The Rising Rates of HIV Among Black and Latino Men: What's Going On?

Kenyon Farrow: Francisco, from your perspective at GMHC: What do you feel isn't working?

Francisco Roque: I think there are a plethora of things. And I think that I really would like to echo, certainly, the importance of us developing homegrown interventions that are developed with men of color at the forefront. I think that part of the success that we can attribute to prevention efforts in the '80s, and the decrease among white male infections in the gay community, is the result of an openness in the way that prevention was executed.

Francisco Roque, Director of Community Health at New York's Gay Men Health Crisis

Gay, white men had many opportunities to insert themselves in the creation and design of innovation and of these interventions that were disseminated. There was an openness to how those were created and distributed. I think that what that does, which is essential, is it gives community a sense of mattering. When men are themselves able to assert agency in a way that they are, in fact, part of the solution and not part of the problem, and they can see themselves as agents of change, I think what occurs with that sort of a dynamic is that it instills in folks a sense of mattering in the world. You see the impact that you have as an individual, whether you're an HIV-positive person or not. You suddenly see your impact, and so you look to matter. You look to gather more evidence of mattering in the world.

I think that we have created a paradigm where, now that HIV is targeting a different community, where there's been this shift, we begin to deal with folks as though they are just broken, solely. And the industry has become more and more professionalized. There are advantages to that. There are advantages to seeing more and more folks with Ph.D.s doing this kind of work.

But there are also disadvantages, because it limits community from being involved in the solution, and in the ways in which we address HIV prevention. And so I think that we need to urgently look for ways to include community, and include black and Latino men in the building of solutions.

Kenyon Farrow: We hear so much talk in this day and age about syndemics, or about the sociopolitical and economic factors that are driving the epidemic. I hear each of you speaking to issues where ... Sheldon mentioning connecting the most vulnerable populations to research, and research institutions; Vaughn talking about needing to expand and have more interventions that are focused on communication and negotiation of safer sex and harm reduction; and then Francisco talking about community involvement in the creation of interventions. All those things are important and I think can work together.

But there's so much discussion now about looking at the impact of housing instability and homelessness, thinking about the impact of homophobia on the epidemic for black and Latino MSM, and joblessness and the economy, and so on and so forth.

So I just want to ask you from, again, each of your vantage points: How do you see these sorts of larger structural issues as impacting the epidemic? And how do you approach your work with that lens? Or if you, in fact, do approach your work with that lens? So we'll go back. We'll start with Francisco on that one.

Francisco Roque: As we look to expand upon what we just said: I think that, absolutely, there are a variety of other factors. I think that we don't really look at substance use in the ways that we could be. I think that there is a huge lack of culturally appropriate and gay-sensitive substance use prevention programs that exist, and that folks can access. I think that we absolutely need to deal with alcohol and other substances in ways that we have not, and really look to incorporate that into our prevention efforts.

I can't tell you; I mean, it's almost nine out of 10 times that folks report that some substance was involved in their decision-making, or in the sex that they're having. And that seems to be more and more the case anecdotally from the folks that we're servicing.

And so I think, absolutely, we need to look there. I think we need to be very real, and look at drug laws. We need to absolutely see what is the impact of drug laws and incarceration, and how we've created these transient communities, where folks come in and out, and the impact that that has; and design interventions that look to address that, and look to work inside of that.

Certainly, we need to look to have impact at a policy level, and change some of those factors. But I think, in the meantime, we need to have some really comprehensive short-term solutions that are addressing the reality that these folks are dealing with. So I think that we need to look at those two issues, in particular.

Certainly, if I were to list a third, it would be access to condoms as something that we assume. I think it's great that the City [New York City], in particular, makes sure that there are condoms readily available in certain locations. I would love to see City condoms in all liquor stores, for example. I think that, in certain neighborhoods, you don't have a local health clinic on every corner, but you absolutely have a liquor store on every corner. I think that it would be really advantageous for us to really push for those types of outside-of-the-box approaches to really increasing access to condoms, as well, and really begin to partner on pressuring legislators into thinking outside of the box and creating some policies around working with folks. You know, as part of getting your liquor license, you have to agree to distribute condoms in your liquor store.

There are all kinds of innovative things that we could be doing. But it seems as though the climate in which we're in has dwarfed our ability to think outside the box. We shy away from that type of innovation, and follow suit and begin to sort of all do simply the prescribed interventions that some of us mentioned earlier.

Kenyon Farrow: Sheldon, from where you sit as a researcher -- and I have been in several rooms with you, in different occasions, and have raised these various issues about the kind of social and cultural and political context in which the epidemic is taking place. And you're in many of those rooms with other researchers much more than I am.

And so, the question is: In terms of syndemics or these other kinds of terms that people are using to look at structural issues driving the epidemic, how much is that really rolling out, in terms of reshaping a research agenda that's looking at those issues, versus individual risk factors?

Sheldon Fields: You're talking about, sort of, those things that really create this endemic effect. We cannot ignore the fact that poverty impacts this. The other things that people do in their lives ... People are not just simply focused on whether or not I am, or am not, going to be at risk for HIV -- if I don't have a home, a place; I don't have food; I don't have a job. Some of that is playing out a little bit more. Now, if you look at even our economy: We talk about jobless rates.

And then you look at jobless rates in people-of-color communities, and it's always exponentially higher than that of the average, or even than that particularly of the white community. So when you don't have access to resources, and you get into a desperation mode, there's a whole other thought process that goes on there ... or not ... that one is subjected to. We need to infuse into our research paradigms a different way of thinking about how to approach our research. This very linear way that we have in thinking about how to do research as only -- like, the randomized clinical trial being the gold standard -- I don't think is necessarily, in this context, working very well.

We need more interdisciplinary teams. As a researcher who has a health care background, I'm very versed on that particular piece of the research -- not so much in terms of sitting down and talking to an economist, or adding an economist to my research team, going, "How do we look at some of these things from a financial standpoint?" Or sitting down and talking to a social worker, or even a medical anthropologist, who can bring a different view to the research team. And then we can start to incorporate some of these other things that have not been traditionally incorporated into research, as we search for answers.

Kenyon Farrow: Vaughn, for you at Gay Men of African Descent: How are you all thinking about the social and cultural factors that are driving the epidemic? And how is that impacting your work there?

Vaughn Taylor-Akutagawa: We do that by making sure that there's a distinctive syndemic orientation. We look at the interplay of mental health, substance abuse, domestic violence, HIV/AIDS diagnosis and threat for getting it, and homelessness, and what that impacts on people's decisions. We make sure that all of our mental health services practice an adaptive conjoint methodology, so that there are clear and consistent trade-offs for what the client wants.

We hear a lot of conversation about meeting the client where they're at; and I think we do a great job. The challenge, without the adaptation of home interventions, is to not leave the clients where they are. So we look at making sure that everything we do is health literate. We're clear about what decisions the client can make and what's real for them, and how to actually help them move to a position that's going to define better health.

We're also clear about defining what a healthy, gay man looks like. And once that standard is set, we don't deviate at all. We say this is what you should be; let's see how close you can get. And help them make sure that they have the other resources available to make sure that they maintain that status.