“Triply cursed”: Racism, homophobia, and HIV-related stigma are barriers to regular HIV testing, treatment adherence, and disclosure among young Black gay men

Abstract

In the USA, young Black gay men are disproportionately impacted by HIV. In this qualitative study consisting of in-depth interviews with 31 young Black gay men and 9 service providers, where we used thematic analysis to guide our interpretations, we found that HIV-related stigma and homophobia, within the larger societal context of racism, were related to sexual risk behaviour, reluctance to obtain HIV testing or care, lower adherence to treatment medication, and disclosure of a positive HIV status to sexual partners. Participants experienced homophobia and HIV-related stigma from churches and families within the Black community, and from friends within the Black gay community, that otherwise provide support in the face of racism. Vulnerability to HIV was related to strategies that young Black gay men enacted to avoid being stigmatised or as a way of coping with their alienation and rejection.

Introduction

The US National HIV/AIDS Strategy emphasises the need to focus resources on the communities most impacted upon by the epidemic. However, the approach to reducing incidence in communities is largely one focused on testing, linkage to care, and treatment as prevention (White House Office of National AIDS Policy, 2010). As such, the strategy relies on individuals, who may not necessarily be comfortable accessing HIV-related services and care, getting tested and, if HIV-positive, regularly seeing their medical provider and taking medications. Unfortunately, the emphasis on testing and treatment essentially transforms HIV into an individual level issue, inadequately accounting for the larger social structures that drive the epidemic, particularly stigma, and the barriers that the larger social context might pose (Van Doorn, 2012). This strongly medicalised approach to HIV prevention increasingly relies on changing individual behaviour, without much attention to the social context or community mobilisation, to promote health and prevent disease transmission. With a new approach to HIV prevention that is based on individuals publically seeking out testing and treatment in clinics, as well as disclosing to their sexual partners, it is essential to understand the social meanings surrounding an HIV diagnosis and homosexuality, particularly among gay men of colour. This is particularly true for young Black gay men, a group that in the USA is disproportionately impacted by HIV and AIDS (Millett, et al., 2012b).

Although stigma is often cited as a factor that relates to HIV vulnerability (Parker & Aggleton, 2003), the mechanisms through which stigma affect HIV vulnerability are not well understood. According to Erving Goffman, stigma is due to “an attribute that is significantly discrediting,” causing a person or group of people to be “reduced” in society based on some physical, behavioural, or social trait seen as being divergent from group norms (Goffman, 1963, p.13). More recently, social scientists have come to view stigma from a more structural perspective, describing stigma as a symptom and byproduct of social and structural inequality, organised along axes of nationality, gender, race/ethnicity, class, and sexual orientation (Aggleton, Parker, & Maluwa, 2003; Castro & Farmer, 2005). Thus, individuals who are positioned at the intersection of social and structural forms of inequality due to their ethnoracial, gender, sexual or class identity may also be stigmatised because of these identities as well. Although many years of research have been devoted to understanding the impact of stigma on HIV-related behaviour, stigma has often been perceived as a “thing” which, in public health discourse, is depicted as a barrier to HIV treatments (Klitzman, et al., 2004) or to HIV testing (Hutchinson, et al., 2004). Stigma is rarely treated as a social process, nor is it often contextualised in the lives of people who experience it (Parker & Aggleton, 2003). Yet the literature does not adequately examine how multiple forms of stigma can have compounded effects in the lives of those who hold multiple marginalised identities. We seek to describe the social experience of those who are multiply “reduced” in society, and thus experience the layered effects of stigma based on their race/ethnicity, sexual orientation, and HIV-status.

