Estrategia innovadora enfocada en parejas del mismo sexo para disminuir la infección del VIH en hombres Latinos

Abstract

The HIV epidemic is a serious and pervasive health issue in the Latino community. While prevention efforts have helped maintain stability in the overall number of infections among Latinos for more than a decade, this population continues to be affected by HIV at high levels. In particular, Predominantly Spanish-speaking Latino men who have sex with men (MSM) are disproportionately impacted by HIV. Several factors contribute to the HIV epidemic among Predominantly Spanish-speaking Latino MSM including substance use; intimate partner violence; the presence of certain STIs; same-sex relationship dynamics; avoidance of seeking testing counseling and treatment out of fear of discrimination and immigration status; and poverty, migration patterns, and language barriers. In particular, epidemiological behavioral research has identified how relationship dynamics in male couples are associated with sexual risk behavior. Consequently, further research is needed to identify and deliver interventions geared toward couple-based risk reduction among men in same-sex relationships. This paper describes the potential significance that innovative couple-based approaches can have on reducing HIV and AIDS cases among Predominantly Spanish-speaking Latino MSM and their same-sex partners.

1. INTRODUCTION: HIV AND STIs AMONG LATINO MSM

According to the most recent CDC data, in 2011, Latinos in the US represented 21 % of new HIV infections (10,159) while representing approximately 16 % of the total US population. For HIV infected Latino men, the most common modes of transmission are male-to-male sexual contact and injection drug use (Centers for Disease Control and Prevention, 2013a; Tung, 2012). Latino men who have sex with men (MSM) are especially impacted, representing 72 % (7,266) of all new HIV infections among Latinos (Kann et al., 2012). Among Latino MSM, 45 % of new infections occurred in those under age 30. Puerto Rican MSM have a substantially higher percentage of diagnosed HIV infections attributed to injection drug use than Latino men born in other countries (Colón-López et al., 2011; Finlinson, Colón, Robles, & Soto, 2006).

The CDC’s newest estimates show that there are about 20 million new sexually transmitted infections (STIs) in the United States each year, costing the American healthcare system nearly $16 billion in direct medical costs alone (Centers for Disease Control and Prevention, 2013b). In particular, MSM are disproportionately impacted by STIs. Trend data available for the first time show that MSM now account for nearly three quarters (72 %) of all primary and secondary syphilis cases. Surveillance data from several major cities throughout the country indicate that an average of 4 in 10 MSM with syphilis are also infected with HIV (Centers for Disease Control and Prevention, 2013c). Rates of reported sexually transmitted infections (STIs) are higher among Latinos than among non-Latino whites (Centers for Disease Control and Prevention, 2007, 2013b).

2. KEY FACTORS CONTRIBUTING TO THE PERSISTENT HIGH LEVEL OF HIV AMONG LATINO MSM

Epidemiological data highlight factors that contribute to HIV risk behavior among Latino MSM. Alcohol and drug use and addiction have been inextricably linked with HIV/AIDS among Latino MSM (Diaz, 2000; Dolezal, Carballo-Diéguez, Nieves-Rosa, & Díaz, 2000; Mizuno, Borkowf, Ayala, Carballo-Diéguez, & Millett, 2013). For example, a recent study found an increase in alcohol and substance use among recently-arrived behaviorally bisexual Latino men in the Midwestern United States (Martinez et al., 2012; Martinez et al., 2011). In addition, a venue-based sample study of Latino MSM found that drug use in the previous 6 months ranged from approximately 40 % in New York City and Los Angeles to 16 % in Miami. The most commonly used drugs were marijuana, poppers, cocaine, and methamphetamine (Rafael M. Diaz & et al., 1999). Another study with an internet-based sample of Latino MSM found that 49 % of the respondents used club drugs (e.g., cocaine, crystal methamphetamines, ketamine, volatile nitrites) in the past 6 months, with poppers being the most popular (32 %) (Fernandez et al., 2005).

In addition to alcohol and drug abuse, domestic violence greatly impacts Latino MSM. In particular, domestic violence has been linked to HIV risk among Latino MSM (Williams, Wyatt, Resell, Peterson, & Asuan-O'Brien, 2004). The National Coalition of Anti-Violence Programs reported that nationwide in 2008, approximately 24 % of domestic violence complaints made by members of the LGBT community were made by recent immigrants. Latinos made up the second largest group with reports following survivors of African-descent. It was estimated that most of these cases were among couples, either in casual or long-term relationships (National Coalition of Anti-Violence, 2008). Another study conducted among Puerto Rican gay men concluded that close to half of the participants experienced some sort of violence in their intimate relationships and sexual coercion and violence that was linked to HIV transmission (Madera & Toro-Alfonso, 2005). However, more research is needed to further understand the impact of intimate-partner violence and HIV risk among Latino MSM.

