members are committed to the principles presented in Table 1.

Table 1.

CBPR Principles of Partnership

To improve community health, we strive to build and maintain trust among each of us – community members, organizational and agency representatives, researchers, and clinicians – through:

Mutual respect and genuineness;

Establishing and utilizing formal and informal partnership networks and structures;

Committing to transparent processes and clear and open communication;

Roles, norms, and processes evolving from the input and agreement of all partners;

Agreeing on the values, goals, and objectives of research and practice;

Building upon each partner’s strengths and assets;

Offering continual feedback among members;

Balancing power and sharing resources;

Sharing credit for the accomplishments of the partnership;

Facing challenges together;

Developing and using relationships and networks outside of the partnership;

Incorporating existing environmental structures to address partnership focuses;

Taking responsibility for the partnership and its actions; and

Disseminating conclusions and findings to research and clinical audiences, community members, and policy makers.

Focus Groups

Focus groups were conducted because the methodology provides the opportunity to investigate participant responses and reactions to HIV risk and intervention more fully than methodologies that collect data from participants individually or have closed-ended questions with predefined response options. Focus groups may reveal key perspectives and nuances that researchers may not be able to foresee. Further, rather than the moderator asking each person to respond to a question in turn, participants are encouraged to talk to one another, ask questions, exchange anecdotes, and comment on one another’s experiences and perspectives (Morgan, 1988; Patton, 1990; Rhodes & Hergenrather, 2002).

In the fall of 2009, nine focus groups were conducted, according to standard focus group research methodology. Focus group recruitment was coordinated by AIDS service organization (ASO) and community-based organization (CBO) representatives, community stakeholders, and lay community leaders throughout NC. Convenience samples of participants were recruited by announcing the focus groups on geographically localized list serves, chat rooms used for social and sexual networking among MSM, and through purposive snowball approaches. Recruitment relied on the trust that members of the partnership have in various MSM communities, including bar communities and “leather” communities. The focus groups were held in the conference rooms in the facilities of trusted community partners in 6 different cities throughout NC: Asheville, Greensboro, Raleigh, Siler City, Wilmington, and Winton-Salem. Eligibility criteria included (a) being male (b) self-identifying as African American, Latino, Hispanic, and/or white; (c) being ≥ 18 years of age; (d) reporting MSM behavior since age ≥ 18 years old; and (e) providing informed consent.

Each focus group was audio-recorded with participant permission. Two male moderators (who also are authors) were present during each focus group, one moderated the focus groups and the other served as the note taker to document nonverbal reactions of the participants and tracking participant dialogue. Focus groups averaged 90 minutes. Each participant received dinner and $40.00 compensation for his time.

To increase validity, a standardized moderator’s guide was used to introduce the methodology, outline the focus group process, and lead the discussion in English for the African American and white focus groups and Spanish for the Latino focus groups. Development of the guide was an iterative process that included: literature review; brainstorm of potential domains and constructs; and development, review, and revision of questions and probes (for clarification) and prompts (for detail). The guide, outlined in Table 2, was crafted with careful consideration to wording, sequence, and content.

Table 2.

Abbreviated Sample Questions from The Focus Group Moderator’s Guide

What kinds of things do you think about when you think about being healthy?

What are your health priorities?

What kinds of things do you think about when you think about being sick or illness?

What kind of health worries do you have?

Where do you usually go for healthcare?

For emergencies?

For non-emergencies?

Why do you go there? What do you like about it? What do you dislike about it?

What is the most important worry you have about your health?

When you hear of, or think about HIV and AIDS, what do you think about?

What worries about HIV do you have?

Would you say that you know enough about HIV? What about sexually transmitted diseases?

How can someone protect himself from these types of illnesses?

Besides using condoms what do men like yourself do to protect themselves?

What do you do to protect yourself?

Why do some people use condoms and others do not?

Why do some people take sexual risks?

What are other reasons why gay men and men who have sex with men would take sexual risks?

How does religion affect sexual risk?

How does alcohol or other drugs affect sexual risk?

What about social expectations about what it means to be a man?

How do these expectations affect sexual risk?