Previous Research

Unlike other populations where HIV incidence is decreasing, infection rates among young Black men who have sex with men are increasing with time (Millett, et al., 2012a). In a 21 city study of men who have sex with men conducted in 2008, 28% of Black men tested HIV positive, with 59% of these unaware of their status (Centers for Disease Control, 2010). Black gay men are also less likely than other gay men to have access to anti-retroviral treatment (ART), and are more likely to receive an AIDS diagnosis when they are diagnosed with HIV (CDC, 2010). A review of prevention research with Black gay men notes that complex social and structural factors may contribute to these disparities, including experiences of racism and homophobia within family, community, and medical settings, and lower awareness of and access to prevention and care services (Peterson & Jones, 2009).

The literature demonstrates that experiences of racism lead to minority stress and poor health outcomes for people of colour, often due to felt micro and macro aggressions that then trigger stressful physical responses when individuals are confronted with potentially stigmatising situations (Brondolo, Gallo, & Myers, 2009). Among sexual minorities, homophobia has been linked to psychological stress, which then manifests itself in poor mental and physical health outcomes (Meyer, 1995). However, much of the previous work does not contend with the multiple forms of stigma and their layered impact on particular individuals who are discriminated against due to various stigmatising affiliations. In a review, Henkle, Brown and Kalichman (2008) contend that particular forms of stigma do not act independently, but instead are nested within each other and together increase the vulnerability individuals experience to HIV. There has been little investigation into experiencing layered stigma and HIV-related risk.

There have been several studies examining the experiences of Black gay men in the USA and encounters with multiple, yet disparate, forms of social and institutional stigma. Haile, Padilla, & Parker (2011) conducted life history interviews with ten older Black gay men and described institutional forms of racism, homophobia, and HIV-related stigma that impacted men's abilities to navigate healthcare systems and social support systems for living with HIV. Participants drew upon the strength they had nurtured to deal with racism to overcome HIV-related stigma after they seroconverted. Han, et al. (2010) conducted four focus groups with young Black gay men, and reported that encounters with racism in the context of the predominantly white gay community hampered HIV prevention efforts for this population. Similarly, Voisin and colleagues conducted focus groups with Black gay youth and found that homophobia and HIV-related stigma, from family members specifically, prevented discussions about sexuality or sexual health from taking place (Voisin, Bird, Shiu, & Krieger, 2013). Societal racism and anticipation of racism from white gay community members led some participants to feel apathy about reducing HIV risk, because they felt devalued in society. Another qualitative study with Black gay men reported their reluctance to access quality medical care for fear that they would be judged for engaging in same sex behaviours or treated badly due to their race (Malebranche et al., 2004). While these studies provide excellent background on encounters with multiple forms of stigma for Black gay men, they do not explore experiences of layered stigma, including within Black gay communities, and their connection to HIV-related behaviour.

We seek to fill a gap in the literature by examining how racism, homophobia, and HIV-related stigma interact in the lived experiences of young Black gay men. We discuss how experiencing various layered forms of stigma leads to coping strategies that are related to sexual risk, delayed HIV testing, delays in seeking treatment and care, and reduced serostatus disclosure to others. These strategies, which men utilised to avoid stigmatising experiences, represent important challenges to policies that frame HIV testing and treatment as the primary methods of HIV prevention in the USA.

Methods

The senior author and a trained research assistant who had a background in HIV prevention and sexual health conducted anonymous interviews with 31 Black self-identified, gay, bisexual, or same gender loving (SGL)¹ men ages 18-30. We included younger men because we sought to inform the adaptation of an existing HIV prevention intervention that had been originally developed for 18-30 year old acculturated Latino and white young gay men, for young Black gay men. Participants responded to fliers posted at five community-based organisations (CBOs), or distributed on the street in San Francisco and Oakland, from Summer 2002 until Summer 2003.² Interested people called the research assistant and were screened for eligibility. Of the 33 interviews conducted, 2 were excluded, one because the respondent appeared to be very confused possibly high on drugs at the time of the interview, and another because the respondent did not meet the inclusion criteria. Thus, there were a total of 31 interviews, a sample size we obtained after achieving theoretical saturation on the themes related to HIV prevention for Black men.

