Latino MSM: Identifying Needs, Eliminating Barriers
April 15, 2015
Latino MSM (men who have sex with men) face multiple barriers to HIV prevention, care, and treatment. This is due in large part to programs that fail to address the homophobia, transphobia, racism, stigma, and anti-immigrant sentiments they face. In the past twenty years, rates of HIV infection among Latino MSM have consistently increased.
Latinos have HIV infection rates three times those of whites, and MSM account for over 80% of cases among Latino men. In addition, certain groups are at even higher risk, such as younger Latino MSM and those born outside the U.S. For the undocumented, their immigration status creates an additional stressor that makes HIV testing and being retained in care more challenging.
Social determinants -- the conditions in which people live -- strongly affect their risk of HIV and the course of their disease. Behavior, while important, does not fully explain the difference in risk among racial and ethnic groups. Instead, the racial HIV gap and the racial health gap in general are strongly linked to the racial wealth gap, which in turn is the direct outcome of segregation and inequalities in housing, education, employment, and health care, as well as racially skewed incarceration.
The higher rates of HIV in communities of color are not simply the result of high-risk behavior, but of the inequalities that make their members more likely to come in contact with the virus and less likely to treat it.
Looking at over 170 media stories, Richard Pitt concluded that "down low" bisexual men of color were often described negatively as deceitful men who threaten the community. White bisexual men were often portrayed as victims, forced into the closet by society.
The mass media offer damaging explanations for the differences in HIV infection among racial groups. Looking at over 170 media stories between 2001 and 2006, sociologist Richard Pitt concluded that "down low" bisexual men of color were often described negatively as deceitful men who threaten the community. White bisexual men were often portrayed as victims, forced into the closet by society (as in the film Brokeback Mountain).
Another common assumption is that communities of color suffer from greater HIV prevalence because people of color are less sexually responsible than whites. Yet studies have reported that women of color and MSM of color report similar numbers of sexual partners and condom use as their white counterparts. Behavioral risk factors, while important, cannot fully explain the racial disparity.
So, fighting HIV by trying to change behaviors alone will not succeed. A strictly behavioral focus may also increase stigma by implying that peoples' bad decisions are solely to blame for their poor health. Raising awareness about the social, political, and economic conditions that fuel HIV combats the stereotype that blacks and Latinos have higher HIV rates because of irresponsible sexual practices or homophobic cultures.
We must move beyond targeting only the risk behaviors of vulnerable groups to address the root causes of the inequalities that prevent self-empowerment, create chronic stress, impair the immune system, and block access to treatment. We must not undermine behavioral interventions that have been successful. But we should accept that such interventions alone will never be able to change the harsh racial disparities of the epidemic.
Access to Care
We now have powerful drugs that can treat HIV, prevent its transmission, and prolong life, but they're reaching only a fraction of the people who need them. The goal of HIV treatment is for everyone to achieve viral suppression -- but only half of MSM with HIV in the U.S. are on treatment. And only 40% of Latino MSM achieve viral suppression. We also know that Latinos are being connected to care at a much later stage of HIV disease and are more likely to be diagnosed with AIDS at the same time they learn they have HIV.
Among the many barriers to early diagnosis and treatment are poverty and lack of insurance, even though HIV drugs are covered by Medicaid and the Ryan White program fills the funding gaps that aren't covered by Medicaid or private health insurance. In many states, the Affordable Care Act has helped many people obtain coverage through insurance marketplaces. But even so, many Latino MSM are not eligible for health insurance, especially if they are undocumented. Latinos continue to be the most uninsured racial/ethnic community in the U.S.
The term "minority stress" is used to express the personal impact of prejudice and stigma from society. It refers to the cumulative effects of residential segregation, educational and economic inequalities, disparate treatment by the criminal justice and mental health systems, and other negative factors not experienced by the majority (white Anglo) community. Minority stress is linked with anxiety, depression, loneliness, and low condom use among Latino MSM.
Residential segregation by race and ethnicity remains a reality for many Americans. The average white person lives in a community that is 80% white, the average African American lives in a community that is over 50% black, and the average Latino lives in a community that is 46% Latino. People who live in low-income minority neighborhoods are significantly less likely to receive early HIV testing and treatment. These differences stem from the deteriorated physical conditions and environmental stressors of these neighborhoods and from their relative remoteness from quality medical testing and health care sites. HIV infection rates are so high in some neighborhoods of color that they are on par with levels seen in Ethiopia and Haiti and meet the United Nations' definition of a "generalized HIV epidemic".
This segregation shrinks a community's social networks, which ultimately increases the "community viral load". A person's viral load is an important measurement of the amount of HIV in the blood and affects whether he or she will transmit HIV, and that contributes to and interacts with his or her community's viral load. Thus, someone who has unprotected sex with a partner from a neighborhood with a high community viral load has a much greater HIV risk than someone who has sex with a partner from a neighborhood with a lower community viral load.
Almost 25% of U.S. Latinos live below the poverty line, employed only part-time or intermittently and pushed into economic insecurity. Latino men are often excluded from all except the lowest paying jobs refused by others. A study of Latino MSM in New York City found that 53% earned less than $15,000 a year, with most below the poverty line. Among gay Latino men, a connection has been shown between financial hardship and the psychological distress that can lead to risky sexual behavior.
A person's country of origin is one important factor when looking at risk factors in different groups. Researchers must pay attention to diversity among Latinos in terms of countries of origin as well as mobility, because it affects their risk behaviors. For instance, Dominicans may negotiate HIV risk and protective behaviors in relationship to the centrality of family reunification as a strategy of immigration among much of this population. By contrast, such negotiations may look quite different for Mexicans and Central Americans living on the East Coast, where there tend to be large imbalances between the numbers of immigrant men and the largely absent or very small numbers of women. In both cases, men may have sexual activity with partners outside of a primary relationship.
The conditions leading to risky behaviors among men and women must be understood as distinct from each other -- an important nuance that is often glossed over by relying on terms such as "Hispanic" or "Latino" when describing these diverse populations.
Undocumented people fear "the system," including the risk that seeking medical help could lead to deportation or other legal problems. Non-English speakers (often parents) must rely on English-speaking relatives (often their children) to communicate with health care providers. In order to obtain testing or treatment, such immigrants may have to sacrifice privacy.
This article was provided by AIDS Community Research Initiative of America. It is a part of the publication Achieve. Visit ACRIA's website to find out more about their activities, publications and services.
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