You know we are almost 30 years into the HIV epidemic, but gay men and men who have sex with men continue to be most affected, how would you explain that?

What would you do if you were in charge of HIV prevention programming… maybe for a local program, maybe for the state, maybe for the national government?

What would you do to keep gay men and men who have sex with men safe?

I want you to be creative. What could we do? What should we be doing?

If you wanted to be tested for HIV, where would you go?

What do you think it would be like?

How can gay men and men who have sex with men be reached?

Where should we go to reach at-risk men in the community?

Is there anything else you’d like to share today?

Human subject review and study oversight were provided by the Institutional Review Board (IRB) of Wake Forest University Health Sciences. Written informed consent was obtained from each participant.

Data Analysis

The audio-recorded discussion was transcribed in full detail by a professional transcriptionist. Verbatim transcripts of the focus groups, created in both Spanish and English, were analyzed to identify themes (Miles & Huberman, 1994) using grounded theory, a systematic qualitative methodology. Rather than beginning the inquiry process with a preconceived notion of what was occurring, the approach focused on understanding the breadth of experiences and building understanding grounded in real-world patterns (Glaser & Strauss, 1967). The goal of the analysis was to identify common themes through the qualitative analytic technique of coding text (Miles & Huberman, 1994). A multistage inductive interpretative thematic process was used by partnership members separately reading and rereading the transcripts to identify potential codes, conveing to create a common coding system and data dictionary, and then separately assigning agreed-upon codes to relevant text. Nvivo (QSR International, second edition), an analytic software program, was used to code and retrieve text. This process was not designed quantify participant experiences.

The approach to data analysis adhered to the principles of CBPR, whereby community members were involved in each phase of the research process, including data analysis and interpretation. After preliminary themes were developed, two group meetings were held with lay community members (African American [n=4] and Latino [n=4] MSM) to examine and further refine preliminary themes. The refinement and validation of findings by community members (i.e., gay men and MSM) and during a community forum, described below, ensured that the findings and their interpretation reflected the lived experiences of gay men and MSM.

Community Forum

Revised themes and their interpretation were presented during a community forum to validate findings and develop recommendations to move knowledge generated to action. Forum attendees were invited by staff from the NC Department of Health and Human Services (DHHS) and Wake Forest University School of Medicine. The invitation list included everyone known by NC DHHS staff and the CBPR partnership as working (paid and unpaid) in HIV prevention, MSM health, and the NC gay pride and equality movement throughout NC. The forum was held in Chapel Hill, NC, to allow easy access for attendees from across the state.

The focus group process, data analysis procedures, and findings and their interpretation were presented to the attendees of the community forum. Forum attendees then participated in a facilitated group discussion and brainstorming session. Five primary questions, presented in Table 3, were used to lead the action-oriented discussion. These questions were developed by the CBPR partnership based on previously used and published empowerment education triggers (Eng, et al., 2005; Freire, 1973; Rhodes, et al., 2009). The discussion was captured in bullet-point format on newsprint and displayed around the room. Community forum attendees used these discussion points to make recommendations that also were captured on newsprint.

Table 3.

Empowerment-Based Community Forum Triggers

What do you see in these findings? In what ways do these findings make sense to you? In what ways do these findings not make sense to you? What can be done?/What can we all do? What should we be doing down the road too to reduce risk among MSM?

Results

Focus Group Participants

A total of 88 men participated in one of nine focus groups. Two groups were held in Greensboro, Raleigh, and Winston-Salem each. Participants reported currently living throughout NC, with 17 participants representing three counties in the western region, 61 representing 11 counties in the central region, and 10 representing one county in the coastal region. Participants had a mean age of 27 (range 18–60) years. The racial/ethnic breakdown was: African American/Black (n=28; 31%), Hispanic/Latino (n=33; 38%), white (n=21; 24%), and other (n=6; 7%). The Hispanic/Latino participants reported being from Mexico (n=20), the US (n=5), Guatemala (n=3), Honduras (n=2), Colombia (n=2), and Venezuela (n=1).

Qualitative Findings

Qualitative data analysis identified 12 themes related to HIV risk (Table 3) and 12 key intervention characteristics and approaches to reduce sexual risk and increase HIV testing (Table 4) among African American, Latino, and white MSM.

