EXPLORING SELF-EFFICACY AND PERCEIVED HIV RISK AMONG SOCIOECONOMICALLY DISADVANTAGED HISPANIC MEN

Abstract

The prevalence of HIV in Chile predominately affects the male population with the primary mode of transmission (99%) through sexual contact. In order to engage in safe sexual practices, men must have high sexual self-efficacy and perceived risk of infection, however, little research examines these variables with respect to HIV prevention. The purpose of this article is to review existing literature on self-efficacy and its connection with perceived HIV risk among Hispanic men, in order to direct future HIV prevention interventions among Chilean men. A literature search was conducted to identify studies for this review using three databases. A combination of keywords was used to conduct the search and a total of 34 articles were analyzed. All of the articles reviewed examined the Hispanic male population with respect to either self-efficacy or perceived risk, or a combination of the two. Major themes emerging from the review include: substance use, condom use, cultural norms, relationship communication, negotiation, and homonegativity. The existing studies provide evidence for preventing future HIV infection among low socioeconomic status Chilean males and begin to establish a positive relationship between self-efficacy and perceived HIV risk. While additional studies are needed to provide further support, self-efficacy and perceived risk should be integral aspects of future prevention interventions.

INTRODUCTION

The most recent report from the World Health Organization (2014) indicated that over 36.9 million people worldwide are living with human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS). The global climate of HIV translates to Latin America where, in 2013, over 1.6 million people were living with the virus, a 0.4% prevalence (UNAIDS Gap Report, 2014)(1) that is continuing to grow among both the male and female population. According to UNAIDS the number of people living with HIV in Chile was estimated to be 39,000, a 0.3% prevalence rate in 2013. The main Chilean population affected by the virus is adult males with the primary mode of transmission (99%) through sexual contact ⁽¹⁾. This data is reflected in the regions of Arica and Parinacota, Tarapacá, Antofagasta, Valparaíso, and the Metropolitan Region of Santiago, where in the past three, five year periods had the highest concentrations of HIV/AIDS ⁽²⁾.

The ratio of men to women living with HIV in Chile was 3.6:1 as of 2011 ⁽²⁾, and with the majority of HIV cases being acquired through sexual contact, there is a need for the implementation of safer sex practices among men, however, traditionally, condoms are not used in this population and are often viewed as mistrust between partners ^(3,4). In order to engage in safer sexual practices, men must feel confident in their ability to speak to their partners regarding such precautions, for example through increased safer sexual self-efficacy ^(5–7). Self-efficacy represents an individual’s belief that he can exert control over his motivation and behavior, and over his social environment⁽⁸⁾. Perceived HIV risk, on the other hand, is the extent to which individuals consider themselves at risk for contracting HIV ⁽⁹⁾. Sexual self-efficacy encompasses partner communication skills, condom use self-efficacy, and relationship and sexual decision making⁽¹⁰⁾, which, in turn, impacts perceived HIV risk and HIV risk behaviors.

Several studies have shown the relationship between an individual’s self-efficacy and HIV risk behaviors ⁽¹¹⁾ and self-efficacy and HIV related knowledge ^(12–14), however there is a gap in the literature regarding self-efficacy and perceived HIV risk ⁽⁶⁾, specifically among low socioeconomic status. Hispanic men. The objective of this literature review is to examine self-efficacy and its connection with perceived HIV risk among Hispanic men, this can help in directing future HIV prevention interventions among Chilean men.

METHODS

Searches were conducted in Medline, Cinahl, and PsychInfo between June 16, 2016 and June 23, 2016. Articles were found using the following key words: HIV, AIDS, self-efficacy, perceived risk, Hispanic, Latino, and male. Initially 710 articles were found from all three databases, after eliminating the repeated articles and selecting by title a total of 124 articles were chosen. Only articles published in the past five years were analyzed, and articles written exclusively on HIV positive populations were excluded from the results. Thirty four articles met the inclusion criteria and were included in the final review.

RESULTS

The majority of the articles (97%) reviewed for this study were peer reviewed descriptive studies. Over half of the studies (59%) analyzed specifically Hispanic or Latino self-identifying male populations, while the remainder of the studies included Hispanic or Latino self-identifying males they also included other races and ethnicities. Most of the articles (67%) focused on either self-identifying sexual minorities or men who have had sex with other men in the past but may not identify as MSM or bisexual individuals.

Self-efficacy

For the purpose of this study self-efficacy encompassed partner communication, relationship and sexual negotiation, and condom use self-efficacy. Condom use self-efficacy describes confidence in using condoms correctly with a partner ^(15–17). While almost all of the articles addressed condom use, only 35% of the studies addressed the positive relationship of condom use self-efficacy and condom use, indicating that those participants with high condom use self-efficacy were more likely than their counterparts to use condoms during oral, anal, and vaginal intercourse.

