Challenging Dogma - Spring 2009

Thursday, May 7, 2009

Foundations Of A New HIV Intervention Among Young Black MSM –Allan Welter

Evidence shows that individual, interpersonal and community level HIV behavioral interventions are effective in reducing the odds of unprotected anal intercourse considerably among MSM (men who have sex with men) (5, 6, 12). The individual-level component of an intervention is effective when modifying HIV-related knowledge, attitudes and beliefs held by MSM. Increasing perceived self-efficacy among MSM in relation to safer-sex behaviors is also crucial in the individual-level component of the intervention. The interpersonal-level component of an intervention is effective when aimed at changing knowledge, attitudes and beliefs about MSM in small groups of people. Group intervention among family members and close acquaintances of MSM is the main focus of the interpersonal-level. Finally, the community-level component of an intervention is effective in motivating and reinforcing behavior change among those who do not participate directly in the individual and interpersonal levels of the intervention (6).
A Hypothetical Alternate HIV-Intervention to the “Use a Condom Every Time” Campaign
New studies have shown that the annual increase of HIV among young black MSM is as high as 15% (3). In response, the public health department of Washington DC chose young Black MSM in metropolitan Washington DC as the key population of interest for a new culturally sensitive HIV intervention campaign running on individual, interpersonal, and community levels. The goal of this intervention was to increase rates of safer sex practices among young Black MSM.
Individual-Level Component of the Intervention for Young Black MSM:
To modify HIV-related knowledge, attitudes, and beliefs among young Black MSM, culturally sensitive advertisements were spread throughout the metropolitan DC area via brochures, dance clubs, radio stations, top40 podcasts, NPR, and common MSM-oriented websites. Advertisements promoted positive attitudes toward safer sex practices among young Black MSM. These attitudes were promoted through images of men participating in safer sex practices. Young black MSM couples were shown valuing safer-sex practices by saying slogans such as, “I love my Boo. Safer Sex is one way we Show our Love” (13). Men in the advertisements were young and relatable to young Black MSM in the metro DC area.
A general sense of well-being and perceived self-efficacy in relation to safer-sex practices were promoted through confidential private and group sessions in open, supportive environments. Sessions were held on weekdays and weekends and were conducted by trained professionals. These sessions ranged from safer-sex demonstrations to discussing difficulties associated with having sex with men and being a young Black man (5). Young Black MSM were recruited through social websites and after-school programs. Incentives such as food, public transportation tokens, and free passes into local 18+ and 21+ clubs were offered to increase turnout rates.
Interpersonal-Level Component of the Intervention:
To modify the knowledge, attitudes, and beliefs of young Black MSM among families and proxy contacts of young Black MSM (5), culturally sensitive messages were spread via brochures, the media, grocery stores, fast-food restaurants, the Internet, and any other accessible place. Respectful images showing families embracing MSM children were circulated. Individual MSM and MSM couples were shown everyday settings being welcomed, loved, and respected by family and friends. Culturally sensitive images were also circulated showing parents and close contacts of MSM playing active, respectful and positive roles in accepting a young Black MSM’s sexuality (6).
Through social networking, use of bulletins, media sources, and Internet advertisements, families and proxy contacts of MSM were actively recruited into the intervention. Incentives such as food, public transportation tokens, BP gasoline cards equal to the value of public transportation tokens, and $20 gift cards to whole foods with free delivery were offered to increase turnout rates. Sessions were offered on weekdays and weekends and were led by experts in this area of intervention. Counseling for families and proxy contacts were aimed at increasing open communication about sexuality with young Black MSM and transitioning to more positive attitudes relating to MSM persons. Support groups composed of multiple families and contacts were formed to help share experiences related to raising MSM children. Social networks supportive of gay children were introduced to families holding negative attitudes toward young Black MSM (5).
Community-Level Component of the Intervention:
A community intervention among young Black MSM was run on the national-level. Upon research, the campaign discovered that most young Black MSM considered safer-sex to be labeled as “good” and unsafe safe to be labeled as “bad” by the public. These beliefs were problematic for two reasons. First, there was a strong sense of masculinity among young Black MSM that corresponded with being “tough” and daring. Engaging in “bad” and unsafe sex could lead to a conscious or subconscious increase in perceptions of masculinity. Second, young Black MSM felt a sense of homophobia imposed upon them when told to use condoms. They felt heterosexuals imposed the belief that engaging in unsafe sex among MSM individuals is and will always be bad, regardless of any relationship circumstances (6). The campaign also discovered that definitions of “healthy” differed between public health officials and young Black MSM. Young Black MSM did not consider an HIV+ person unhealthy until they were diagnosed with AIDS. This potentially rises from high recognition between young Black MSM of effective HIV treatment (11). There were high levels of awareness of the high HIV infection rates among young Black MSM. This awareness may have led to the feeling infection as inevitable and therapy as painless. Low self-efficacy in relation to protecting oneself from HIV may be leading to higher rates of unsafe sex among young Black MSM.
The nationwide intervention used mass-media campaigns, taking advantage of the culturally sensitive data gained. Prime-time commercials, newspapers, popular magazines, websites commonly frequented by young Black MSM, NPR, and various radio stations transmitted the intervention. Advertisements portrayed HIV as sneaking into the body and hiding in an infected human’s DNA so the treatment could not touch the virus. This shifted the young Black MSM view of engaging in safer-sex as “good” to engaging in safer-sex as actively defending oneself against the sneaky and cowardly virus. It also challenged the notion of having only HIV as being in a healthy state because it made visible the fact that the virus lives inside the individual. To combat the perception of masculinity, advertisements showed young Black MSM protecting others from HIV through engaging in safer-sex practices, effectively associating masculinity with safer sex practices.