Table 4.

HIV Risk among African American, Latino, and White Gay Men and MSM

Sexual health becomes a priority when one is older, is sick, or has a “scare” Among some communities of MSM HIV and STD knowledge remains low, including Latino MSM Non-self-identifying MSM Online MSM Manhood is affirmed through sex Men who engage in same-sex behavior are labeled as not “real” men For non-self-identifying men, this may be intensified as they try to overcome external and internal perceptions about their masculinity Insertive sexual partner is more of a man than receptive partner during anal sex Men who engage in same-sex behavior are victimized Poverty, racism, and immigration threaten a man’s masculinity Latino MSM report high levels of loneliness and social isolation African American MSM report feeling isolated from their church Stereotyping may lead to risk Condom use may be antithetical to sex as an expression of love, trust, and closeness between men Condomless sex (barebacking) is eroticized The perceived role of alcohol and drug use on risk is complicated Barriers to condom use exist Barriers to HIV testing exist

HIV Risks

Sexual health becomes a priority when one is older, is sick, or has a “scare”

Participants noted a variety of health issues that they worry about, specifically diabetes and cardiovascular disease. They recognized the importance of exercise, eating healthfully, and reducing stress. When probed to share their thoughts about sexual health, participants noted that they and other MSM do not worry about their sexual health or risks of HIV or STD infection. In fact, as a participant noted, “When you are older, you might worry about it or if you get sick, but the worry isn’t about HIV or STDs though… you might worry about how to get Viagra.”

Another participant noted, “I think I only worried about HIV when I thought I had something. I think I am like most guys; I found out I was fine so I didn’t continue to worry.”

Among some communities HIV and STD knowledge remains low

Participants also indicated that they and their friends lack comprehensive knowledge of HIV and STDs. As a white participant reported,

“There are lots of gay men, men I know, who know nothing about HIV. No one is worrying about it, and people are taking risks because they don’t have all the facts.”

The lack of knowledge about HIV and STDs was reported to be greatest among three sub-communities of MSM: (1) Latino MSM, (2) MSM who do not identify as gay but engage in same-sex behavior, and (3) MSM who use the Internet for sexual networking. A Latino participant noted,

“I think that many of us are here [in the US] from other places, you know, from Latin America. We have very little information about these types of diseases. We didn’t learn about them at home and here there is no information, especially for those who speak Spanish.”

Participants also noted that MSM who do not identify as gay and have sex with both men and women, may know less about HIV and STDs. Participants noted that these men often are missed in typical prevention efforts; they do not go to gay-oriented bars and clubs, do not read gay-oriented publications, and may not disclose risks to providers or sexual partners. As a white participant noted, “Men are online but they are looking to hook up fast, and they don’t get information, know if they are infected or doing something that can spread disease.”

An African American participant added, “I was that man, you know, figuring myself out. I had a girl and I had men [as sexual partners]. I knew nothing. I may not have wanted to acknowledge the information that was available. To think about AIDS and condoms might mean I was gay. I ignored what was available because I was afraid. It would mean I was gay or I was doing something risky. Or I was hurting someone else.”

Besides asserting that they lacked information about HIV and STDs, participants illustrated this lack of information during the focus groups. For example, a Latino participant mentioned that he thought that HIV could be transmitted by sharing a glass with someone who is infected with HIV.

Manhood is affirmed through sex

All of the focus groups concluded that manhood is often perceived by men and women to be best affirmed through sex with women. A participant reported, “It might differ in intensity by race but I think all men have to prove themselves, and sex is a way to do it.” Participants reported that men who engage sex with other men are often viewed as weak, effeminate, and “running around in skirts.” MSM may feel like they have to hide and deny who they are, and thus, they are less likely to have the supportive networks to help them cope psychologically and identify and navigate health-promoting resources that might assist in risk reduction. Their self-image and self-esteem might suffer, which may contribute to depression and subsequent risk behaviors. An African American participant reported,

“Being black and gay, I have to cope with being perceived as less than a man. It hurts because society tells us, from when we are young: boys must be men, and men must have sex with women.”

