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Black Heterosexual Men & HIV Prevention
1. FORGOTTEN POPULATION IN HIV
PREVENTION
Beyond The DL: Black/African American
Men Who Have Sex With Women
Camille A. Abrahams, MS
Dorcey Jones, MPH
Adam Viera, MPH
Harm Reduction Coalition
Monday, November 9, 2009 American Public Health Association Meeting
1
2. Presenter Disclosures
Camille A. Abrahams, MS
The following personal financial relationships with
commercial interests relevant to this presentation
existed during the past 12 months:
No relationships to disclose
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3. Harm Reduction Coalition
Founded in 1994 to work with individuals and communities at
risk for HIV infection due to drug use and high-risk sexual
behaviors.
Committed to reducing drug-related harm by initiating and
promoting local, regional and national harm reduction
education, interventions and community organizing.
Offer specific expertise in how to best incorporate the
principles of health and safety promotion for drug users.
3
4. HRC Programs & Services
Policy Advocacy
Lifting the Federal Ban on Needle Exchange
National and Regional Conferences
Next conference: Austin, TX. November 16-21,
2010
The Institute @HRC – Training & Capacity Building
Harm Reduction Training Institute
Skills and Knowledge on Overdose Prevention
(SKOOP)
LGBT Project
CBA for Communities
CBA for CBOs (formerly the African American 4
Capacity Building Initiative (AACBI))
5. Examples of (Free!)
CBA Services from HRC
Providing skills-building trainings and
technical consultation in the following areas:
Organizational Infrastructure and Program
Sustainability
Evidence-based Interventions and Public
Health Strategies
Program and Outcome Monitoring and
Evaluation
Community Mobilization
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6. Outline for Today’s Presentation
Overview
Problem Statement
Why is HRC addressing this issue?
What have we uncovered?
Capacity Building Assistance (CBA)
Strategies
Closing Remarks 6
7. Overview
Behavioral interventions, government funding,
social services and media attention targeting
HIV prevention among heterosexual
Black/African American men lag far behind
their representation in the epidemic.
It is necessary to rethink the approach that
targets women engaged in high-risk sexual
behavior without considering their sexual
partners.
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8. Problem Statement
How can we utilize capacity building assistance
strategies to address the lack of prevention
efforts for Black men who have sex with
women?
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10. The Facts…
45% of new HIV infections (56,300 people annually)
are among Blacks/African Americans
HIV is the 2nd leading cause of death for black men
ages 35-44 (CDC, 2006)
Of all black men living with HIV/AIDS, the primary
transmission category was sexual contact with other
men, followed by injection drug use and high-risk
heterosexual contact. (CDC, HIV/AIDS Surveillance
Report, 2007)
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11. More facts…
Over one-fourth (28%) of all AIDS cases among men
in the US occurred through injection drug use and
heterosexual sexual contact. Over three-fourths of
those cases were among men of color, with African-
American men comprising more than half (55%).
CDC
HIV transmission patterns among Black men vary
from those of white men. Although both groups are
most likely to have been infected through sex with
other men, white men are more likely to have been
infected this way. Heterosexual transmission and
injection drug use account for a greater share of
infections among Black men than white men.
(CDC, HIV/AIDS Surveillance Report, 2008)
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12. Transmission rates for black adult &
adolescent men living with HIV/AIDS,
2005
CDC, 2006
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13. Purpose of Formative
Research
Raise awareness and increase knowledge about
this issue in the community
Understand the factors that influence the HIV risk of
Black/African men who have sex with women
Solicit feedback from community stakeholders and
key informants to determine the HIV prevention
needs of African American heterosexual men
Strategize and develop capacity building assistance
solutions that can support the work of community
based organizations and health departments
implementing HIV prevention strategies with African13
American heterosexual men
14. Assessing the Situation
In order to better understand the views of our CBA
consumers regarding the HIV prevention needs of
Black men:
Hosted two interactive forums on this issue in 2008
Regional Community Advisory Group Webinar,
January 23rd
In partnership with the NYS Dept. of Health,
February 15th
Conducted an extensive Literature Review re:
Heterosexual African American men and HIV
Prevention
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15. Assessing the Situation
Organized and facilitated an institute for the United
States Conference on AIDS (Fort Lauderdale, 2008).