The research assistant interviewed the participants at an office in downtown San Francisco. Semi-structured in-depth interviews lasted approximately 90 minutes. Topics included family, work/school, religion/spirituality, peers, sexual identity, history of HIV testing, HIV disclosure, recent sexual experiences, thoughts on HIV prevention for young Black gay men, and community involvement. The data we primarily rely on for this analysis came from a series of questions in the interview guide:

• Can you tell me about coming out? What are some of the obstacles you have faced or will possibly face in the future?

• Can you explain to me how religion or spirituality plays a role in your life today?

• Could you please tell me your last experience getting tested?

• Could you tell me what you might have heard from your family, friends, or church about HIV/AIDS?

• Why do you think a growing number of young black men are becoming infected with HIV?

In addition to these questions, the interviewer also asked participants about their past two sexual experiences.

The research team also interviewed nine Black service providers who worked with young Black gay men at seven local CBOs in San Francisco and Oakland. The providers were contacted directly and invited to participate in the study. These interviews focused on barriers to accessing HIV prevention services and treatment, accessing community institutions, listings of social groups of young men, and the provider's assessments of the HIV-related risk behaviours within each particular social group of young men. The data we present are primarily responses to the following items in the interview guide:

• To what extent does the economic status of young men in this group affect their lives?

• Could you please tell me how young men in this group cope with racism?

• To what extent does masculinity play a role in the lives of these men?

• To what extent do young men feel comfortable with their sexuality? If they feel shame, how might they cope with these feelings and beliefs? How should a HIV prevention program address this issue?

• How do young men seek out HIV/AIDS prevention services?

All study participants provided informed consent and received $35.00 for their time. Interviews were tape recorded and transcribed, and any identifying information was redacted from the transcripts. The University of California San Francisco Committee on Human Research approved the research protocol.

Analysis

Transcripts were entered into Atlas*TI. A codebook was developed, based on a subsample of transcripts, the interview guide, and the primary research questions. Transcripts were broadly coded for content by team members who met weekly to discuss the coding scheme and to build consensus on how certain segments of the transcripts would be coded. To achieve reliability, two coders applied codes to a subset of transcripts and the codes were compared, with an aim to build coding agreement threshold of 90%. Discrepancies were discussed as a team and consensus was built until the coding was consistent across coders and transcripts.

An additional level of analysis was then applied to reports of coded text related to stigma and their corresponding interview transcripts, which were further examined for major themes related to stigma and analysed using a thematic analysis approach (Rubin & Allen, 2004). A line-by-line analysis was conducted on reports and relevant interview transcripts to generate additional themes and subthemes related to stigma, which were then coded across the data set if they provided explanatory value across cases, with the team again building 90% coding agreement with a subset of interviews. This coding process also generated memos related to the analysis, which contained illustrative quotations to represent themes in the data.

Results

Sample Characteristics

The young men interviewed for this study were between 19-30 years old, with a mean age of 25.5 years old. Out of the 31 participants in the study, 74% identified as gay, 16% identified as bisexual, 7% identified as SGL, and 3% (1 person) identified as ‘straight who likes men.’ Our sample contained 16 (52%) HIV-negative men and 15 (48%) HIV-positive men. Of the nine service providers interviewed for the study, all identified as Black gay men. Service providers had worked in HIV-related jobs from 3 to 20 years, and reported an average of 9 years working in the field.

Thematic analysis

The analysis yielded three important themes: (1) Homophobia and HIV-related stigma existed within the larger social context of racism; (2) Coping with social rejection, stemming from racism and homophobia, was cited when men chose to engage in unprotected intercourse with other Black gay men; and (3) Anticipated slights and rejection hindered efforts to disclose a positive serostatus to friends, family, and sexual partners, to go for HIV testing, and to seek treatment.

