These are my rough notes, so I’m sorry if they’re not always perfectly clear. If you have questions, don’t hesitate to ask them in the comments section! -KWB
Presenters:
Murry Penner, Deputy Executive Director, National Alliance of State and Territorial AIDS Directors
Terrence Moore, Racial & Ethnic Disparities Portfolio, National Alliance of State and Territorial AIDS Directors
Patrick Wilson, Ph D., Assistant Professor of Sociomedical Sciences, Mailman School of Public Health, Columbia University
References:
Racial & Ethnic Disparities Information @ National Association of State and Territorial AIDS Directors
New HIV Incidence Reports @ Centers for Disease Control and Prevention
Willo Pequegnat, “Conducting Internet-Based HIV/STD Prevention Survey Research: Considerations in Design and Evaluation”
National Guidelines for Internet-based STD and HIV Prevention @ National Coalition of STD Directors
PrEP Information @ Centers for Disease Control and Prevention
PrEP Watch @ UCLA
Kevin Baker’s Notes:
The purpose of this institute is to focus on the current state of the art in HIV prevention with gay men and other MSM populations, including a frank discussion of barriers and challenges. In light of the newly published incidence data from CDC, this conversation is crucial.
PENNER: I want this to be participatory and interactive. We have a few remarks, but after that, we’d like an open discussion. We are particularly interested in hearing thoughts and experiences about working with Black and Latino gay men, Internet-based interventions or recruiting, and PREP/pre-exposure prophylaxis.
MOORE: We’ve been working with NASTAD on these issues ever since the HIV data for Black gay men came out from CDC in 2005. NASTAD has invested in some research to find out exactly what is happening across the country in terms of dedicated resources and available human capacity for HIV prevention with BGM. We did a survey asking about what funds were specifically allocated for projects with BGM at state and local health departments, and we were shocked. It’s a paltry sum. We have published three issue briefs on the HIV impact on BGM, the third and most recent of which is the most substantial. It lays out the scope of work we’ve done over the past few years, and also encapsulates the stories, thoughts and feelings of the Black gay men we spoke with all over the U.S. We have identified some recurring themes, and urge you to read and distribute this document. Although no group is monolithic, we as prevention providers really need a clearer understanding of what it’s like, on a basic level, to be Black and gay in the U.S.
WILSON: Our work has really focused on identifying the scope and scale of health departments’ and CBOs’ responses to the HIV crisis among BGM. HD’s have some real strengths, including some very competent staff — not just competent in terms of their jobs, but culturally competent. Where HD’s are succeeding, this plays a huge role. It’s not something you train for, it’s something you HIRE for. BGM will have more luck reaching BGM.
CBOs may have less consistent levels of technical competence, but they excel at cultural competence. The most outstanding work is being done by CBOs who hire peers (Black gay men) to shape and lead their prevention efforts. This is the shortest path to cultural competence.
Capacity building issues are a big barrier for CBOs, and we found the HDs don’t support CBOs as well as they might.
We all know that there’s not enough money for this work, but within that basic situation, there’s a lot of complexity around funding. We’ll be exploring that in the future.
Structural factors impact work with this population (as with any other): geography, religion, economics.
Self-concept and self-esteem among BGM can be a huge psychological barrier. It makes it difficult to reach the men we need to reach, and it makes it harder for the behavioral interventions to "stick".
In our interviews, we identified some strong themes clustered around cultural norms. All groups are shaped by norms, of course — white women as well as black men, straight as well as gay — but many of our interviewees were very aware and conflicted about the role that norms among Black men around hetero-dominance and hyper-masculinity. These issues are certainly present and "life issues" among all groups of American men, but of particular concern in working with Black and Latino MSM.
PENNER: We know that nearly 80% of gay men will never be exposed to a proven-effective behavioral intervention, so on a very basic level, we just don’t have the money needed to achieve the scale of operations needed to turn the tide. We have tools that work, but not enough money to use them widely.