Traditional Hispanic culture gender norms, such as machismo, decrease sexual self-efficacy and HIV prevention behaviors. Thirteen of the studies examined the unique relationship between Hispanic culture and sexual risk taking. Machismo emphasizes the man’s role as protector and familial caretaker ⁽¹⁸⁾, however it often encourages men to have multiple sexual partners ^(19,20), decreases condom use ^(10,18–24), increases alcohol and drug use behaviors ^{(19,20,22,24)}, depresses MSM behaviors ^(22,25), and encourages sex in exchange for relationship power ^{(10,18,24,26–28)}. Experiences of homonegativity among Hispanic males also decreased condom use self-efficacy and was a significant predictor of unprotected anal sex ⁽²²⁾.

Alcohol is known to influence risky sex practices and has been associated with neurological impairment and poor condom use skills ⁽²⁷⁾. Half of the studies (50%) discuss alcohol and drug use as factors that decrease condom use self-efficacy and increase the likelihood of multiple partners and unprotected sex. The direct, positive correlation between substance use and condom use self-efficacy exhibit yet another barrier to increased HIV prevention behaviors among Latino males.

Just over a quarter (26%) of the articles examine partner communication and sexual negotiation as important factors to decreasing HIV risk behaviors. The topics most commonly discussed among partners include sexual history ⁽²⁹⁾, condom use ^{(18,23,24,29–32)}, and relationship status ^(9,29,33). In all studies analyzing partner communication, positive relationships were found among sexual history, condom use, and relationship status discussions, indicating that the more a couple spoke about these three topics the greater their sexual self-efficacy.

Perceived Risk

Among the articles reviewed, participants were often aware of risky sexual behaviors, but still participated in the behaviors because they perceived the benefits of sexual exchanges (e.g.money and relationship power) as outweighing the cost of potentially contracting HIV ^(26,29). Hispanic males using alcohol and drugs prior to sexual intercourse had a greater perceived risk of contracting HIV than those who did not. In addition, alcohol and drug users were also less likely to utilize condoms as protection during sex ^(34,35). Most of the men studied, regardless of sexual orientation, had low HIV perceived risk regardless of risk taking behaviors ^(9,25,34-36). Two articles concluded that good sexual negotiation and partner communication were correlated with low perceived risk ^(9,33). Although only 24% of the articles reviewed for this study discuss perceived risk, important implications can be drawn for the development of future prevention interventions.

CONCLUSION

The results of this review indicate that despite the increasing prevalence of HIV among socioeconomically disadvantaged Chilean males ⁽²⁾, there are relatively few articles published that aim at analyzing the relationship between sexual self-efficacy and perceived HIV risk among Hispanics. Rather this study examined the two variables individually in an effort to draw conclusions regarding their relationship in order to influence future HIV prevention interventions.

Studies focusing on self-efficacy examined condom use self-efficacy, Hispanic cultural norms, substance use, homonegativity, and partner communication with respect to HIV prevention. Condom use self-efficacy and partner communication had positive relationships with sexual self-efficacy and increased prevention behaviors, indicating that future interventions for this population should include building communication and negotiation skillsets, potentially through role playing, increasing condom knowledge, changing condom attitudes, and emphasizing the importance of protection in prevention. Homonegativity, substance use, and machismo had positive relationships with risky behaviors, as homonegativity, substance use behaviors, and machismo ideals increased so did the likelihood of participants engaging in risky sexual behaviors. Although only the negative aspects of machismo were examined, the caretaker role of machista males has potential to increase HIV prevention behavior and sexual self-efficacy. Future interventions should take into account cultural ideals for the Latino population and should address the negative impact of alcohol and drug use on prevention behaviors.

Sexual relations in exchange for relationship power, money, and alcohol and drugs increased participant’s perceived risk, but participants still engaged in the behaviors. Future interventions should address sexual exchanges as important risk behaviors for individuals with low perceived risk, guide participants as to how to take precautions to prevent HIV in such situations, and increase participant’s self-efficacy through partner communication skill building. In most of the studies, men had low perceived risk of contracting HIV although they exhibited high risk taking behaviors, increasing HIV knowledge may help enable participants to view HIV as a “real” threat to their sexual wellbeing.

This study concluded that future HIV prevention interventions for Chilean males should be aimed at increasing sexual self-efficacy through workshops discussing condom use, partner communication and negotiation, and relationship agreements while emphasizing the importance of machismo and alcohol and drug use behaviors in HIV risk taking. They must also include HIV knowledge in order to increase perceived risk and decrease risky behaviors. Limitations of this review include the limited number of articles focusing on heterosexual males and the low number of articles focusing on Chilean men.