Given the need for men threatened by dominant masculine ideology to preserve their manhood, MSM may not use condoms consistently. A white participant noted,

“The pressure is intense. I can’t be a ‘real’ man so I might not use condoms because I hurt, or do not care about myself enough to take precautions. I have let the sadness overwhelm me and done things I shouldn’t have done, I mean not used condoms when I should have.”

Participants also noted that MSM may try to overcome the feelings of not being perceived as “real” men by increasing numbers of female and male sexual partners. As opposed to engaging in risk as a result of “just not caring” because they are lonely or depressed, participants noted that some MSM may feel that risk behaviors help them preserve their masculinity. As a participant suggested, “Sometimes in society, as men, we can be excused for our actions if it is about getting off; if it is about someone else getting off, then you have a problem, then you are a faggot.”

Many participants reported a history of being ostracized, harassed, and physically victimized by others for identifying as gay or engaging in same-sex behavior. They reported that being victimized reinforced their negative self-image, which led to further risk behavior.

Poverty, racism, and immigration threaten a man’s sense of masculinity

Participants concluded that because they are unable to fulfill expectations related to being independent and being a “breadwinner,” whether for immediate or extended family, they may assuage threats to masculinity through sex. As an African American participant noted,

“Sometimes a man can’t do what [he] is ‘supposed’ to do, you know, make money. Every man feels it, homosexual or not… And when you aren’t making it at work, you feel bad about yourself. Men are supposed to make it work.”

A second African American participant responded, “So you go out and find someone who wants you bad or you conquer someone [sexually], get what you want, prove it to even yourself that despite everything, you are a man.”

Latino MSM report high levels of loneliness and social isolation

Participants reported that MSM often feel lonely and isolated from others. Participants reported that Latino MSM may not receive social support from general Latino communities, because they engage in same-sex behavior and thus feel like they must hide and deny who they are to avoid rejection. Latino MSM also may not be connected to other MSM communities because of language and cultural barriers. Finally, Latino MSM may be isolated from one another because of (1) the distances they may live from one another in rural communities, (2) a lack of physical spaces to congregate, and (3) their fear of discovery.

African American MSM report feeling isolated from their church

Participants reported that the churches that they had been raised in were not supportive of MSM. Many participants reported that they had two options: being dishonest about who they are or being rejected by their churches. An African American participant summed up saying,

“My church is important to me, but imagine, what it is like to be around all that… it isn’t hatred really. It is, I guess, but it is more about my disappointment. The church I grew up in, the church that my family belongs to and have been committed to feeds the intolerance, feeds the bigotry to my own family about people like me. So where did I turn when I was trying to figure all of this out? I had no one at my church, and that made it even harder.”

Participants noted that the church “teaches” intolerance and thus African American MSM, particularly, must struggle with sexual identity development without the supportive network that they were raised with. They also may choose to “fake it” and live a double life by “getting married [to women], having a family, and getting off with other men.”

Stereotyping may lead to risk

Participants identified stereotyping as contributing to sexual risk. For example, within the gay community, African American men are sometimes perceived as more desirable because they are perceived to be “stronger,” “dominant,” “Mandingos,” “sexually aggressive,” and “mystical,” with larger penis sizes than other men. An African American participant shared, “There is prejudice within the community but many black men can find, excuse my language but I am serious, it is easy to find an ass to tap, and many men who are looking for the black Mandingo are not worried about using a condom.”

Latino men were identified as being seen as “hot blooded,” “exotic,” and “super sexual.” Latino MSM also are assumed to be less likely to be infected with HIV or STDs, and thus condom use may be perceived as less important.

An African American participant explained, “You feel rejected by your friends, family, and church, so it feels good to be wanted by other men for whatever reason; after all isn’t that what humans want: to be desired, cared for, and loved? Even for a short time?”

Condom use may be antithetical to love, trust, and closeness

Condoms may be contrary to the meanings that men give to sex. An African American participant asserted,

“I am going to say it straight up. There is too much emphasis on the sexual act. What about the meanings of sex between men? You may say that I should use a condom, but what if I am not ready? I am meeting other needs by having sex with another man. That is a big step for me, expressing who I am with all these conflicts and negative images. You need to consider who I am, where I am from, acknowledging who I am by having sex with a another man is a step in the right direction so maybe people shouldn’t jump to the fact that I do or don’t use a condom.”