Homophobia and HIV-related stigma in the context of racism

Young men reported experiencing homophobia, and HIV-related stigma, in the context of racism within the larger society. Racism often limited their social and spatial mobility to settings within predominantly Black neighborhoods due to segregation. Within these predominantly Black social settings, participants described rejection from their families, and violent reprisals from people living within their neighbourhoods when it became apparent that they were gay. Our participant, Lorenzo, who coined the phrase “triply cursed” described multiple experiences of homophobia and HIV-related stigma from within his family, as well as from his neighbours, which all took place within the larger context of racial discrimination. Lorenzo reported that when he was growing up he felt confined to his Brooklyn, New York neighbourhood after being followed and verbally harassed by white men in a train station when traveling to a predominantly white neighbourhood. In his Brooklyn “ghetto,” he described people throwing things at him, “I was a short, fat kid coming into my sexuality and you know it was tough. I had to run to school, run home from school; run to the store, run home from the store. Because somebody either threw a rock at me or something like that.” Pointing out that he was “coming into his sexuality” and therefore subjected to violence from neighbours, yet forced to remain in “the ghetto” due to segregation, Lorenzo encountered homophobia within the larger societal context of racism.

Lorenzo went on to explain that he later became estranged from his mother who judged him for being gay and HIV-positive,

You know she doesn't understand this; she's very judgmental, close-minded.....She hates gays, and it's a trip... One time when I was younger my mom prepared a meal and after I left my mom threw the plate away because she just didn't want the germs. My sister was like, “What are you doing?” She's like, “Well I don't know where he –” She threw the fork away. “I don't know where he's been.” So, I have already dealt with that mentally because I haven't spoken to my mom in over a year. (Lorenzo, HIV-positive, age 30)

After telling the interviewer that he had no role models growing up who were Black gay men, Lorenzo went on to elaborate, “Being, you know, gay or having HIV as a Black man, those are like being triply cursed. You could look at it that way.” In this comment he seems to bring together these cumulative life experiences as a Black gay HIV-positive man, and being subject to racism from whites, while estranged from the Black community and his family for being gay and HIV-positive. Several informants discussed the rejection they received from immediate family members upon their disclosure of a gay identity, and/or their HIV seroconversion.

Indeed, Lorenzo's experience is echoed by a service provider who describes the fear Black gay men face over the loss of their communities, rejection from their families, and violent reprisals from people living within their often segregated neighbourhoods when they consider publicly announcing their same sex attraction:

I think it's a lot of the pressures. Like the whole family structure and the way it's set up is that you have to get married, you have to have kids and you have to do all of these things...It's always a horrible [burden]...to be gay and out. So I can remember growing up and thinking, ‘Oh my God I can't be gay.’ Because these are all the things that come with being gay. You dress up in drag. You're totally hated by your entire community. So I think that forces, if you have any kind of feelings you certainly would not come out in a Black community. Because number one you're going to lose your family, number two you're going to lose your community, and you're going to have to get the hell out of there to avoid fights and getting beaten. (Michael, Service Provider)

As Michael explains, being gay as a Black man often means the loss of one's family and community, being subject to violence within segregated neighbourhoods, and essentially necessitating that young men flee in order to avoid physical reprisals. This is the impact of the layered stigmas of homophobia within the larger context of racism, where the men lose the social institutions, namely family and community, which provide solace and support in the face of racism.

Physical and emotional forms of rejection occurred within families, separating men from the very people from whom they have traditionally received support. Over half of our informants discussed the rejection they received from immediate family members upon their disclosure of a gay identity or their HIV seroconversion. The following young man came to San Francisco after his positive HIV status was discovered by his grandmother:

