Free Attitudes Of African-American Males On Condom Use And HIV Transmission Research Paper Example
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African American (AA) males have disproportionately high HIV incidence and prevalence. A review was conducted on the risk and protective factors, consequences, and interventions related to HIV among AA males. Particular focus was given on the role of attitudes in shaping HIV prevention through condom use. Attitudes were found to be influenced by individual attributes such as age, gender, type of community, socioeconomic status, self-efficacy, and knowledge. There are also partner-related factors and factors arising from cultural and social norms. Social institutions such as the church, family, community, and the health care system can further have a positive or negative impact on attitudes. There are negative consequences of HIV on the person, family, and community underscoring the need for public health interventions. The social institutions mentioned are effective channels in the development and delivery of HIV prevention services.
The most common route of transmission of HIV is through anal or vaginal intercourse. The virus is present in the blood and body fluids of infected individuals. During sexual intercourse, breaks in the skin or the anal or vaginal epithelium facilitate the entry of HIV-infected cells as well as free virions leading to a new infection (Fox & Fidler, 2010). Hence, barrier protection through correct and consistent condom use can significantly bring down the risk of contracting or transmitting HIV. Despite condom use as effective prevention, HIV incidence remains high among African American (AA) males. For this reason, it is important to explore the attitudes of AA males toward condom use so that appropriate interventions can be made.
The purpose of this paper is to summarize available evidence from the literature on the attitudes of AA males on condom use and the impact of such attitudes on HIV transmission. A search and retrieval of relevant articles was done to create a complete picture of HIV among AA males. The information includes the epidemiology, risk factors, protective factors, and consequences of HIV infection. The emphasis of the discussion on risk factors will be attitudes pertaining to condom use. In addition, existing public health interventions addressing low rates of condom use in AA males and gaps in research on the topic are included.
The search terms used were the following: African, American, Black, males, attitudes, barriers, condom, use, HIV, public health, promoting, intervention, HIV, and prevention. A combination of these terms were used, e.g. African American or Black + male + attitudes + condom + use, African American or Black + males + barriers + condom + use, public health + intervention + HIV + prevention + condom + use, and promoting + condom + use + African American or Black + males. The search was conducted in three journal databases – ScienceDirect, CINAHL, and PubMed. The search was limited to those published from 2010 to present. The titles and abstracts were scanned to determine relevance and comprehensiveness of information. Twelve studies were selected for use in this paper.
Overview of HIV
HIV is a sexually transmitted disease that presently has no cure. Although antiretroviral therapy is available in the U.S. and is shown to be effective in reducing viral loads down to undetectable levels, it does not result in complete eradication (CDC, 2014). Thus, even individuals who comply with their medications and achieve undetectable viral loads can still transmit the disease. In addition, early symptoms can be mistaken for the flu and given the long latency period, the newly-infected person, unaware of his or her infection, can transmit HIV. It is regarded as a crisis in the African American community both because of the high incidence and the heavy burden of disease (CDC, 2014). The infection can progress to AIDS which is a terminal condition.
African Americans (AAs) compose 13.6% of the population but disproportionately account for 50.3% of the incidence of diagnosed HIV based on data from 37 US states (CDC, 2011). At this rate, it is estimated that one in every 16 AA males will be infected with HIV within their lifetime. The most vulnerable are AA men who have sex with men (AA-MSM). About 61.1% of all HIV cases among males involve AA-MSM while heterosexual intercourse was the mode of transmission in 23.1% of cases (CDC, 2011). Nearly 12% was attributed to intravenous drug use. The prevalence rate among AA males is high at 2,388.2/100,000 persons - thrice that among White males (Hill & McNeely, 2011). Seroprevalence is also high at 10.5% especially in the population of homeless AA men (Tucker et al., 2013).
In a sample of homeless men that included AA males, unfavorable attitudes to condom use were significant predictors of not using condoms as was having sex with someone considered to be a primary partner (Tucker et al., 2013). The predominant perception was that condom use made sexual intercourse less enjoyable, and it was a hassle to carry condoms. Trust, on the other hand, is attributed to a primary partner thus reducing the perceived HIV risk of that partner leading to unprotected sex. Additional risk factors were low self-efficacy in condom use, minimal knowledge about HIV, using hard drugs prior to sex, and casual sex in public places such as a park or alley.