Participants also reported that because sex can be an expression of “love,” “trust,” and “closeness” between two men, not using condoms is not always about risk, “not using one’s brain,” or “not thinking clearly.” As a Latino participant noted, “Sex isn’t just about getting off.”

Barebacking is eroticized

Some participants noted that sex is meant to be “fun” and part of the fun of sex is the erotic excitement of sex without barriers. As an African American participant noted, “You and your man want to feel each other and don’t want a condom between your connection.” Participants reported that backbacking (having anal sex without using a condom) is portrayed as, and is perceived by, MSM to be “hotter” than sex with a condom; another African American participant noted, “There is no way I can think that seeding [ejaculating inside of] a brother is not hotter than using a condom.”

The perceived role of alcohol and drug use on risk is complicated

Participants had differing perspectives about the role of alcohol and drugs on risk. Some participants, particularly those in the predominantly white focus groups, reported alcohol and drug use affects judgments about risk and protection. African American and Latino participants, however, tended to report that alcohol and drug use is an “excuse” for risk. As a Latino participant noted,

“I think people just say: ‘I got drunk last night and let him cum [ejaculate] inside me.’ But the truth is, if they didn’t want it to happen, it wouldn’t have happened.”

Barriers to condom use exist

A total of five barriers to condom use were identified. First, the most commonly-mentioned barrier to condom use and the most adamantly held belief was that condoms decreased sensation for men. Next, condoms were reported to reduce spontaneity of sex. Third, a white participant asserted, “[Condoms] are just too difficult to use.” Fourth, participants also reported that a barrier to condom use included condoms not being immediately available. As an African American participant noted, “Not everyone prepares for sex.” Another African American participant who reported using condoms consistently shared that he keeps condoms in convenient locations throughout his house because does not want to interrupt sex to find them.

Finally, some participants, particularly Latino participants, reported insufficient knowledge about, and improper use of, condoms. Participants noted that they had heard of men washing and/or reusing condoms and not using them consistently throughout the sex act. Participants themselves were confused about animal versus latex condoms and reported not knowing that they could get them for free at ASOs, CBOs, and public health departments.

Barriers to HIV testing exist

Participants noted that they lacked information about testing resources and the testing process. For example, participants had questions about where to be tested, eligibility to access HIV testing and other public health services, the availability of interpretive services, and the costs associated with HIV testing. Some participants were unfamiliar with nontraditional HIV testing (e.g., off-site venue-based and nontraditional testing). Participants suggested that further testing options should be provided. They also reported high levels of distrust of the US healthcare system and providers, and many did not believe that their health information would be kept confidential. Latino participants reported believing that whether they were documented or not their records could be used against them.

Some public health department staff also were identified as discriminating against MSM clients/patients based on ethnicity/race, perceived documentation status, economic status, and/or MSM behavior. However, in their interactions with these staff, it was not always clear to participants what the cause of the discrimination was (e.g., race/ethnicity, economic status, or MSM behavior). Thus, public health testing facilities are not always perceived as comfortable places by most participants although community-based testing venues, such as testing at or sponsored by ASOs, were identified as being welcoming.

Moreover, participants reported feeling that using public health department services was stigmatizing because they tend to be located in communities with fewer resources. Finally, participants noted that as men who “must be independent and strong” seeking testing, care, and treatment for HIV and STDs showed signs of weakness.

Intervention Approaches and Characteristics

Because the CBPR partnership was committed to moving towards action, the moderator’s guide explored potential intervention approaches. Participants identified twelve approaches and characteristics that should be explored to reduce HIV risk among MSM (Table 5).

Table 5.