Research shows that as many as two-thirds of new HIV infections occur among gay men in committed relationships, which points to the dynamics of relationships as factors associated with sexual risk behaviors (Sullivan, Salazar, Buchbinder, & Sanchez, 2009). Therefore, relationship status stands out as an important context for understating HIV among Latino gay men (Beougher, Gomez, & Hoff, 2011). A study conducted at Emory University found that a significant number of men in longer-term relationships are unaware of their partner's HIV status (Sullivan et al., 2009). In fact, many gay men in relationships believe that they are at less risk for HIV and are therefore less likely to have been recently tested for HIV (Sullivan et al., 2009; Wu, El-Bassel, Donald McVinney, Fontaine, & Hess, 2010). Previous research shows between 40 –60 % of Latino gay men have primary partners (Rafael M. Diaz & Ayala, 1999; Jarama, Kennamer, Poppen, Hendricks, & Bradford, 2005; Ramirez-Valles, Garcia, & Campbell, 2008) and that being in a relationship increases the rate or is predictive of unprotected anal intercourse with a primary partner (Diaz, Stall, Hoff, Daigle, & Coates, 1996). However, more research is needed to explore how relationship dynamics are associated with sexual risk behavior. There is also an urgent need to develop culturally and linguistically congruent interventions and programs to address these concerns.

Behavioral data also suggest that Predominantly Spanish-speaking Latinos are disproportionately at risk for HIV compared to their English-speaking Latino and non-Latino counterparts (Rhodes et al., 2010; Wohl, Tejero, & Frye, 2009; Wolff & Ellis, 2009). Predominantly Spanish-speaking Latino men are less likely to report: using a condom at most recent intercourse; seeking or accessing health services; and having a personal doctor and health insurance when compared to English-speaking Latino men or non-Latino men (North Carolina Department of Health and Human Services, 2004; North Carolina Institute of Medicine, 2003). In addition, research suggests that less acculturated Latinos are more likely to engage in risk behaviors because of pre-and-post migration experiences including discrimination, stigma and isolation (Hines & Caetano, 1998; Marsiglia & Navarro, 1999).

3. ADVANCING NOVEL HIV PREVENTION INTERVENTIONS WITH PREDOMINANTLY SPANISH-SPEAKING LATINO MSM THROUGH THE LENS OF COUPLE-BASED APPROACHES

The U.S. National Institute of Mental Health (NIMH) and the Centers for Disease Control and Prevention (CDC) launched a call to maximize: (1) healthy sex interventions, (2) community and structural interventions, (3) integrated biomedical and behavioral interventions, and (4) interventions to improve uptake of HIV testing. The NIMH and CDC also highlighted the need to address research gaps in designing risk-reducing and sexual health-promoting interventions for MSM, including intervention to address mental health, substance use, HIV disclosure, and stigma (Grossman et al., 2011; Kuehn,2011).

Focusing on one area of innovation – a couple-based HIV/STI prevention – is an approach that warrants further expansion, taking into consideration the call from the NIMH and the CDC and given: (1) the substantial evidence indicating that condom use among MSM is less likely with partners in more established relationships compared to “casual” partners (Adib, Joseph, Ostrow, & James, 1991; Berger, 1990; Bosga et al., 1995; Chng & Geliga-Vargas, 2000; Dawson et al., 1994; R. M. Diaz et al., 1996; Doll et al., 1991; Elford, Bolding, Maguire, & Sherr, 1999; Fitzpatrick, McLean, Dawson, Boulton, & Hart, 1990; R.B. Hays, Kegeles, & Coates, 1990; R. B. Hays, Kegeles, & Coates, 1997; Hoff, Coates, Barrett, Collette, & Ekstrand, 1996; Koblin etal., 2003; McKusick, Horstman, & Coates, 1985; Misovich, Fisher, & Fisher, 1997; Myers et al., 1999; Myers et al., 1992; Piaseczna et al., 2001; Valdiserri et al., 1988; Wagner, Remien, & Carballo-Dieguez, 1998); (2) the limited research to address the growing health needs of Predominantly Spanish-speaking Latino MSM (Bedoya et al., 2012; Martinez et al., 2012; Martinez et al., 2011) and drug users (Bedoya et al., 2012; Díaz, Heckert, & Sánchez, 2005; Rhodes et al., 2012); and (3) the lack of couple-based interventions for MSM identified in meta-analyses and systematic reviews of HIV prevention intervention trials with stronger scientific design (Johnson et al., 2002; Johnson et al., 2005; Manhart & Holmes, 2005; Semaan et al., 2002).

There is evidence consistent with the view that a couple-based approach can be effective in promoting sexual risk reduction among populations at elevated risk for HIV (Hoebbel & Fals-Stewart, 2003; Stappenbeck, Hoebbel, & Fals-Stewart, 2004). A meta-analysis of 66 studies on the efficacy of HIV counseling and testing revealed that mixed HIV serostatus couples who received joint HIV counseling and testing had substantial improvement in condom use, whereas those counseled individually showed scant improvement following HIV counseling and testing (Higgins et al., 1991). Another study found that married or cohabiting drug-abusing men who were assigned to 12-session couples risk reduction intervention reported significantly fewer sexual risk behaviors and a higher proportion of HIV testing compared to married or cohabiting drug abusing men who were assigned to a traditional 12-session individually-based substance abuse counseling and HIV education intervention (Hoebbel & Fals-Stewart, 2003; Stappenbeck et al., 2004). The Social Intervention Group (SIG) at Columbia University has demonstrated that Connect is efficacious in reducing sexual risk behavior among mixed-gender couples at 3-months and 12-month time points following receipt of the intervention (El-Bassel et al., 2003, 2005). While the literature reviewed here indicates substantial promise within the burgeoning body of evidence supporting couple-based HIV/STI prevention, the focus has been almost exclusively on mixed gender couples.

