Shared Communities, Structural Contexts, and HIV Risk: Prioritizing the HIV Risk and Prevention Needs of Black Heterosexual Men

Abstract

Black heterosexual men (BHM) are seldom mentioned in HIV prevention research, policy, and interventions, despite evidence that heterosexual contact is becoming the leading exposure category for BHM.

The disparate effect of HIV/AIDS on BHM; the debunked “down low” myth; the contexts of BHM's lives in terms of disproportionate poverty, unemployment, and incarceration; and a growing empirical base linking these factors to increased HIV risk, underscore the need to prioritize HIV risk and prevention initiatives for BHM.

We highlighted the structural contexts of HIV risk for BHM, and four community-based approaches to address HIV risk and prevention for BHM: (1) men's health programs; (2) workforce and postincarceration release programs; (3) linkages to women's prevention programs; and (4) faith-based initiatives.

We know Three facts about heterosexually transmitted HIV in US Black communities. First, heterosexual exposure accounted for 87% of new HIV cases among Black women in 2009.¹ Second, HIV is more efficiently transmitted from men to women.² Third, Black men accounted for 69% of HIV cases due to heterosexual exposures among men in 2009. Despite this, Black heterosexual men (BHM) are seldom mentioned in HIV prevention research policy, and interventions. Black heterosexual women (BHW) and BHM live, work, socialize, worship, and form romantic and sexual relationships in the same communities, and as epidemiological data document, share sexual HIV risk within their communities. However, national HIV prevention policy, practice, and research often regard BHM and BHW separately.

Public health officials routinely use the word crisis to describe the HIV/AIDS epidemic in Black communities.^3–5 Crisis is not hyperbole. Blacks represent 13% of the US population, but represented 52% of HIV cases in 2009.¹ BHW and Black men who have sex with men (MSM) have rightly been the focus of most HIV policy, research, and interventions. In 2009, HIV incidence among BHM (20%) was relatively low compared with that of Black women (87%) and Black MSM (68%).¹ However, this incidence is hardly insubstantial in light of evidence of a generalized HIV epidemic among heterosexuals in poor predominantly Black US urban communities.^6–8

The disparate effect of HIV/AIDS on BHM, the structural contexts of BHM's lives in the US, and research linking structural factors to increased HIV risk, all underscore the need for public health officials, policymakers, and HIV prevention researchers to prioritize HIV risk and prevention initiatives for BHM. We organized our commentary around three themes. First, we focused on the structural contexts of HIV risk for BHM. Second, we highlighted four community-based approaches that could be used to address HIV risk and prevention for BHM. Finally, we recommended some policy implications and structural approaches needed to prioritize BHM's HIV risk and prevention needs.

A WORD ON LANGUAGE

To emphasize the salience of sexual risk behavior (e.g., unprotected sex between MSM) over identity (e.g., bisexual or gay) in transmitting and contracting HIV, public health officials and HIV prevention researchers routinely use terms such as MSM. Although we agree with the rationale behind this nomenclature, we consciously used the term heterosexual men in this commentary. The term men who have sex with women (MSW) also describes behavior accurately. In the context of BHM and risk, however, the term MSW also evokes the “down low” myth, the small number of Black men who have sex with both men and women, but do not identify as gay or bisexual, and who have been blamed for the high rates of heterosexually transmitted HIV in Black communities. Despite debunking, the myth persists.^9–11 Thus, although the term MSW includes BHM, it also elicits the idea of MSM who may also have sex with women. The term MSW might also pose barriers to HIV prevention efforts, with some BHM developing a false sense of security about their HIV risk. Research documented that some BHM who engage in risky behaviors (e.g., unprotected sex with multiple women) might perceive themselves to be at little or no risk for HIV because they are not “down low brothers.”¹² Accordingly, we used the term BHM rather than MSW to highlight men who are exclusively heterosexual.

STRUCTURAL CONTEXT OF BLACK HETEROSEXUAL MEN'S LIVES AND HIV RISK

HIV/AIDS is not randomly distributed among Black men. Rather, as with the larger Black community, a host of structural factors, such as poverty,^6,7,13–16 unstable housing,^6,17–19 incarceration,^20–23 and impoverished neighborhoods,^6,7,24 are associated with BHM's increased HIV risk. Structural factors such as poverty, unemployment, and incarceration, magnified by the legacy of institutionalized racial discrimination, have historically and adversely affected Black men (and women) in the United States.