Meanwhile, a study of rural and urban AA males in a community in Mississippi validated how negative attitudes toward condom use were associated with a low rate of use at just 25.8% of the respondents (Williams & Sallar, 2010). In a Likert-type questionnaire, more urban than rural AA males agreed that using a condom did not feel natural or good, and also believed condoms were only for gays. More urban than rural AA males also thought that condom use undermined their masculinity as they wanted to get their partners pregnant, and the practice contradicted their religious beliefs as well. Compared with urban AA men, a higher number of rural AA males cited the desire to provide sexual pleasure to their partners as their reason for not using condoms.
Overall, the respondents from both urban and rural sites did not believe that using condoms can effectively prevent STIs and HIV (Williams & Sallar, 2010). In fact, they voiced suspicion and ambivalence in regards to the role that condoms play in the prevention of sexually transmitted disease. These negative attitudes were reflected in lower rates of testing for HIV and suboptimal knowledge of the infection and its transmission. Also, 21% of the participants stated that they believed they can tell if a person has HIV through his or her physical appearance such as manner of dressing (Williams & Sallar, 2010). Personal judgment that a person may have HIV is deemed a more reliable preventive strategy than using condoms as the latter was regarded as more useful in preventing pregnancy.
Frye et al. (2012), in their study of adult heterosexual AA males, validated the prevailing negative attitude that condom use diminishes sexual pleasure. The participants stated that its use created erection problems as well. In addition, the AA men associated condom use with infidelity. Thus, condom use was low with steady partners whom they trust and echoes the findings of Williams and Sallar (2010). Conversely, the participants used condoms more often with casual or new partners especially when visual assessment of the female leads to a judgment that the latter has HIV. Again, this attitude mirrors that of the participants in the study by Williams and Sallar (2010).
Among gay adolescent AA-MSM, apathy towards personal wellbeing is a significant risk factor leading to sexually risky behaviors such as unprotected sex. In a qualitative study by Voisin et al. (2013), gay adolescents lamented the homophobic reactions from family, friends, and the community. For instance, some were told they will die of AIDS just because they were gay. Compounded with the stigma of being gay and limited informational and emotional support from their families, many gay AA teenagers do not see the point of using condoms as they believed they were going to die eventually. Distrust of mainstream media, similarly noted by Frye et al. (2012) and Williams and Sallar (2010) also generated negative attitudes toward health messages. Thus, there was a lower likelihood of behavior change.
A study of adult AA-MSM noted that socioeconomic status, namely low levels of education and low income, was also a contributory factor to higher HIV risk and was related to limited health care access and the suboptimal quality of care received (Hill & McNeely, 2011). For instance, they were unable to access the services of private clinics within their community. At the same time, they receive what was regarded as unsatisfactory and discriminatory care from predominantly White physicians and health care staff (Hill & McNeely, 2011). Distrust arising from culturally incongruent communication and services is again recognized as an issue preventing AA-MSM from talking about their HIV status. In turn, nondisclosure limits the delivery of related interventions.
In a study of older adults that included male heterosexual AA respondents, the risk factors were unprotected sex, intravenous drug use, and minimal knowledge of the disease. Unprotected sex arose from the thinking that STIs were diseases of younger people (Ramos, 2012). The thinking that condoms were unnecessary when the female partner was postmenopausal also predominated. At the same time, lack of familiarity with how to use condoms, problems with erectile dysfunction, and perceived hassle of use also led to negative attitudes about condom utilization. These attitudes persist as physicians often do not initiate discussions with older adults about sex and the latter do not raise their concerns.
Protective factors among adolescent AA males include the probability of initiating discussions on sexual intercourse and contraception with partners, peers, and even their parents (Voisin et al., 2013). Thus, a supportive parent-child relationship wherein parents can effectively communicate risk reduction strategies to their teenage sons is helpful (Harris, Sutherland & Hutchinson, 2013). Especially for adolescent AA-MSM, acceptance of their gender preference and a nonjudgmental approach engenders positive communication.