It is also important to note that while MSM account for the majority of HIV cases in the U.S., the number of rigorously-tested behavioral risk reduction interventions—a crucial component of the public health response to HIV given the absence of a vaccine or cure—is lowest for MSM compared to other populations (Johnson et al., 2002; Semaan et al., 2002). Furthermore, only a few interventions in the DEBI Project target MSM, and none target Predominantly Spanish-speaking Latino MSM or Latino gay couples. As such, a need exists to develop a couple-based HIV/STI preventive intervention that is culturally and linguistically appropriate and contextually tailored for Predominantly Spanish-speaking Latino MSM in same-sex relationships.

Our community-based research team has proposed the adaptation of "Connect 'n Unite" (CNU), a 4-session couple-based HIV preventive intervention for stimulant-using Black MSM in same-sex relationships, to reduce the disproportionate HIV burden borne by Latino MSM. In particular, relying on current epidemiological and ethnographic research that points to an increasing proportion of HIV and AIDS cases among Predominantly Spanish-speaking Latino MSM and men in long-term same-sex relationships, we adapted the intervention to target both of these areas simultaneously by recruiting Predominantly Spanish-speaking Latino MSM and their same-sex partners.

CNU sessions cover several topics including self-care (e.g., information about HIV/AIDS, stimulant use, self-care plan); communication (e.g., use of effective communication styles); relationship strengthening (e.g., identification of unwritten rules and sexual decision-making); and couple problem solving (e.g., identification of a support mechanism for each partner). The intervention was found effective in increasing condom use and HIV testing and decreasing harmful substance use among Black male couples (Wu et al., 2010).

Given the high rates of HIV among Latino MSM and the social forces and structures that impact the health of Latino MSM, the potential intervention should cover several components including HIV and STI information; the impact of migration-related changes and lack of Spanish-language prevention campaigns; limited access to health services; and risk reduction strategies with a focus on sexual behaviors and illicit drug use. In particular, migration has emerged as a risk factor for HIV/AIDS in the United States. These particular components should be guided by theories that have previously been used for reducing risk behaviors and illicit drug use, including social cognitive theory (SCT) (Bandura, 1986) and a relationship-oriented ecological framework (Bronfenbrenner, 1977), both of which have also informed previous evidence-based interventions for couples, including CNU. SCT is the most frequently used theoretical basis for HIV prevention interventions trials in the U.S. (Semaan et al., 2002), and SCT-based interventions result in clinically significant risk reduction (Kalichman, Carey, & Johnson, 1996). The central tenets of SCT utilized by the original and revised Connect interventions are self-efficacy and outcome expectancies. A relationship-oriented ecological perspective informs a couple-based, multi-level approach to sexual risk reduction by focusing on different levels of key individual, relational and contextual factors that play a role in initiating and maintaining protective behaviors among intimate partners.

A couple-based intervention for Predominantly Spanish-speaking Latino MSM and their same-sex partners should also incorporate components that address issues surrounding domestic violence. Preliminary research indicates that domestic violence is extremely high among Predominantly Spanish-speaking Latino MSM and leads to other sets of health concerns, including mental health issues such as depression and anxiety and risky sexual behaviors. Domestic violence needs to be addressed by emphasizing empowerment approaches, building social networks, and referring individuals to domestic violence resources. In addition, the intervention should take into consideration the diversity of the Latino population in the US, lived experiences of Latino MSM, and migration experiences of Latinos as a factor shaping sexual behaviors.

All of the potential components of the intervention, including HIV and STI information, access to health services, and harm-reduction skills should be evaluated, examined, and revised to develop an effective HIV prevention intervention for the targeted population. Given the limited research related to Latino gay couples as a context, and in particular, among Predominantly Spanish-speaking Latino MSM in same-sex relationships, a needs assessment should also be conducted to further understand the issues affecting this community. These findings should then inform the development of the intervention.

The adapted CNU intervention for Predominantly Spanish-speaking Latino MSM should contain elements that effective HIV prevention interventions share, including (1) having a solid theoretical foundation, (2) offering multiple sessions, (3) setting goals and discussions discussions on condom use and testing, as exemplified with adapted and refined key activities, including homework assignments, (4) increasing awareness, knowledge, and positive attitudes and beliefs about risk reduction, (5) increasing risk reduction norms and social support for protection, (6) providing positive reinforcement for healthy individual and couple-based behavioral change, and (7) providing guidance on how to utilize available services. It will also need to incorporate, through an adaptation and refinement process, perspectives from service providers. The potential adapted intervention will not only benefit Latino MSM, their same-sex partners and communities, but will also help inform future research and intervention strategies for other vulnerable populations.