Identified Key Intervention Approaches and Characteristics

To reach MSM to reduce risk and increase testing interventions should: Use role models Build on informal social networks Be natural helper based Fill knowledge gaps and correct misconceptions Provide guidance how to access resources (e.g., HIV and STD testing, condoms, and other services) Offer safe spaces for facilitated supportive men’s group dialogue around issues of masculinity; family, religious and societal expectations; and intimacy among men Provide practical guidance on managing triggers and coping Harness technology: Hotline, interactive website, Twitter, MySpace, and Facebook Develop a coupon system for free testing at non-public testing venues Promote condom use and HIV testing within the context of men’s relationships Support MSM and preventionists in the field through community organizing and advocacy skills development Focus on developing culturally congruent programming to reach MSM who live in rural communities, speak Spanish, do not go to gay bars/clubs, and MSM who are considered to be hidden

First, participants noted that interventions should use mentors and role models. Participants identified the potential of using positive and identifiable role models to support MSM. As an African American participant noted,

“We need role models, especially for 15–21 year olds. You know, gay men who are professional and doing the right things. Taking care of themselves, using protection, or at least making smart decisions about their lives. It would help young MSM know that they will be ok.”

Participants noted that these role models could reach out and mentor adolescents and younger MSM about coming out, condom use, and self-respect. Participants felt that mechanisms needed to be in place for MSM to mentor one another. Furthermore, participants suggested that broad community campaigns should be developed to change how others perceive gay men and MSM. As an African American participant asserted,

“We need professional, African American gay men to come out. Once there’s a large group of teachers and lawyers and doctors and administrators and they’re out there on TV, on the Internet, in your classrooms, etc, open and comfortable, then people will feel better about themselves. Right now all they see is Queer as Folk and Noah’s Ark [television series], and they see a bunch of men having sex and think that all we do is dress up like women.”

White gay men were identified as having a few role models, but participants reported that these role models tend to be based on negative stereotypes.

Second, participants asserted that HIV prevention interventions for MSM should build on existing and informal social networks and move towards community building. Participants reported they could help one another learn about HIV, prevention, and accessing testing and care. Participants also suggested that identifying those men who have the potential to be trained to be comfortable talking and offering sound advice about sensitive issues and remain discreet, come into contact with many men because of jobs or social networks, have some level of literacy, are trustworthy, and are generally helpful to others would be appropriate to train to serve as community health workers, peer educators, or lay health advisors.

Other intervention characteristics that were identified by the participants included filling knowledge gaps and correcting misconceptions; providing practical guidance on resources and how to access them, including HIV prevention, testing, care, and treatment; and offering safe spaces for supportive dialogue about masculinity; family, religious, and societal expectations; and the meanings and expressions of love and intimacy between men. Participants suggested that successful interventions should help MSM explore triggers and develop ways to avoid and cope with these triggers. This may include helping MSM determine where condoms should be kept in one’s apartment or house for convenient access; whether a bar or club might be a trigger for risk; and how to cope with triggers healthfully.

Participants noted that technologies such as telephone hotlines, interactive websites, and social media such as Twitter, MySpace, and Facebook should be harnessed. A hotline or interactive website designed specifically for MSM of color could provide: practical information (e.g., where to get free condoms); social support (e.g., someone to talk to about coming out, reducing risks, and managing triggers); and other community resources. Participants noted that a hotline or interactive website would need to be visually titillating to appeal to gay men and MSM, tagged with key Meta tags, and marketed widely online and in the geographic community.

Although participants did not report what an intervention that was implemented using Twitter or Facebook might look like practically, a participant, who noted receiving updates about a porn star via twitter, said, “It seems like we could learn something from the porn industry.” It is important to note that participants concluded that African American and white MSM seem to use the Internet more than Latino MSM.

Participants also noted that a coupon system for free testing at non-public testing venues would provide MSM with more options for free HIV testing. MSM could get tested at urgent care centers, for example, without the stigma associated with accessing public health departments.

Participants indicated that promoting condom use and HIV testing within the context of sexual relationships may be more successful for some MSM. Intervention messages would be framed around consistent condom use and knowing one’s HIV serostatus within the context of one’s relationship through the promotion of counseling and testing as the relationship turns more serious and prepares to exclude condom use. Thus, rather than messages that assert consistent condom use, defined as each and every time, the messages would imply that condom use may be a more contextual decision; those who chose to have multiple partners may “need” to use condoms to protect themselves and their partners, and those who have one partner may have other options. As a participant noted, “Telling me to use a condom is silly; if I had a partner we could decide to get tested and decide from there what to do.” Participants reported that approach may resonate with some MSM as they establish ongoing relationships and traverse the developmental tasks of relationship building and trust, intimacy, and partnership. Participants felt that prevention efforts must take into account the relationship status and goals of MSM.