Peers of young Black MSM began delivering messages advocating for safer-sex practices. MSM oriented safer-sex demonstrations were made mandatory in public schools [through the wand of Barack Obama?], increasing the perceived self-efficacy relating to safer-sex among young Black MSM. To deconstruct homophobic undertones of safer-sex interventions, open dialogue relating to engaging in unprotected sex within monogamous MSM couples was encouraged. The term monogamous was emphasized, just as is true for heterosexual couples. Finally, role model stories of young Black MSM were distributed throughout the country over various forms of media in an attempt to increase a sense of value and well-being among young Black MSM.
Improvements of Proposed Intervention on the “Use a Condom Every Time” Campaign
Proposed Intervention Does not Run Only on the Individual Level:
One fundamental improvement of this intervention over the “Use a Condom Every Time” campaign is that it is not run merely on the individual level. Accounting for the group dynamic (4), this intervention will be able to shift behaviors of entire groups of young Black MSM rather than individual MSM (4). Essentially, people who do not participate in the intervention on the individual level are still influenced by the intervention through the cultural shift of attitudes related to safer-sex practices (5). The community and interpersonal proportions of this intervention attempt to shift HIV-related beliefs for entire groups rather than individuals.
Additionally, this intervention specifically addresses the wider social context affecting health related behaviors of individuals (4). Contextual issues are put forth regarding masculinity and unprotected sex among young Black MSM. Young Black MSM may have had unprotected sex to increase their sense of masculinity. This intervention used masculinity as a contextual tool of intervention, showing young Black MSM protecting others through safer-sex as masculine. This would not be possible in the “use a condom every time” campaign.
Homophobic Societal Undertones related to Condom Use are Eliminated:
MSM have “experienced hatred, abuse, and a lack of acceptance by their families, friends, communities, and society in general” (5, 6, 14). We have shown that these negative experiences, potentially leading self-destructive psychological natures, can result in MSM engaging in unprotected sex because it is dangerous (6, 14).
This intervention works on the interpersonal level to decrease homophobia among families, friends, and close contacts of MSM. This will hopefully lead to a decrease in self-destructive tendencies caused by homophobia. A potential decline their rates of unprotected anal sex may be observed as a result (14). Additionally, homophobia is addressed on the national level. Counter to the “use a condom every time” campaign, this intervention opens publicly accepted discussion among monogamous MSM couples to decide whether they want to use condoms in their relationship. In effect, the intervention removes society’s homophobic desire to dictate the behaviors of MSM through “always use a condom” campaigns. This allows MSM and the intervention to interact without the negative pretense of perceived homophobia. In circumstances such as these, MSM are less likely to be defensive and more likely to listen to the message being put forth by the campaign (5, 14). Intervening at the group and interpersonal level allows maximum efficiency in decreasing homophobic experiences of MSM individuals, leading to increases in safer-sex practices (12).
Health Not Assumed to be Highly Valued by most MSM:
The proposed intervention directly addresses the fact that the definition of “healthy” differs between young Black MSM and public health professionals. To get around this discrepancy in definitions, the intervention circulated images depicting HIV as deceptive and cowardly. This image of deception leads to young Black MSM acting in defense of their body, regardless of the definition of health.
MSM may hold a high value for not contracting HIV, but they may also have a low perception of self-efficacy in relation to engaging in safer sex. The new intervention addressed this potential low perceived self-efficacy for using a condom among young Black MSM, an aspect completely left behind by the “use a condom every time” campaign. Since the new intervention does not require that MSM use a condom every time, the pressure associated with having to use a condom in every sexual encounter for the rest of one’s life is diluted. Additionally, confidential group and private sessions were run that showed MSM how to engage in safer-sex practices. Role-playing was implemented to help MSM gain the strength and courage to insist to their partners that a condom be used if they feel it is necessary. Note that both individual and group level interventions were required to address the potential effects of low perceived self-efficacy relating to safer sex among young Black MSM.
Concluding Statement
The proposed intervention improves upon the “how to use a condom every time” campaign in three significant ways. First, this campaign is run on the individual and group level. While increasing perceived self-efficacy relating to safer-sex practices among young Black MSM, we are also shifting beliefs and behaviors of entire groups with relation to HIV (4, 12). Second, young Black MSM men do not perceive the intervention as homophobic. As a result, it is more likely for young Black MSM to take in messages of the intervention. The campaign also addresses homophobia through interventions among families and proxies of young Black MSM. Lower levels of homophobia among MSM proxies will lead to an increased sense of well-being. Young Black MSM will feel more valued and welcomed in everyday aspects of life, which can lead to decreased self-destructive actions and increases in the frequency of safer-sex practices. Finally, the proposed campaign improves on the “use a condom every time” campaign in that it does not assume “health” to be highly valued among most young Black MSM. Without this contextual assumption, the intervention was able to target factors that were truly related with low frequencies of safer-sex practices and intervene based on those factors.
Evidence shows that individual-level, interpersonal-level and community level HIV behavioral interventions are effective in reducing the odds of unprotected anal intercourse considerably among MSM (5, 12). It is crucial for all three components to be a part of the intervention. The community level component is necessary because it allows those who were not directly involved in the intervention to still be influenced by the intervention and because it analyzes health-related behaviors within the cultural context (4). The interpersonal level is essential because reduced levels of homophobia among proxies of MSM will lead to higher senses of well-being among MSM. This may correlate with decreases in self-destructive behavior, and potentially increases in safer-sex practices. Finally, the individual level component is essential because it provides HIV-related knowledge directly to individuals and increases individual perceived self-efficacy relating to safer-sex practices. Implementing all three components into an intervention significantly improves on the “use a condom every time” campaign, and will be effective in increasing the frequency of safer-sex practices within the target population.
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