Expert Panel Discussion
Key Informant Interview Video, “Forgotten
Population”
Solutions-based Focus Groups
Gathered information from primary population
Target Population Survey (February 2009)
Discussion Group (Albany, NY. September 2009)
Coming Soon…
Modified target population survey, Fall/Winter
2009 15
16. What Have We Uncovered?
Via Community Advisory Forums, Focus
Groups, Key Informant Interviews and
Literature Review
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17. Key Themes
Factors that Influence HIV Risk of African American
Men Who Have Sex With Women
Healthy Relationships
Masculinity & Sexuality **
Class & Poverty
Substance Abuse & Drug Policy
Incarceration/Prison System
Mental Health
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18. Black Men: Healthy Relationships
Key Findings
HIV prevention interventions/strategies targeting African
American heterosexual men should:
Define what healthy relationships are
Explore what intimacy means in a relationship
Explore one’s identity as a parent, a romantic partner
and a member of a family unit
Teach and promote honest, effective interpersonal
communication
Develop alternative outlets of communication
about relationship issues
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19. Black Men: Masculinity & Sexuality
Key Findings
HIV prevention interventions/strategies targeting African
American heterosexual men should:
Deconstruct old norms about masculinity WHAT IT MEANS TO
BE A MAN
Develop new norms around masculinity
In the US there has been a significant history of sexual exploitation and
objectification of the Black male. Black men often are referred to by
their presumed sexual preoccupation and/or prowess rather than being
seen as complex multi-dimensional beings with strengths as well as
weaknesses. (Frimpong, 2009)
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20. Black Men: Class & Poverty
Key Findings
HIV prevention interventions/strategies targeting African American
heterosexual men should:
Address the fact that HIV/AIDS not a priority for most individuals
Recognize that homelessness & joblessness are at the forefront
of concerns
Increase access to available resources
Build new resources for African American men that address ALL
of their needs
Should partner with job training, GED and other
educational/vocational programs
Black and African American men face discrimination in education and
employment. Because of this, Black men often cannot obtain gainful
employment, putting them at a significant disadvantage in our technological
economy. Lack of employment is linked to increased involvement in activities
that can increase risk of HIV infection such as substance use, commercial sex,
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homelessness and incarceration. (Frimpong, 2009)
21. Black Men: Substance Abuse &
Drug Policy
Key Findings
HIV prevention interventions/strategies targeting African
American heterosexual men should:
Focus on non-Injection Drug Users (IDU), i.e. crack
cocaine, prescription drugs, alcohol, etc.
Address stigma associated with drug use
Partner and collaborate with needle exchange
programs
Recognize the sexual activity of substance users
Incorporate harm reduction strategies
Be inclusive of Black heterosexual males during
the development and implementation process
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22. Black Men: Incarceration/The
Prison System
Key Findings
HIV prevention interventions/strategies targeting African American
heterosexual men should:
Work to build the representation of Black heterosexual men in
service organizations (as employees, clients/consumers, CAB
members, etc.)
Recognize incarceration as a fluid experience
Develop effective recruitment and retention strategies to engage
this population
Recognize the impact of media on perception of Black men
Work to destigmatize HIV/AIDS in the correctional system
Nearly one-third of all Black men have been incarcerated either
as adolescents or adults. Cycling in and out of the prison
system can negatively affect Black men's ability to keep and
maintain jobs and relationships. 22
23. Black Men: Mental Health
Key Findings
HIV prevention interventions/strategies targeting African American
heterosexual men should:
Start at home (focus on building support within families and
other existing relationships)
Educate society on the importance of mental health
Validate the concerns of Black heterosexual men
Build self-esteem and self-worth
Address the social norms among Black men
Address drug use and concurrent issues
Build support systems (mentoring, communication, education,
etc.)