Blacks in the United States have disproportionately higher rates of poverty compared with other ethnic groups. In 2010, the official national poverty rate was 15.1%; among Blacks, the poverty rate was 27.4%, the highest of all ethnic groups.²⁵ Epidemiological studies documented the relationship between poverty and heterosexual HIV risk. The HIV prevalence of 2.1% among heterosexuals in urban poverty areas was 20 times greater than that of all heterosexuals in the United States (0.1)%.⁶ Moreover, HIV prevalence is highest among urban heterosexual Blacks (2.1%) compared with Latinos (1.8%) and Whites (1.1%), and significantly higher for heterosexuals with less than a high school education, the unemployed, and those with annual incomes less than $9,999.⁷

Poverty is also linked to unemployment. In January 2012, the seasonally adjusted unemployment rate for Black men aged 20 years and older was 12.7% compared with 6.9% for White men in the same age group.²⁶ Black men also face disparate rates of incarceration. In 2008, Black men were 6.5 times more likely to be imprisoned than were White men.²⁷ Black men's disparate incarceration rates have implications for HIV risk because the HIV/AIDS rate among prisoners is 2.4 times greater than that of the general population.²⁸

Despite abundant evidence linking structural factors to HIV risk and calls for more structural interventions,^29–34 structural approaches to HIV prevention in general, and for BHM in particular are rare. An exception is the MEN Count intervention, which integrated housing and employment case management with HIV risk reduction counseling for a clinic-based sample of BHM in Boston, Massachusetts, and documented significant reductions in unprotected sex, unemployment, and homelessness (A. R., unpublished data, December, 2011).

PROMISING COMMUNITY-BASED APPROACHES TO HIV RISK AND PREVENTION NEEDS

Community-based organizations (CBOs) that serve Black communities, particularly those that have not traditionally provided HIV/AIDS-related services, are an untapped resource for HIV prevention. CBOs are adept at providing services to BHM, or knowing where to find BHM. The recognition that communities and CBOs should play a vital role in HIV prevention is hardly new. Since 1993, the CDC³⁵ has provided guidelines for community planning groups. More recently, the National HIV/AIDS Strategy report recommended that high-risk communities adopt community-level approaches to reduce HIV risk.³⁶ We highlighted 4 community-based approaches that could be used effectively to reach BHM with HIV prevention and testing services: (1) men's health programs, (2) workforce and postincarceration release programs, (3) linkages to women's HIV prevention programs, and (4) faith-based initiatives.

Outreach Through Men's Health Programs

HIV/AIDS is not the only disease that adversely and disproportionately affects BHM. Black men, particularly those in high-risk urban areas, have the lowest life expectancy compared with all other populations, and experience disproportionately higher death rates for all-cause mortality.³⁷ Thus, clinics designed to address men's health are an ideal site for incorporating HIV prevention activities. For example, the aforementioned MEN Count intervention was implemented at the Whittier Men's Health Clinic in Boston (A. R., unpublished data, December, 2011).

Project Brotherhood (Chicago, Illinois)³⁸ is another example of a community-based approach to increase health awareness and improve the health of Black men. Project Brotherhood creates a safe space for Black men to seek health services through a variety of integrative social support services, including HIV prevention and testing. Among its signature programs is a state health department–funded Train the Barbers Program that uses a Project Brotherhood–designed culturally specific curriculum to train barbers to provide HIV/AIDS awareness and prevention services. The MEN Count and Train the Barbers programs exemplify how HIV prevention initiatives can be integrated within men's health programs to increase awareness about HIV/AIDS in Black communities and enlist BHM in HIV prevention.

Workforce, Postincarceration, and Violence Prevention Programs

Employment development programs are another largely untapped resource for reaching BHM. We are aware of no community-based programs that include primary HIV prevention services within their existing workforce and lifestyle development programs. Because Black men are likely to represent a significant proportion of those seeking assistance from CBOs that provide workforce development and job placement services in urban areas, these CBOs are another untapped resource for the integration of HIV prevention and testing services.

This is also the case with prison-release programs. Although a number of community-based programs exist for former inmates with HIV/AIDS, HIV prevention programs for men leaving prison, despite their increased HIV risk, are rare.³⁹ Project Start recommends that HIV/sexually transmitted disease intervention programs address HIV risk reduction needs and other needs, such as housing, employment, and family integration. Because risk behavior resumes soon after release, targeting men within the first few weeks of release is a critical time for intervention.³⁹

Reaching Black Heterosexual Men Through Women

Another innovative way to reach BHM with HIV prevention messages is through their intimate partners. The Circle of Care (COC),⁴⁰ a Philadelphia-based network of agencies that use a family-centered model to provide services to families with HIV/AIDS, adopted this approach upon recognizing that Black men routinely accompanied their female partners to prenatal screenings and care. Having provided services to many HIV positive women with multiple pregnancies, the COC realized that it also had ongoing relationships with their patients’ male partners. Men attending the program's baby showers started to ask the program's nurses, “Why don't you do things for us?” ⁴¹ Other than HIV testing and HIV/AIDS prevention pamphlets, the COC realized that they had no programs for heterosexual men, and in response, launched Straight Up!, an HIV testing and prevention initiative for heterosexual men.⁴²

Faith-Based Initiatives

Although many Black religious institutions have been criticized for their failure to address HIV/AID in Black communities or heterosexist approaches to HIV/AIDS,^43–45 many have also provided outreach and prevention services. For instance, the Balm of Gilead is a national organization established to partner with Black churches to raise HIV/AIDS awareness and prevent HIV/AIDS in Black communities.⁴³ In November 2010, Black clergy leaders in Philadelphia launched an HIV prevention campaign in which more than 100 churches and mosques participated, and 30 churches offered on-site HIV testing. The influence of Black churches⁴³ attests to the need for Black religious institutions to assume greater leadership in HIV prevention to Black communities in general, and BHM in particular.