But back home I had a very bad experience. I was donating blood, they call it plasma how they drain the liquid off your blood. [My grandmother] received a letter in the mail – well I did but she [my grandmother] opened it.... and she made a big issue out of it. “We don't want this germ or disease on my house,” and so she kicked me out on the streets and basically knocked all my teeth loose and slammed the door in my face. She turned her back on me. It was a hard and a physical thing, God knows I've never been through that in my life and mentally too. Because mentally [that] was the most devastating effect. And the thing about this is [that] the family is so close to me and they just closed me out like I didn't exist. I'm just a germ now. (Sheldon, HIV-positive young man, age 27)

Here, Sheldon describes being literally banished from his family and community due to his HIV status. He describes it as “devastating” and says that he is “just a germ now,” recalling Goffman's definition of stigma in which individuals are reduced to their particular “marked” status. Once Sheldon arrived in San Francisco, he was able to access temporary housing, as well as HIV-related services and counselling.

Participants tacitly acknowledged the systemic and ongoing exclusion that racism presented in their lives, making social rejection within the Black or Black gay community all the more bitter within the context of larger societal forms of racism and segregation. This theme of experiencing multiple and compounded forms of stigma, stemming from racial oppression, a gay identity and an HIV diagnosis was also revealed by other participants. David, another HIV-positive participant, explained that he felt that the government and his community were putting him in a “whole other bracket”:

But after I found out about [my status] myself, it opened up not only understanding for myself, but also to see the mentality of others. Some people are still in denial. And how you can be separated. Because okay, you have this now, so now you're in this category. It's not only your own community, but it's political. They're keeping record. You know, so it's like a whole other bracket. African American, gay, and now, you have AIDS. So you're just all the way over here. They shift you. So you're in a class all by yourself. (David, HIV-positive, age 27)

David discusses feeling marked, stigmatised, and being separated from people in his community into “a class all by yourself” due to his status as African American, gay and HIV-positive. This sense of isolation, being “shifted,” is directly attributed to that sense of being multiple stigmatised, experiencing layered forms of stigma.

Unprotected intercourse as a strategy to cope with homophobia and racism

Rejection of young men by families and community members sometimes led participants to seek acceptance and connection through unsafe sex. In fact, some described their decisions to engage in high-risk activities as strategies to manage the alienation they felt from losing their family ties and to have an intimate connection with other Black men. In the first instance, Vincent, an HIV-positive participant, alludes to unsafe sex with other Black men as a way to deal with homophobia and family rejection:

Our family tends to disown us when they find out that we're gay. So we're searching for that love from someone else that we were missing from our families and we're trying to make it up by having sex with these guys. And so we figure if we love this person and give them our body no matter what unconditionally that they’ll love us. It's the love that we need. And then we don't seem to think [about having safer sex] and that's why a lot of us are coming up HIV-positive. (Vincent, HIV-positive young man, age 29)

Vincent states, “It's the love that we need,” implying that family-based love and support have been withheld, due to homophobia. The homophobia that motivates familial rejection often leads men to seek acceptance and cope with their loss through having sex without condoms.

In a handful of other cases, young men cited the broader context of racism as an additional motivation for seeking out sexual connection from other Black men. Many men felt that while condoms provided a barrier to sexually transmitted infections, including HIV, they also inhibited the closeness and acceptance they received from their partners. Robert, another young man who is HIV-positive, described the need that unsafe sex fulfilled for him:

I've always had issues with relationships...I don't know [that] I'm much different than all the other cultures, but I know in the African American community I think that when it comes to that whole unconditional love and wanting to find the right person and all that stuff, that's not – that whole “all American dream” is not what the African-American community gets...It's also -- it's a lot of inward turmoil going on in regards to how much we really love ourselves and how much we need a partner to validate what we are, who we are, [and] define what basically our life [is]... I think that whole thing is, especially with condoms, if I can touch and feel that I'm sensing some stuff, I can feel something from you. But if there's something [a condom] in between [us] I'm not catching the vibe as well...So I don't know what you're feeling about me. (Robert, HIV-positive young man, age 28)

Robert explains that the “American dream” of romantic love is not for African Americans, implying that racism excludes him from achieving this ideal, and the emotional distress that arises from the need to feel validated, and to cope with racial inequality, inhibits condom use between Black men who need to “feel something” from partners who are like themselves. Thus, unprotected sex is cast as a form of validation and achieving the “whole American dream” despite societal racism.