Creating safe spaces for Black heterosexual men to
express the problems in their lives
Increase stress management/coping skills
Address family origins and explore past life experiences 23
24. Video Screening
What are Black men’s role
How did you get to know in lowering their risk for
your sexuality as a Black HIV in these
man? communities?
Forgotten Population: Voices
of Heterosexual Black/African
American Men
How do you think drug policy (such as mandatory minimum
sentencing on drug charges, drug free school zone laws, etc.) has
played a role in Black men rebuilding their communities that have been
broken because of the war on drugs?
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32. Capacity Building Strategies
New skills-building training: Black Heterosexual Men
& HIV Prevention
Pilot tested, June 2009
Goal to increase the ability of direct service
providers to understand the lack of HIV prevention
services, and address the hierarchy of needs of,
Black heterosexual men through developing a
sense of why they are at risk for HIV, and
formulating best practices for prevention
intervention strategies for this population.
How to engage the target population
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33. Other Possible CBA Strategies
Training
Strengthening HIV Prevention Interventions
How to Recruit and Retain Skilled Staff That Reflect The
Target Population
Holistic Screening & Assessment: Meeting All the Client’s
Needs (e.g. Education, Unemployment, etc.)
Client Recruitment & Retention
Engaging Hard to Reach Population (incentives)
Cultural Competency
Addressing Role of men in African American community
How to Develop Home-Grown Interventions
Sexy Harm Reduction
How to Develop and Implement Effective Behavioral
Interventions in the Corrections System
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34. Other Possible CBA Strategies
Technical Assistance (i.e. adapting interventions, mentoring and
coaching)
Strengthening HIV Prevention Interventions
Adapting existing interventions for heterosexual African
American men
Community-Based Needs Assessment
Population-Based Needs Assessment
Developing Home Grown Interventions (i.e. partner-level,
family-level interventions)
Organizational Development & Program Sustainability
Staff Development: Hiring Culturally Competent Peers and Staff
Strategic Planning
Partnership & Collaboration: Help Organizations learn how to
collaborate with non-traditional organizations (e.g. faith based,
corrections, job training, youth-serving organization, law
enforcement)
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35. Other Possible CBA Strategies
Community Mobilization
Ex-offenders and incarcerated men re: right to health
care in the corrections system
Develop norms among Black men around seeking
preventive healthcare and social services
Resource Sharing/Information Dissemination
Sexual Harm Reduction/Risk Reduction
Media Strategies: How to Diversify the Perception of
African American men in Popular Culture
Incarceration and HIV Prevention
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36. Closing Remarks
WE WILL NOT SOLVE ALL PROBLEMS!
HOWEVER, WE ARE TAKING THE FIRST OF MANY STEPS
TOWARDS A SOLUTION
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37. Acknowledgments
The African American Capacity Building Initiative (AACBI) would like to thank
the following people and institutions for contributing to our work on this
important issue:
Jagadisa-devasri Dacus, Harm Reduction Coalition
Rona Taylor, Ms. Foundation
Natalie Baptiste, SUNY Downstate
Andrea Brooks, Camillus House
Allen Kwabena Frimpong, Youth R.I.S.E.
Peter Thomas, PhD, MPH, Centers for Disease Control and Prevention
Darrell Wheeler, PhD, MPH, MSW, Hunter College School of Social Work
Sy Belfor and Niyah Rahamman, Mr. Man Productions
Samantha Franklin, Columbia University
Dr. Williams, SUNY Albany
Kelvin Sapp
And all the key informants and community stakeholders who participated in
our formative research.