THE BIGGER PICTURE: POLICY IMPLICATIONS AND STRUCTURAL APPROACHES

Our advocacy for greater attention to BHM's HIV risk and prevention needs prompts a call for policy and structural-level action. One of the obvious policy implications is how HIV prevention dollars should be allocated to address BHM's HIV risk and preventions needs. Given that HIV prevention represents the smallest category of the federal HIV/AIDS budget, adding another group to the list of HIV prevention spending priorities is a daunting prospect at best. In President Obama's fiscal year 2012 HIV/AIDS budget request, funds for HIV prevention accounted for just 4% of the budget.⁴⁶ An increase in funds for HIV prevention is urgently needed. Certainly, it is more cost-effective to prevent HIV/AIDS than to care and treat HIV/AIDS.

Barring an unlikely increase in HIV prevention funds, we believe that the answer lies not in dividing an already limited pool of funds, but rather in redefining sexual HIV risk. Informed by our aforementioned critique about the limitations of language (e.g., “down low,” MSM, MSW), sexual self-identification, and HIV risk for BHM, we recommend that HIV prevention initiatives and the dollars that fund them define sexual risk as vaginal or anal sex without condoms, regardless of the gender of sexual partners.

The National HIV/AIDS Strategy advocates for greater coordination of HIV programs across all levels of government.³⁶ A syndemic approach may hold great promise for such coordination.³⁰ A syndemic approach examines how two or more diseases or conditions cluster and interact within certain populations and how social conditions (e.g., poverty, racial discrimination) influence the concentration and consequences of diseases and conditions.^47,48 HIV is not a distinct and separate disease;⁴⁸ it interacts with other sexually transmitted infections,⁴⁹ mental health problems,⁵⁰ and substance abuse and violence.⁵¹ HIV prevention in Black communities demands greater coordination across a broader range of agencies, not just those that address HIV/AIDS.³⁰ Another implication is the need to fund community-based men's health programs that integrate HIV prevention within existing health promotion and disease prevention programs for BHM.

Finally, we advocate for policies and interventions that address the structural antecedents of HIV risk for BHM. Policy initiatives designed to address the disparate effect of HIV in Black communities are likely to have limited impact because they focus almost exclusively on individual behavior, and ignore structural factors and social inequality, the “fundamental causes” that produce the disparity in the first place.^52–57 In short, there is a dire need for macro-level structural interventions to decrease HIV risk in BHM and Black communities.^29–34 We highlighted four (and there are many others) structural interventions that could facilitate HIV risk reduction in BHM: (1) job training and workforce development programs to reduce unemployment and poverty, and increase incomes,^29,57 particularly for those with incarceration histories; (2) antiracial discrimination policies to reduce the disproportionate surveillance, arrest, sentencing, and incarceration of Black men; (3) policies to reduce opportunities for discrimination in hiring of people with incarceration histories (for example, the City Council of Philadelphia unanimously passed a nonbinding resolution to encourage employers not to ask about incarceration histories in an attempt to break the link between unemployment and incarceration for many Black men)⁵⁸; and (4) increasing access to free condoms in various settings (e.g., community centers, libraries, restrooms).³³

Despite increasing calls for structural approaches to HIV prevention,^29–34 and the proven effectiveness of structural interventions for addressing health issues such as physical activity and decreasing smoking,⁵⁹ structural approaches to HIV prevention have lagged. There are at least three main challenges. One is the “large gap between those interested in structural interventions and the policymakers who have to implement them.”^59(p684) A second is the perception that individuals are, or should be, solely responsible for their health outcomes.^33,59 This perception is likely strengthened by the stigmatized behaviors that increase HIV exposure (e.g., injection drug use, sex with multiple partners, same-sex behaviors), and the disproportionate effect of HIV/AIDS on populations perceived responsible for their diminished socioeconomic position. Third, there is a lack of political will to advocate for controversial, emotionally, and politically sensitive topics that must first be addressed before adopting a structural approach.

CONCLUSIONS

One of the CDC's most disturbing recent estimates is that the lifetime risk of being diagnosed with HIV is 1 in 16 for Black men in the United States.¹⁴ Although current epidemiological data suggest that HIV/AIDS among Black men will remain most prevalent among those who are MSM, evidence that heterosexual exposure is a growing risk factor for BHM in many urban areas is a cause for alarm. The National HIV/AIDS Strategy indicated that, “the United States cannot reduce the number of HIV infections nationally without better addressing HIV among gay and bisexual men.”³⁶ Similarly true, we believe, is that local, state, and national HIV prevention efforts will fail to reduce HIV incidence in Black communities without an improved and specific focus on the HIV risk and prevention needs of BHM. It is time for recommended policy and prevention actions and resources for “preventing HIV among Black Americans”³⁶ to explicitly include and prioritize the HIV risk and prevention needs of BHM. It is unreasonable to expect that BHM will independently recognize their risk for contracting and transmitting HIV and engage in risk reduction behaviors, when public health officials, policymakers, and HIV prevention researchers do not.