Moreover, the same theme of intimacy and acceptance in light of the effects of layered stigma emerged in interviews with service providers. Marlon explained that his programme participants experienced various forms of internalised oppression due to the stigma attached to their race/ethnicity and sexuality, and that the intimacy young Black men sought in one another must be addressed in HIV prevention programmes:

In a world in where you are constantly bombarded by with negative stereotypical images of Black men. Where you are looked at in particular ways, like, sometimes...it's only in this interaction with another male, you feel this level of acceptance and bonding. So, to put a condom between that takes something away from the depth of intimacy that you can feel with another person. Prevention [efforts don't] talk about this issue. (Marlon, Service Provider)

Again, the context of larger societal racism emerges as a theme, particularly in Marlon's frank discussion of negative stereotypical images of Black men in the media. He explains that the need to find acceptance and bonding is a way for young Black gay men to cope with their experiences of social and institutional stigmatisation, as he states, “It is only in this interaction with another male, you feel this level of acceptance” which he contrasts with societal rejection. Condoms, he explains, “take something away” from that depth of intimacy that provides that acceptance, a coping strategy enacted in the face of stigmatising experiences.

The impact of layered stigma on HIV testing, serostatus disclosure and seeking treatment

Young men were isolated also from their Black gay peers. Many chose not to disclose their HIV status due to the threat of damaging gossip, which was how HIV-related stigma was socially produced and often precipitated social and even physical rejection. HIV's relationship with death and sickness fueled slights that were directed against young people who were HIV-positive, causing those living with HIV mental distress and fear of rejection. Patrick, a negative young man, explains that he stopped going to a youth centre when he realised the dynamics of HIV disclosure:

Like people coming down to the centre and like if someone - if some of the kids knew about another kid who had HIV and if they didn't like them, if they would get into an argument or something they'd use that against them...That was really, really messy to me and that was a lot of mess. Because I actually witnessed - I had to actually witness to be honest at least between maybe 8 to - almost 10 kids seeing them cry because of that...The kids who would have HIV, they think that they can confide in someone else because they're a friend or they're at the youth centre. They think that they can tell them that [but] the minute they would get mad at them they would use that against them. (Patrick, HIV-negative young man, age 22)

The air of gossip and judgement in the Black gay community made young people extremely hesitant to share their status with friends or to seek out support when they were HIV-positive. The inscription of HIV as a source of ridicule and anger caused grave concerns among community-based service providers. Some had made particular programming decisions to take issues of HIV-related stigma into account, including choosing not to offer HIV testing on the premises of youth centres.

Another strategy participants utilised to manage HIV-related stigma was being reluctant to get tested for HIV. For example, the following young man had sex with a man he later discovered was HIV-positive:

Actually it took me - I was like scared. I didn't like test after I did that for probably like maybe almost a year and a half. Because I was so scared to find out what the results were. But then I was talking to one of my older friends and he was like, ‘Just get it over with. It's better just to know.’ Because I didn't even want to know I was so scared then. (Raysean, HIV-negative young man, age 22)

Even when young men engaged in activities that they knew could transmit the disease, they were afraid to get an HIV test for fear that the results might show them to be HIV-positive. Raysean explains that he feared seroconverting because of his health, but also because the information of an HIV positive status could be “used against me” by friends in the Black gay community.