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Funded by the Centers for Disease Control & Prevention
38. For More Information
Harm Reduction Coalition
22 West 27th Street, 5th Floor
New York, New York 10001
Tel: 212-213-6376
Fax: 212-213-6582
Website: www.harmreduction.org
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Hinweis der Redaktion
Welcome Introductions: Me & the Team
The African American Capacity Building Initiative (AACBI) offers: technical consultation and training to enhance the effectiveness of HIV prevention interventions by assisting organizations in adapting and tailoring those interventions to best serve the needs of their clients. AACBI will work with organizations to adapt and tailor the CDC ’ s Diffusion of Effective Behavioral Interventions (DEBI) Projects for successful use in communities. These specifically targeted interventions have been developed and used with African Americans on individual, group, and community-level bases and have shown phenomenal success in reducing high-risk sexual and drug use behavior while also building the knowledge base and skill sets of African Americans at high risk for HIV infection.
Read Bullet #1 There is a need to change the framework under which current prevention intervention models operate. Currently, “priority populations” for prevention strategies are designated by how people infected with HIV identify their transmission risk and who among them have the highest rates of infection. This does not take into account those individuals who are infected in other ways (i.e. female-to-male sexual transmission). Nor does this address those individuals whose transmission risk is unidentified. Read Bullet #2
There is a need to generate awareness around this particular issue, and to solicit feedback on why there are gaps in services and resources for this population from direct service providers in community based organizations, health agencies, amongst researchers, policy-makers. As capacity building assistance providers, we decided to step forward and strategize about the best way to engage and connect heterosexual black men to HIV prevention services Caveat: We are talking about men who have sex with women only…not men on the down low. There are programs, services and research that are addressing that specific population. So, I want to be clear about who I’m talking about today. Glad to see that the topic of heterosexual transmission is all over the agenda at this conference. It’s about time!
Read highlights of stats We know how HIV is transmitted, be it among Black men or any other man: through unprotected anal or vaginal intercourse with an HIV+ person or sharing injection equipment with an HIV+ person. We know much less about how psychosocial, contextual, political and historical forces influence Black men's risk taking. Education, employment and incarceration must be addressed, especially with financially marginalized men.
METHODOLOGY AACBI hosted a community advisory group (CAG) forum with their consumers – staff of community based organizations and health departments – to determine how capacity building assistance can support them in developing and sustaining programs to meet the unique HIV prevention needs of heterosexual black/African American men. The CAG forum included an expert panel sharing research, best practices and strategies for developing HIV prevention programming for heterosexual black men. Afterwards, consumers shared their experiences and suggested potential strategies for engaging the target population. Lit Review – Adam Viera The literature review was conducted to broaden the picture and determine the factors that influence HIV risk among Black/African American heterosexual men. AACBI/HRC was able to generate ideas about potential partnerships and collaborative opportunities to address this issue through programmatic capacity building assistance. The Forgotten Population Institute included information on national demographics and statistics on rates of infection and transmission rates among Black men. The perspective of the target population in the New York Metropolitan area was shown through a documentary film put together by the African-American Capacity Building Initiative entitled The Forgotten Population . In addition, anecdotal experiences in program management, and advocacy working with this population was also explored through our panel discussion which featured speakers Dr. Peter Thomas from the CDC, who currently is doing research around this population, Ms. Andrea Brooks from a CBO called Camillus Health Concern who directly works with Black Men at risk who are homeless, and Mr. Allen Kwabena Frimpong, from Youth RISE, who at the time directly worked with HIV infected and affected youth under a Ryan White IV funded prevention intervention program. Now he works on international harm reduction issues. Lastly, breakout sessions based upon the Key Topics developed for the Forgotten Population documentary were used to brainstorm what the barriers were working with this population and also what could be done on a capacity building standpoint in assisting this population with their needs by coming up with best practices. Through the forum and consumer focus groups conducted, AACBI/HRC was able to identify barriers and solutions to designing interventions and providing capacity building targeting heterosexual African American men.
