Latino MSM: Identifying Needs, Eliminating Barriers
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.
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.
The diversity of Latinos in the U.S. makes generalization difficult, but homophobia is especially high across Latino cultures. Certain beliefs about masculinity can increase shame and make MSM more likely to hide their sexuality. Montgomery and Mokotoff followed 5,156 MSM with HIV from 1995 to 2000 and found that 34% of Black MSM, 26% of Latino MSM, and 13% of white MSM reported also having sex with women. The authors concluded that bisexual activity is relatively common among Black and Latino MSM with HIV, that few identify as heterosexual, and their female partners may not know of their bisexual activity.
Lesbian, gay, bisexual, and transgender immigrants face multiple challenges that are often made invisible by the predominant view of immigrants as heterosexual. Research suggests that sexual minorities are able to immigrate by relying on friends, not family. This may help immigrants deal with disclosure and discrimination by creating distance from their biological families. But it also means that the support they may need from their family abroad will require discretion. Access to HIV prevention or care resources may require involvement with gay-identified groups, which may not appeal to certain immigrants. In addition, family reunification statutes in immigration law may not apply to same-sex partners.
Migration does not protect immigrants from the social norms they sought to escape. People fleeing from HIV stigma continue to confront it, including within sexual minority communities (based on their immigration status, race, ethnicity, or HIV status). The mental health effects of stigma might increase the vulnerability of sexual minority immigrants to behaviors that put them at increased risk for HIV, such as injection drug use, alcohol, and unprotected anal sex. Women and gender-nonconforming people may be vulnerable to rape and violence.
"Familism" is important in many Latino cultures. A high value is placed on the immediate and extended family for support, emotional connection, loyalty, and solidarity. Familism often plays a positive role in the lives of Latinos in the U.S. For example, strong bonds of family support have been linked to high self-esteem, low rates of substance abuse, and the ability to negotiate condom use among Latino adolescents.
But familism can be a source of conflict for Latino MSM. It is often the frame through which they understand and organize their sexuality. This often means they internalize a sense of shame, which leads them to keep their same-sex behavior secret in order to preserve family honor.
Fortunately, research has also shown a generational divide between Latinos who are older, more religious, and inclined to traditional views about gender and sexuality, and younger Latinos. This generational difference is possibly due to the rapidly shifting sociopolitical climate that is becoming more inclusive of LGBT populations.
Education and Awareness
Culturally sensitive sex education, and condoms, must be freely and easily available to all populations, especially to people at high risk for HIV. As the National HIV/AIDS Strategy notes, "it is important to provide access to a baseline of health education information that is grounded in the benefits of abstinence and delaying or limiting sexual activity, while ensuring that youth who make the decision to be sexually active have the information they need to take steps to protect themselves."
There is a need for greater cultural competency among HIV service providers, public health officials, and advocates. Cultural sensitivity training should include information about local immigrant communities, their characteristics, and their challenges, in order to help immigrants navigate their unique barriers to HIV testing, disclosure, and treatment. Since immigrant communities are subject to immigration laws and regulations, which vary by state, public health officials must be educated on the impact of those laws on the ability of immigrants with HIV to access care.
Ensuring that immigrants in samesex relationships can obtain family-based immigration benefits would also help reduce their vulnerability. President Obama's recent Executive Order on immigration is seen as a step forward, but it might not have any effect on LGBT communities. And Congressional efforts to block it make its future uncertain.
One of the biggest barriers to health equity is HIV stigma and silence. In communities of color, the stereotype of HIV as the consequence of "deviant" behavior has perpetuated shame and discouraged people from testing and treatment. By expanding the HIV discussion to include the societal factors that contribute to high HIV rates among Blacks and Latinos, we can shift the stigma away from individuals and extend responsibility to the systems and communities themselves. Further, the conditions that increase HIV risk are often the same ones that create health inequities in communities of color. An integrated focus on health and wellness will go a long way toward reducing stigma and, in turn, the epidemic in communities of color.
- Research on Access: Examine and eliminate societal barriers that prevent Latino MSM from seeking HIV prevention and care services. There is little information on adapting interventions in culturally sensitive ways.
- Mental Health Research: Research has identified such mental health issues as loneliness, depression, family stress, discrimination, and stigma. They can significantly affect healthy functioning, well-being, and ability to use services.
- Prohibiting Discrimination Based on Sexual Orientation or Gender Identity: Ensure that same-sex marriages are treated equally to opposite-sex marriages. Agencies that receive state funding must revise procedures to ensure that same-sex spouses receive equal treatment regarding patient rights and services such as family visitation.
- Improving Data on LGBT People: To better understand and address the health care needs and health disparities of Latino LGBT populations, ensure that questions on sexual orientation and gender identity are included in all surveys.
- Collaborations: build strong, effective partnerships with the federal government, state and regional health departments, and community-based organizations, health care providers, LGBT service organizations, key opinion leaders, and institutions across the U.S.
- Latino LGBT Outreach and Enrollment in the ACA: Assist LGBT individuals and families to find health care coverage that fits their needs and budget.
Luis Scaccabarrozzi is director of health policy and advocacy at the Latino Commission on AIDS.