Service providers agreed and worried about young programme participants who were engaging in high-risk activities, yet were unwilling to get tested. Thus, they believed that very few young men had accurate knowledge of their serostatus:

I think the biggest problem in this community is people who don't know their status. They may go get tested but may not pick up their results. They can even get the results and live in the denial that they have it. Because the denial is often so deep that you would [rather] risk letting the disease progress in the body.... than admit to yourself.... Because if you have this disease now, then there is some responsibility because “HIV Stops With Me”...so now I have this responsibility to protect all these other people. That is a huge weight for some people to carry, who may have lost their families because they are gay or [because of] their [HIV-positive] status. It's like the one means that I had for connection, which was largely sexual in this community, is now taken away from me because I have a responsibility to inform people that I sleep with that I'm positive. (Desmon, Service Provider)

Desmon realised that there were long-term consequences to refusing to test, since HIV treatment is most effective if it is started early on in the infection. Yet, HIV may very well ruin one's “means for connection” in the Black gay community once a person discloses their positive serostatus and uses condoms. As Desmon states, their one chance for community acceptance, which was all the more needed in light of the loss of families due to homophobia, and the racism and exclusion experienced from white communities, may be undermined by the epiphany of a positive serostatus. Indeed, some study participants explained that they did not disclose their HIV positive serostatus to their sexual partners, for fear of rejection or even, in one case, the threat of a violent assault.

In some cases, young men got tested but did not seek treatment due to complexities of accessing care, exacerbated by structural factors, such as poverty, as well as social factors including racism and HIV-related stigma. In the following example, William, an HIV-positive man, states that people of colour feel like they don't have a right to access health care. William did not seek treatment for a year and a half after being diagnosed with HIV. He explains that multiple social and institutional factors, including racism, HIV-related stigma, and poverty, prevented him from seeking medical services:

Well, I think historically, in our community, first of all, you can't afford to go to treatment. Let's be honest. Most time, you get sick. People of colour historically don't run to the doctor right away. They wait till they, ‘Hmm, I can't move. Let me go to the doctor.’ I know when I got sick, because my mother didn't have insurance, I went to the emergency room. Because like, you know, wait till you get sick and you go there and you don't have to pay nothing, So that was one thing...And if you just petrified and you scared, you don't know what to do, so you just like, ‘Okay, what's the next step?’ So I think that was going on. That's one reason why...And then there's the fear, the fear of being seen at the clinic. Not wanting anyone to know why you [are] there. (William, HIV-positive young man, age 26)

William states that people in the Black community cannot afford to get treatment, and they wait until they are really sick before they seek medical attention. This delay seems to be due to poverty as well as racism, because he mentions “people of colour historically don't run to the doctor right away.” However, he does not say, “poor people” but rather “people of colour.” Finally, the decision to delay medical attention and treatment was further informed by a fear of being seen at the HIV clinic, due to HIV-related stigma highlighted by William's comment about “the fear of being seen at the clinic, not wanting anyone to know why you [are] there.” Racism within healthcare settings, and poverty layered with HIV-related stigma present barriers to seeking timely treatment in this instance, a theme we found in several interviews with providers and Black gay men.

Discussion

Although other studies have examined stigma, few have looked at the various forms of stigma and how they mesh to make condom use, HIV testing, treatment, and disclosure difficult for young Black gay men. The term ‘triply cursed’ arose from an informant's name for the exclusion he felt due to the stigmatisation Black gay HIV-positive men confronted due to their race/ethnicity, sexuality, and HIV serostatus. Racial and ethnic inequality represents just one manifestation of stigma that Black gay men face; however, the social marginalisation (nurtured by homophobia and HIV-related stigma) they experience from traditional sources of social support within Black communities, such as families and Black gay communities themselves, poses additional challenges for leading healthy, caring lives.

Similar to other studies, we found that our participants turned to the Black gay community in order to cope with heterosexism within Black communities, as a way to deal with emotions related to the stigmatisation they experienced from family and communities of origin (McDavitt, et al., 2008). Unfortunately, our findings also echoed other studies concluding that communities of young Black gay men reject individuals if it becomes known that they are living with HIV (Radcliffe, et al., 2010). Thus, the very people and communities to which young men turn towards for support and acceptance become sources of rejection and isolation. The stigmatisation of homosexuality and HIV made it extremely difficult for young men to be honest with people in their various communities about their sexual identities and health status. Not only did this silence contribute to a reluctance to test and disclose, it also undermined their ability to seek out services, and to reach out to friends and family who might otherwise be able to help individuals cope with chronic illness and other issues related to sexuality.