The sexual partner’s positive attitude or acceptance of condom use also promotes a favorable attitude towards this practice among AA-MSM teens and adult heterosexual AA males and has been a dependable predictor of actual condom utilization (Frye et al., 2012; Voisin et al., 2013). Thus, the successful ability of the AA male, whether adolescent, adult, gay or heterosexual, to discuss and negotiate with partners regarding condom use is a protective factor. Another protective factor influencing both actual use and consistency over time is the belief that the benefits of using condoms far outweigh the disadvantages (Frye et al., 2012; Ramos, 2012). However, this belief is mediated by trust in the health care system which provides related services. For this reason, the availability of culturally congruent care is an additional protective factor.
Teen participation in formal sex education promoting STI and HIV prevention and/or training on preventive measures also contributes to risk reduction (Voisin et al., 2013). Particular among AA-MSM teens who primarily obtain sex education from the LGBT community, the resources available in this community such as education and screening services determine the degree that they engage in preventive behaviors such as protected sex (Voisin et al., 2013). Ethnic-specific media messages further play a protective factor as they increase the trust and receptiveness of AA males to the health message increasing the probability of behavior change (Harris, Sutherland & Hutchinson, 2013).
Unprotected sex or low rates of condom use, often in conjunction with other risk factors, predispose AA males to HIV and STIs (Ramos, 2012; Williams & Sallar, 2010). Conversely, the rate of HIV transmission is also high when unprotected sex is the norm. HIV requires lifetime pharmacotherapy to delay illness progression to AIDS (Fox & Fidler, 2010). However, the side effects of medications including gastrointestinal upset and neuropathy may reduce the quality of life. Moreover, progression to AIDs makes the individual susceptible to cancers and infections that increase the chance of mortality. A diagnosis of HIV/AIDS also fosters anxiety and depression.
Moreover, knowledge of an AA male’s positive HIV status raises moral conflicts within the family. African Americans, through the influence of the church, associate HIV and AIDS with homosexuality which is regarded a sin. Many AA-MSM youths relate how their families may accept them but continue to ignore their being gay or their HIV status (Harris, Sutherland & Hutchinson, 2013). On the contrary, lack of acceptance causes open conflict among family members. At the same time, the physical, emotional, and financial burden of caring for the AA male especially when HIV progresses to AIDS may still fall on the family.
Low rates of condom utilization owing to unfavorable attitudes also put the community at risk (Hill & McNeely, 2011). High-risk sexual behaviors hasten the transmission of HIV to sexual partners. Especially when there are multiple partners, a continuing rise in HIV incidence is expected. While health is associated with the ability to meaningfully participate in social, cultural, economic, and political activities, a high incidence of disease affects community life (Tucker et al., 2013).
Public Health Interventions
One public health intervention was the mass media communication (radio and television) of developmentally and culturally appropriate information targeting to improve attitudes and behaviors towards condom use and HIV prevention (Sznitman et al., 2011). The 3-year intervention was implemented in cities in New York and Georgia. A randomized trial found that almost all of the participants from the two cities, 20% of whom were AA adolescents, have seen and heard the messages. There was increased self-reports of engaging in protected sex, negotiating condom use with a sexual partner, and greater self-efficacy in condom application among intervention participants compared with the control group.
One-on-one education and STI/HIV prevention skills training for AA male teens delivered using an adapted Focus on the Future (FoF) framework in a public health clinic was another strategy (Crosby et al., 2014). The FoF structures the client encounter to include rapport building, building awareness of HIV disparity affecting AA males, capitalizing on positive behaviors and past experiences with condom use, and providing guided practice in the appropriate use of a condom. The FoF also entails explaining how planning to use a condom and negotiating it with the partner is necessary in preventing HIV. The single-session educational activity ends with a summary of what was taught.