MOORE: I am very concerned about a growing vilification of gay men of color, as if they are "disease vectors" who are somehow responsible for the HIV crisis amon women of color.
There is a complexity about human sexuality that is rarely talked about and not captured in our interventions. We have begun to use epidemiological terms like "Men who have Sex with Men (MSM)" as if they describe identities rather than behaviors, and that’s simply a huge mistake.
GENERAL DISCUSSION: Among many segments of G/B men, hook-up sites on the Internet are replacing bars as places to find sexual partners. In some cities, bars and clubs are closing as people choose to hookup online. This has complex long-term implications for the gay community in general, as well as for HIV prevention. The gay community as we know it today (as well as the gay rights movement) grew out of social relationships that developed in gay bars. On an individual level, people may come to a bar to find sex partners, but if they come often enough, they will make some friends, and then friends of friends, and it is of such social networks that identity communities are made. So what happens to the gay community in a world without gay bars?
From the prevention perspective, we have often behaved as if we are entited to access gay bars for education and outreach purposes. That’s something of a separate issue, but what we need to ask now is, how do we reach this population if their bars all close?
AFTERNOON SESSION was mostly discussion, and it was very lively. We started out talking about strategies and struggles for reaching young gay and bisexual men, who make up the biggest part of new infections in San Antonio and across the country. Certainly at BEAT AIDS, most of our newly-identified infected folks are young gay men (and I mean young). Roughly 80% of them report that they know they have had sex with someone who is infected within the past year. Beyond the obvious heartbreak, we’re not sure what to make of this. Do they believe it’s inevitable? Or do they think it’s no big deal in the age of HAART? These are questions that prevention workers and researchers are desperately trying to answer.
We discussed how despite the fact that "Internet outreach" is such a hot topic in prevention at the moment, the term describes a lot of different activities…some of which are cheap, some of which are not, some of which are easy, some of which are not, and some of which are effective and some of which are not. Also, Internet prevention messaging has its own barriers. For actual Internet-mediated prevention interventions, the average retention rate is 5-8% after three months. For an in-person intervention, that would be a totally horrible outcome, but you can get samples and populations through Internet outreach that you might not otherwise be able to reach.
We also had a long discussion about what sort of prevention programs might be effective for men who are long-term PLWAs.
Finally, we had spent a couple of hours in a very, very animated discussion about PrEP. If you’re not familiar with pre-exposure prophylaxis, it basically means that an individual who knows that he or she is going to have risky/unprotected sex, and he or she takes a pill (one of the currently available antiretrovirals) before sexual contact. Randomized clinical trials are currently under way to determine the efficacy of these regimes, but it’s already pretty clear that there is SOME protective effect, and it’s known that some gay men (and some doctors) are engaging in a "homegrown" version of this practice.
People tend to have a lot of opinions about PrEP, and there are a lot of thorny issues still to be addressed. Who gets it? Who pays? It’s hard to imagine ADAP paying for PrEP, but it’s also pretty obviously unfair to only provide it to people who can afford it.
But whatever people may think of PrEP, and however the policy issues shake out, it’s pretty clear that the basic knowledge about how to do PrEP and how efficacious it is will soon be available. PrEP is coming, so we need to figure out what role it will play in HIV prevention.
I got hardcopies and digital documents for all three volumes of the BGM issue briefs that the presenters created for NASTAD, so I’ll share those with everyone when I get back!
A final note: I met a young man who does medical case management at an HIV clinic specifically for youth in Oakland, CA. He’s from San Antonio, and comes back every once in a while to visit his family. He’d love to do a presentation for our youth group!
So, that was my day. Tracy Goody of Pfizer (who presented to us at August’s Agency Staff Meeting) is hosting a reception tonight, and she has invited our whole team, so we’ll be doing that, and I imagine I’m going to read a bit and hit the sack after that. More to come tomorrow!
Yours in the struggle,
Kevin Baker