Participants also acknowledged that MSM and preventionists in the field, including allies working within ASOs, CBOs, and public health departments, need community organizing and advocacy skills development. Participants also noted that more focus must be placed on: reaching rural and other “hidden” MSM; implementing Spanish language interventions to reach Latino MSM; and utilizing interventions venues other than bar settings and gay pride events.

Community Forum

Community form attendees included representatives from the lay community (n=4), ASOs (n=8), CBOs (n=7), the NC DHHS (n=8); two historically black colleges (n=3); and two academic research institutions (n=4). The sample were racially/ethnically diverse and included males and females and gay and non-gay attendees.

After reviewing the focus group findings and engaging in a half-day facilitated discussion using the questions outlined in Table 3, forum attendees identified the following priorities for research and practice to reduce HIV risk among MSM. First, natural helper interventions, including community health workers, peer leaders, or lay health advisors, should be developed, implemented, and evaluated to increase HIV and STD knowledge; develop and bolster positive social norms and attitudes about masculinity; and improve access to resources within existing and informal social networks of MSM. This approach was identified as potentially reaching large numbers of MSM.

Furthermore, mentoring programs that reach beyond a narrow focus on HIV prevention among MSM should be explored as an approach particularly relevant for younger MSM. These programs should focus on developing a sense of community and belonging among young MSM and provide facilitated dialogue for them to learn from one another about coming out, condom use, and self-respect. Moreover, attendees recommended general comprehensive sexual health programming (e.g., based in schools) to reach all adolescents while targeted programming (e.g., based in the house system or the house ball community as described [Sanchez, Finlayson, Murrill, Guilin, & Dean, 2009]) to reach young MSM.

Next, chat room-based interventions should be developed, implemented, and evaluated to increase knowledge of HIV and STD prevention, care, and treatment; local resources (e.g., where to get free condoms locally), and testing options and processes among MSM who use geographically oriented chat rooms for social and sexual networking. MSM using chat rooms were identified as potentially at increased risk for HIV and STD infection, more difficult to reach, and less likely to receive venue-based prevention messages.

Attendees suggested that individual- and group-level interventions should be developed to help MSM explore triggers and develop ways to avoid triggers and cope more healthfully. These types of interventions, however, must move beyond typical HIV prevention components (e.g., HIV knowledge and condom use self-efficacy) and help MSM reconcile their sense of masculinity; family, religious and societal expectations; and intimacy.

Forum attendees suggested that a coupon system for free testing at non-public testing venues should be explored. Further recommendations that emerged from the community forum included a telephone hotline or interactive website designed specifically for MSM of color may serve as an ancillary resource access for prevention and testing information. Furthermore, the potential use of social media (e.g., Twitter, MySpace, and Facebook) in HIV prevention should be explored. For example, updates about special HIV testing opportunities at non-traditional venues like bars and clubs sponsored by ASOs and CBOs may be appropriate content for Twitter, while periodic “cues to action” (e.g., reminders about condom use and annual HIV and STD screenings as recommended by CDC for sexually active MSM) could be disseminated through to social networks on Facebook by health educators or even trained volunteers.

Finally, skills development for MSM, preventionists, interventionists, and practitioners in the field could build community capacity, and thus expedite the science and prevention of HIV and STD infection among MSM.

Discussion

This study was conducted by an established academic-community partnership committed to producing knowledge for action. This study identified rich qualitative insight into the needs and priorities of a diverse sample of MSM in a region of the US that is experiencing disproportionately high rates of HIV and STDs.

