What We Know

Rights Matter: Structural Interventions and Vulnerable Communities

Altman, D. Interamerican Journal of Psychology (2007), 41(1): 87-92.

This is an edited version of the Jonathan Mann Memorial Lecture given at the XV International AIDS Conference in Bangkok, Thailand, on July 14, 2004, and makes a strong case for addressing the structural drivers of HIV.

Understanding and Integrating the Structural and Biomedical Determinants of HIV Infection: A Way Forward for Prevention

Kippax S. Current Opinion in HIV and AIDS (July 2008), 3(4): 489-94.

This article offered the important argument that the successful integration of structural and biomedical approaches to HIV prevention depends on biomedical and social scientists working together. The authors compared successful and unsuccessful prevention interventions/programs, and highlighted the importance of structural factors in determining HIV risk. For HIV prevention programs to be effective, the focus must include both behavioral and structural factors, and must consider the cultural context in which behavior occurs. The authors concluded that multidisciplinary teams provide a good starting place for the development of effective prevention programs that take combination approaches.

Coming to Terms with Complexity: A Call to Action for HIV Prevention

Piot P., Bartos M., Larson H., et al. The Lancet (September 2008), 372(9641): 845-859

The authors presented a well-articulated, evidence-based argument for combination approaches to HIV prevention. They authors recognized the complexity of the HIV epidemic, but emphasized importance of not becoming overwhelmed by this complexity. They pointed out weaknesses in the HIV response, including insufficiently scaled implementation of proven approaches, funding limitations, and failure to address structural determinants. They also used available evidence to describe  key epidemic elements in a step-by-step manner, elucidating each with concrete examples; and concluded with an extensive call to action, listing detailed action steps for each element.

Comparisons of Disparities and Risks of HIV Infection in Black and Other Men Who Have Sex with Men in Canada, UK, and USA: A Meta-Analysis

Millett, G.A., Peterson, J.L., Flores, S.A., et al. The Lancet (July 2012), 380(9839): 341-348.

The authors conducted a meta-analysis on factors associated with disparities in HIV infection in black men who have sex with men (MSM) in Canada, the United Kingdom, and the United States from 1981 to 2011. They based  their findings on aggregated data from racial comparative studies with outcomes associated with HIV risk or infection from seven studies from Canada, 13 from the United Kingdom, and 174 from the United States. The analysis included a number of factors, including seropositivity, drug use, structural barriers, and access to prevention services, among others. The study found racial disparities in terms of HIV status, sexually transmitted infections, and initiation of antiretroviral therapy among MSM in the United Kingdom and the United States. The study concluded that eliminating these disparities will be impossible without addressing structural barriers that restrict access to clinical care.

A Novel Approach to Prevention for At-Risk HIV-Negative Men Who Have Sex with Men: Creating a Teachable Moment to Promote Informed Sexual Decision-Making

Eaton L.A., Cherry C., Cain D., et al. American Journal of Public Health (January 2011), 101(3): 539545. doi:10.2105/AJPH.2010.191791.

Serosorting provides an alternative to condom use and thus addresses the problem of safer-sex “fatigue.” However, there are challenges to this approach, which relies on informed decisionmaking regarding selection of lower-risk partners. This study, conducted in 2009, tested a brief, one-on-one, peer counselor–delivered intervention based on informed decision making to address the limitations of serosorting. In Atlanta, Georgia, 149 at-risk men were randomly assigned to standard care or an intervention arm that addressed serosorting. The intervention was based on conflict theory, which prepares people for informed decision making and creates a “teachable moment,” wherein participants are more open to change. The results at follow-up showed that men in the serosorting intervention reported fewer sexual partners, increased condom use, and greater efficacy in assessing HIV risk. The authors concluded that serosorting is feasible and low-cost and could have an impact on the HIV intervention.

Reaching Men Who Have Sex with Men (MSM) in the Global HIV & AIDS Epidemic: A Policy Brief

Global Forum on MSM & HIV (November 2010).