A randomized controlled trial (RCT) that investigated the effectiveness of the intervention showed that participants had improved self-efficacy in applying a condom and also had improved rate of condom use at the 2-month and 6-month follow-up (Crosby et al., 2014). On the other hand, the counterpart of the FoF among older adults is the Reeducating Older Adult in Maintaining AIDS Prevention (ROADMAP) program (Negin, Rozea & Martiniuk, 2014). The structure of the education and training sessions are similar with the F0F. An RCT employed to ascertain effectiveness demonstrated that, in comparison with the control group, participants in the intervention group had more consistent condom use.
Adult AA males are the target participants of the Many Men, Many Voices or 3MV intervention (Hill & McNeely, 2011). It consists of a weekend retreat where small-group 2-3 hour sessions for culturally congruent education and training on STI/HIV prevention are delivered. The intervention aims to address the social and behavioral determinants of STI/HIV including personal identity, social support systems in the AA-MSM community, the dynamics of sexual relationships, racism, homophobia, religious norms, and sociocultural norms (Hill & McNeely, 2011). Another RCT demonstrated effectiveness in that the 3MV retreat participants reported lower rates of unprotected anal sex and higher and more consistent rates of condom use during anal intercourse. There was also a decrease in the number of reported sex partners and improved rates of HIV screening.
The Strong African American Families-Teen (SAAF-T) is another public health initiative (Kogan et al., 2012). It recognizes the important role of the family in influencing the attitudes of high school students and thus entails family skills training within a 5-week long program. An optional part of the training is condom skills. The RCT conducted to evaluate program effectiveness showed an increase in self-reported efficacy and condom utilization rates among the youth compared with the control group.
Further, the church is an institution that AA males trust and regard as important because it is owned by AAs and are for AAs. In his study, Pitt (2010) showed that many AA men whether straight or gay regularly attend church and even hold important roles within the organization or attend activities of the different ministries (as cited in Hill & McNeely, 2011, p.8). Despite the church being a largely homophobic institution, engaging faith-based organizations in AA communities is still a viable public health strategy in promoting HIV prevention. Indeed, while church leaders can speak out against homosexuality, they cannot remain reticent about the high prevalence of STI/HIV/AIDS in their communities.
Hill and McNeely (2011) describe several success stories of faith-based interventions and include the Churches United to Stop HIV (CUSH), Teens for Age Prevention (TAP), Metropolitan Community AIDS Network (Metro CAN), and Project Bridge. All these programs are based in the community and were developed with the active participation of the organizations in collaboration with academic and non-profit institutions. Because the programs were accessible, culturally tailored, and run by AAs for AAs, utilization of services such as education on condom use and HIV screening was high.
Gaps in Research
More studies need to be done on the sustainability of consistent condom use following public health interventions. For instance, the longest post-intervention follow-up conducted in the studies was 6 months. It is important to determine if positive behavior is adopted for the long term such as one year. For media interventions, knowledge on sustainability determines the frequency of delivering the same or new messages. What has not been done is research on culturally-tailored STI/HIV prevention in schools. AA male adolescents noted that sex education in schools mainly focus on preventing teen pregnancy (Hill & McNeely, 2011), but the issue of STI/HIV is not being addressed adequately.
There is disparity in HIV/AIDS affecting African American males given the high incidence and prevalence in this population compared with Whites. While condom use is the single most important behavior that can significantly reduce the risk of infection, the rate of use is low among AA males. Negative attitudes are shaped by age, gender, place of residence (i.e. rural or urban), socioeconomic status, knowledge, self-efficacy, and lifestyle. Other risk factors contributing to negative attitudes relate to the sex partner, expectations about sex, and homophobia. In addition, cultural and religious beliefs, social support networks, the mainstream media, and experiences with the health care system also promote negative attitudes. Distrust of the media and the health care system and experiences of discrimination further engender negative attitudes about condom use.
However, the same institutions – church, family, media, and health care system – can be protective factors if they are transformed into sources of support through public health interventions. Many of these interventions are effective. For instance, fostering the ability to negotiate condom use enhances self-efficacy. However, more research is needed on long-term sustainability of outcomes and improving school-based sex education to further enhance prevention. As risk and protective factors vary among individual AA males, an individualized and culturally congruent approach is indispensable in ensuring success.
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