Multiple streams of discrimination and stigma converge to produce silence around HIV and thus fuel an epidemic in the Black gay male population. The rejection young Black gay men experienced from families and communities led them to enact coping strategies, like seeking acceptance and intimacy through unsafe sex. Yet, these coping strategies then led to a need to test for HIV, an activity that was delayed due to HIV-related stigma and its effect on one's social status within the Black gay community. Racism, homophobia, and HIV-related stigma also contributed to delayed treatment, and structural factors, such as poverty, also created barriers to care. For example, an inability to pay for needed care, in addition to the fear of being “seen at the clinic,” led one participant to delay care for 18 months following an HIV diagnosis. These are all social and structural dynamics that must be considered in any form of “test and treat” paradigm.

Perhaps one of the most sobering findings in this study was the HIV-related stigma that participants experienced in the Black gay community itself. The stigma of illness of any kind, particularly among men, instead led to a social environment in which individuals preferred to keep any diagnosis of ill health to themselves. The silence that surrounded the illness prevented men from supporting one another, but also inhibited any efforts to organise the Black gay community to demand funding for prevention, better access to treatment, or culturally sensitive medical services. This secrecy also may contribute to the poor health outcomes that HIV-positive Black gay men suffer, because young men lack social support to seek out testing and treatment options, and are therefore more likely to be diagnosed later and suffering poorer health (Galvan, Davis, Banks, & Bing, 2008; Millett et al., 2012a).

Programmes that work at the community level to mobilise various sub-communities to confront the stigmatisation of homosexuality and HIV within Black communities, and racism in mainstream society, have tremendous potential to bring about a change in the social processes that generate stigma and the vulnerability to HIV that it creates. Programmes must also aim to bolster psychological mechanisms at the individual level to help young men cope with stigmatisation of their identities, and instill young Black gay men with a sense of pride to offset some of the social rejection that they experience. In addition to this, programmes must seek out ways to create a sense of community among young Black gay men, regardless of status, in order to provide support for having safer sex, for getting tested, for getting into treatment, and for dealing with the multiple sources of stigma they encounter.

Limitations

For our sample, we recruited young Black men who were gay, bisexual, or same gender loving-identified. Therefore, the interactions of racism, homophobia, and HIV-related stigma might function somewhat differently among non-gay-identified young Black men who have sex with men who also engage in sexual risk behaviours that put them at risk for contracting and transmitting HIV, but who do not adopt such an identity. A more complete understanding of the interactions of racism, homophobia, and HIV-related stigma among non-gay/bisexual/same gender loving-identified men should take these perspectives into account. We also acknowledge that social desirability may have informed some of the responses our participants gave in the semi-structured interviews, a common limitation in face-to-face data collection.

Conclusion

This study has multiple implications for HIV prevention programmes and research regarding the social and structural issues affecting young Black gay men. Policies influenced by the test and treat paradigm must take into account research that examines the social and structural factors that influence individual decisions to seek health services. Clearly programmes must attend to the effects of societal racism that work in tandem with homophobia and HIV-related stigma within Black and Black gay communities. All three forms of stigma directly impact the transmission of HIV. Programmes must teach young Black gay men about the role of stigma and its relationship to social and structural forms of inequality, and encourage young men to challenge these manifestations of social power in order to shift community norms. Policymakers and advocates must consider the impact of social inequality and stigma, and attend to changing community norms while also instituting far-reaching structural changes such as implementing universal healthcare, in order to offer HIV prevention a new more effective approach to pursue with this vulnerable population.