Black gay and bisexual men are the group most impacted by HIV in the United States. While the Centers for Disease Control and Prevention (CDC) projects that if current HIV diagnoses rates persist, 50% of black gay and bisexual men will be diagnosed with HIV in their lifetime, this also suggests that 50% will remain HIV negative. Though an immense amount of resources and time have been dedicated to fighting the HIV epidemic among black gay and bisexual men, not much is known about the strategies black gay and bisexual men use to remain HIV negative. Understanding how black gay and bisexual men are able to remain negative -- despite being constantly labeled "high risk" for or "vulnerable" to HIV by public health researchers and health care providers alike -- might provide us a roadmap for how to achieve better health outcomes and ultimately end the AIDS epidemic.
A recently published article in the journal Men and Masculinities explored black men who have sex with men (MSM)'s motivators and strategies for maintaining HIV-negative status. The study comprised focus group discussions conducted with black MSM in New York City. It found that many participants attributed their ability to stay HIV negative to a strong sense of religious and spiritual identity, social support from friends and family, and social engagement with other HIV-negative black MSM in safe spaces. Other strategies included the ability to take personal agency in asking sexual partners about their HIV status and strategically choosing sexual positioning to reduce risk for HIV transmission. The study noted the need to provide safe social spaces for black gay and bisexual men to engage around HIV prevention and the need to incorporate HIV prevention messages into religious/spiritual contexts. It is important to note that this study was conducted in 2012, the same year the U.S. Food and Drug Administration approved emtricitabine/tenofovir disoproxil fumarate (Truvada) for use as pre-exposure prophylaxis (PrEP). Consequently, participants did not mention PrEP as part of their strategy to prevent HIV acquisition, as it was not publicly available to them at the time of the study.
"One takeaway is that HIV-negative black MSM want to be better attended to by public health HIV prevention, beyond counseling and testing," said Jagadisa-devasri Dacus, Ph.D., LMSW, who conducted the study and is the lead author of the article. "The scarcity of programs and interventions to support their maintained HIV negativity needs to be addressed as a primary prevention effort." This underscores the need for community-based organizations and health service providers to constructively engage HIV-negative black gay and bisexual men as part of their comprehensive HIV prevention strategy.
Dacus provides some insight into what intentional engagement of these men might look like: "Strengths-based approaches to HIV prevention will necessitate both consideration and inclusion of prevention research, policy, practices, programming, and interventions for black gay and bisexual men," he said. "First, more funding needs to be available to support research that is strengths-based. What this will entail is for policymakers to recognize the gap in our research knowledge about how and why black gay and bisexual men are able to remain HIV negative in the face of such alarming seroprevalence."
He adds: "Second, strengths-based research will in turn inform evidence-based interventions that can support what black gay and bisexual men are doing 'right' by maintaining seronegativity, even if they are not practicing safer sex all the time. Third, with the existence of these strengths-based interventions, social services providers can develop a program of services that support black gay and bisexual men's HIV-negativity maintenance. These services can range from psychoeducational groups to support groups to social groups that explicitly and intentionally promote their efforts to maintain HIV negativity."
These suggestions signify a major departure from the strategies HIV service organizations currently employ, the bulk of which include provision of condoms and PrEP, HIV testing and counseling, and engagement and retention in care for individuals living with HIV. While these are wildly important, more programming is needed to help sustain, support, and supplement the individual efforts of HIV-negative black gay and bisexual men.
Another recent study published in AIDS and Behavior on HIV-negative, substance-using black gay and bisexual men in Los Angeles had similar findings to the aforementioned study. Participants in this study described various strategies for avoiding HIV transmission throughout various "steps" of the hooking-up process. The four critical timepoints participants identified were (1) looking for sex partners, (2) choosing sex partners, (3) lead up to hookup, and (4) immediately before or during hookup. One strategy participants reported using when looking for sexual partners was avoiding bathhouses and social venues that gay men frequent. In choosing sex partners, some men carefully screened online profiles and avoided potential partners who used drugs. In preparing for a hook-up, some always carried condoms, took PrEP, and restricted their drug use. Last, immediately prior to or during sex, some discussed HIV status with their partners, strategically chose their sexual position, and/or always used condoms.
"This study has made me think critically about what we think of as 'risk' and the role of the HIV prevention community in supporting black MSM," said Derek Dangerfield, Ph.D., assistant professor at Johns Hopkins School of Nursing and co-author of the study. "Many of the participants in this study felt that pharmaceutical interventions such as PrEP might not be best for them and that they had enough personal agency to maintain their HIV status," he added. The findings of this study inspired Dangerfield to further explore adaptive behaviors for viral load suppression among black gay and bisexual men. "We are currently conducting another study in Baltimore and Los Angeles exploring strategies for maintaining HIV treatment adherence and viral suppression among black MSM, given that many are not virally suppressed," he said. "Rather than highlighting pathologies of black MSM, I have been excited to continue exploring the resilience and strengths of the community to create a healthier discussion for HIV prevention."
It is important to keep in mind that while participants in both studies mentioned an array of strategies for maintaining their HIV-negative status, all are not equally effective. Additionally, while these strategies might be effective in prevention of HIV acquisition, it might be incorrect to conclude that participants utilize all of them together during every sexual encounter. Last, it is important to remember not to use research on men who are HIV negative to stigmatize or stereotype people living with HIV. But it is to useful to illuminate strategies HIV-negative men employ for staying negative, and perhaps longitudinal studies of cohorts of black gay and bisexual men are important to understand changes in sexual practices over a lifetime, as well as whether changes in their risk reduction strategies occur as they age, as they enter long-term relationships, or as new biomedical prevention models become available.
It is evident that while engagement of black gay and bisexual men living with HIV is pertinent to winning the fight against the epidemic, especially in light of the undetectable equals untransmittable (U=U) movement, it is also important to engage HIV-negative men in tangible ways to ensure that they stay negative. This concerted effort will help bring us closer to ending the HIV epidemic in this community.
Adedotun Ogunbajo, M.P.H., is a Ph.D. student at Brown University.