The partnership identified 12 themes related to sexual risk among African American, Latino, and white MSM. Findings suggest that despite 3 decades since the identification of HIV, MSM in the southeastern US continue to need targeted sexual health and HIV and STD prevention education to increase knowledge and reduce misconceptions. Social norms and expectations about what it means to be a man must be addressed as findings from this study indicate that some MSM try to overcome external and internal perceptions about their masculinity through risk behavior. Masculinity has been associated with risk but the directionality of the association is inconsistent; better construct operationalization and measurement and empirical evidence continue to be needed (Fiorentino, Berger, & Ramirez, 2007; Mahalik, Burns, & Syzdek, 2007; Rhodes, et al., 2009). It has been suggested that men are socialized to believe that there are three aspects of their gender selves: economic, socio-political, and sexual (Whitehead, 1986). Men’s inability to be successful economically and socially increases the likelihood that they will try to exhibit masculinity through increased sexual prowess and often increased sexual risk. Although Whitehead’s research was conducted with Jamaican and African American heterosexual men, the efforts for men to utilize sexuality to demonstrate that they too are “strong men” may be relevant for MSM of all races/ethnicities. These men are struggling to reconcile their difficulties fulfilling traditionally masculine roles, and may use sexual risk to salvage their gendered selves. Facilitated small-group dialogue for MSM to discuss and reconcile issues of masculinity; family, religious, and societal expectations; and intimacy among men may be a step to self awareness and risk reduction, and the effectiveness of interventions designed with these components should be explored.

Participants indicated the need for creative intervention strategies to reach MSM to reduce their risk for HIV and STDs, as well as reduce barriers to condom use and accessing health care, including using mentors and role models within informal social networks that rely on natural helping approaches to fill knowledge gaps, correct misconceptions, and provide guidance on available resources and access. Although approaches that fall along the natural helping continuum, have been promoted (Eng, Rhodes, & Parker, 2009; Institute of Medicine, 2003), the US Preventive Services Task Force has noted their current inability to make evidence-based recommendations about their use because insufficient published studies have evaluated their effectiveness (CDC, 2009). Thus, further research is needed to determine whether such approaches can positively impact risk.

Technology was suggested as a potential mode for intervention delivery. There has been growing interest in Internet-based interventions; however, these tend to be only successful when they are based in the existing social structures of online communities (Noar, Black, & Pierce, 2009; Rhodes, et al., 2010). Online interventions that are not authentic to the online environment have been less successful in effectiveness trials due in part to high attrition rates (Bull, Vallejos, Levine, & Ortiz, 2008). The use of Twitter, MySpace, and Facebook, as examples, in HIV and STD prevention has remained limited despite their unique potentials and deserve further research.

Participants also suggested developing a coupon system for free testing at non-public testing venues, promoting condom use and HIV testing within the context of men’s relationship, and supporting MSM and preventionists in the field through advocacy training and skills development. It has been suggested that the most successful interventions to prevent HIV may need to be based on responding to immediate community priorities and needs while building capacity for communities to act on their own behalf (Gupta, Parkhurst, Ogden, Aggleton, & Mahal, 2008). Thus, interventions may benefit from providing key skills (e.g., communication, problem-solving, leadership, social support) that may be lifelong and transferable to other community concerns.

Limitations

Participant selection was based on a small convenience sample of men ages 18 and above and, therefore, the findings cannot be generalized to all MSM generally or MSM within this region specifically. However, for the purposes of formative research, the findings from this study may inform HIV prevention with MSM from similar communities and backgrounds. Further, although the focus group format for soliciting perspectives on HIV among MSM generated rich qualitative data, the presence of peers may have prohibited discussion of stigmatized behaviors. This methodological limitation would be difficult to overcome, even if individual interviews had been conducted, given the devaluation and subordination of same-sex sexual behavior and everything considered gay or feminine within hegemonic masculinity. However, this may be a step toward building trust to investigate issues shrouded in stigma and silence. Further research using alternate data collection methodologies, such as individual in-depth interviews and venue-based intercept assessments, may provide further data and insights into MSM behaviors in this community.

Conclusions

As the HIV epidemic has evolved, prevention efforts must evolve as well. With increasing disproportionate rates of HIV, a need exists to explore, understand, and intervene upon factors associated with exposure and transmission among communities most at risk. Nowhere is this more urgent than in the southeastern US, which bears a disproportionate burden of HIV. This study provides insight into the salient beliefs of a racially/ethnically diverse sample of MSM toward sexual health.