This six-page policy brief succinctly argues that men who have sex with men (MSM) shoulder a disproportionate burden of HIV globally, and therefore countries need to increase their commitment to and coverage of MSM populations. It identifies the following strategic areas for increased work, with specific action recommendations for each: (1) increased investment in effective HIV treatment, care, and support for MSM; (2) expanded coverage of quality services for MSM; (3) increased MSM-related knowledge through research; (4) decreased violence, stigma, and discrimination against MSM; and (5) strong MSM networks linked to the Global Forum on MSM & HIV, or MSMGF. Quotes from MSM activists throughout the world are included.

Accessing Men Who Have Sex with Men through Long-Chain Referral Recruitment

He, Q., Wang, Y., Li, Y., et al. AIDS and Behavior (July 2008), 12(4 Suppl): S93-S96. doi:10.1007/s10461-008-9388-y.

The authors compared men who have sex with men (MSM) identified by two methods: convenience sampling and long-chain referral. Long-chain referral relies on study participants to recruit their acquaintances to the study, who in turn recruit their acquaintances. Long-chain referral identified more MSM who were migrants, young, from lower-income groups, and at higher risk for HIV than those identified by a convenience sample (such as all men attending a certain clinic). The authors said that long-chain referral can reach subgroups better than convenience samples. The article also reported behavioral risk outcomes associated with various subpopulations.

Reaching African-American Men on the Down Low: Sampling Hidden Populations: Implications for HIV Prevention

Icard, L.D. 2008. Journal of Homosexuality 55(3), pp. 437–449.

Studies of the impact of the HIV epidemic among African-American men who have sex with men (MSM) have largely neglected men who self-identify as heterosexual but who engage in same-sex behavior. These men, commonly referred to as “men on the down low,” pose formidable challenges to researchers conducting prevention studies. The authors discussed the benefits and drawbacks of various sampling methods to identify these hard-to-reach MSM and described a novel approach to reaching these men. Instead of relying on self-identified gay men or gay establishments, the researchers successfully used three recruiters who frequented known cruising areas (a park and the Internet) to find men who would meet the general classification of men on the down low.

They See You as a Different Thing: The Experiences of Men Who Have Sex with Men with Healthcare Workers in South African Township Communities

Lane, T., Mogale, T., Struthers, H., et al.Sexually Transmitted Infections (November 2008), 84(6): 430-433. doi:10.1136/sti.2008.031567.

This qualitative study described interactions between MSM and health care workers (HCWs) in South Africa and found that many men who have sex with men (MSM) felt their options for non-stigmatizing sexual health care services were limited by homophobic verbal harassment by HCWs. Gay-identified men sought out clinics with reputations for employing workers who respected their privacy and sexuality, and some challenged workers who mistreated them. Non-gay-identified MSM presented masculine, heterosexual identities and avoided discussing their sexuality with HCWs. The authors concluded that the strategies MSM employ to confront or avoid homophobia from HCWs may not be conducive to health promotion, and that initiatives to improve appropriate care from public-sector HCWs are urgently needed.

Discordance between Sexual Behavior and Self-Reported Sexual Identity: A Population-Based Survey of New York City Men

Pathela, P., Hajat, A., Schillinger, J., et al. Annals of Internal Medicine (September 2006), 145: 416-425.

The researchers described discordance between self-described sexual identity and behavior among men who have sex with men (MSM) and the relationship between self-described sexual identity and risk behaviors. Of 9,802 New York City men reporting a sexual identity, 12 percent reported sex with other men. MSM who self-identified as heterosexual were more likely than their gay-identified counterparts to belong to minority racial or ethnic groups, be foreign-born, have lower education and income levels, and be married. Heterosexual or “straight-identified” MSM were more likely to report having only one sexual partner in the previous year than gay-identified MSM, but were less likely to have been tested for HIV and were less likely to have used condoms during their last sexual encounter. The authors concluded that medical providers cannot rely on patients' self-reported identities, and that public health messages should target risky sexual activities rather than a person's sexual identity.


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