Based on the data collected thus far, there are 5 key issues that are influencing factors for the HIV risk behaviors of Black/African American heterosexual men. They include: (1) healthy relationships with black women, (2) class and poverty, (3) substance use/drug policy, (4) incarceration, and (5) mental health issues. These factors need to be addressed in effective behavioral interventions (EBIs) for the target population, either through the adaptation of existing EBIs or the promotion of “home grown” interventions. The Key Topics developed with questions from the film were: On Healthy Relationships… Give me some words to describe what it means to be a Black Man in America. What do the words Black Masculinity mean to you? How did you get to know your sexuality as a Black man? Where do you think people get their ideas and perceptions about the sexuality of Black men from? How do you think these things influence Black Men as well as Black Women? From a scale of 1-5 (1 being Excellent to 5 being the Worst), where would you say the state of affairs between Black Men and Women stand? Why? What is your idea of a Healthy Relationship? What does being “intimate” with your partner look like/ how does that play out? What does having “instant gratification” with you partner look like/play out? Do you think intimacy and/or instant gratification is important in establishing a healthy relationship with your partner? Why? Give me some words to describe Black Women? Black Men who have men as their partners? Does the gender of a person that a man chooses to have sex with affect how a man is seen as masculine/’manly’? If so, in what ways? On Class and Poverty… With all the knowledge and outreach with the availability and increase in the usage of condoms, HIV rates in predominantly Black urban communities are still on the rise – What do you think drives the increasing rates? What is Black men’s role in lowering their risk for HIV in these communities? Given speeches from those such as Bill Cosby and Barack Obama about Black Men taking personal responsibility for their actions – Where do you think the idea that Black Men from poor urban communities are not capable of being responsible comes from? How does personal responsibility look for financially stable Black Men? What does being socially responsible look like for Black Men that want to improve the quality of life in their communities? Do you think Black men that identify as heterosexual see themselves at risk for HIV? Why? What are the barriers that you think Black men face when it comes to accessing medical services? On Substance Abuse and Drug Policy… With the wave of the crack and heroin in urban communities many still face the aftermath of the damaging effects from the war on drugs – How do you think the drug war has influenced Black men participation in the selling of illegal drugs? In what ways do you think drugs have played a role in the increase of HIV rates? How do you think drug policy (such as mandatory minimum sentencing on drug charges, drug free school zone laws, etc.) has played a role in Black men rebuilding their communities that have been broken because of the war on drugs? On the Prison System… With the alarming rate of incarceration of Black men in America’s prison system, how do you think their incarceration contributes to HIV prevention efforts? What are your thoughts on Black men who are incarcerated being tested mandatorily for HIV infection? Do you think that men who are incarcerated should have access to condoms? Why? How do we begin to prepare Black men who are being released from prison to maintain healthy relationships with their partners? On Mental Health How do you feel when you hear the statement that “Black men are hypersexual and violent individuals”? Why do you feel this way? How do you cope with your feelings and emotions as a Black man? Do you think your ways of coping work for you and are healthy? What is your opinion on the statement that “Black men hold their feelings and emotions inside, and so they act out in violent ways”? Do you agree/ disagree? Why? Are Black men receptive to mental health services? Yes/No? Why? What are the struggles and barriers with dealing with your identity as a Black man? How have you overcome these struggles and barriers?
We are not going to go through all of these. However, I want to highlight some of the ideas that stood out that came from community stakeholders and members of the target population.
What it means to be a man
HIV/AIDS not a priority Homelessness & joblessness is at the forefront Desperation amongst African-American women (regardless) to find partnership Access to Resources limited Quality of services offered to people is based on class status
The perspective of the target population in the New York Metropolitan area was shown through a documentary film put together by the African-American Capacity Building Initiative entitled The Forgotten Population .
CONCLUSION Open safe spaces for Black Men need to be made available. HIV prevention agencies must acknowledge underlying social, political, and economic factors that Black men deal with in their communities and in their lives. With the complexity of problems and the vulnerability of our social political climate, programs for Black men should tackle the intersecting issues of employment, education, incarceration, drug abuse and bad drug policy, as well as HIV stigma related to drug use and sexual behaviors. HIV prevention programs targeting Black heterosexual men must meet their immediate needs, increase their access to available resources and build new resources for African American men where unavailable. These programs must operate on various levels, from individual-level to community-level, and understand the unique needs of Black heterosexual men in HIV prevention.