Good Health Education For HIV/AIDS Prevention Among Men Who Have Sex With Men Research Paper Example
A major public health issue in the U.S. and globally is the continuing prevalence of HIV which can progress to AIDS. The infection is transmitted primarily via sexual contact. Although they compose just 2% of the country’s population, disease incidence is noted to be highest among men who have sex with men (MSM), otherwise referred to as gay or bisexual men (HIV, 2012). In 2010, 61% of all persons newly infected with HIV, or roughly 28,200 cases, and 51% of all persons diagnosed with AIDS were MSM (HIV, 2012). Hence, the population of MSM is at the highest risk for contracting HIV and represents an important target for the delivery of screening, treatment, and education services.
Reducing the number of new AIDS cases and self-reports of condomless anal intercourse among MSM adolescents and adults represent two objectives of Healthy People 2020 (ODPHP, 2015). The specific target is to reduce the number of new AIDS cases by 10% from 15,966 in 2007 to 14,369 in 2020. Unprotected anal sex will be reduced from 13.7% of MSM at baseline to 10.3%. Another objective is to increase the number of MSM who report having undergone HIV testing within the past year from 62.2% to 68.4% (ODPHP, 2015). These national health goals reflect the gravity of the problem and emphasize the need for intensive health education among the MSM community and other strategies for preventing HIV infection among the uninfected and the progression to AIDS among those who already have HIV.
This issue of HIV/AIDS among MSM is of personal interest to me because of its resurgence despite the availability of highly-active antiretroviral therapy (HAART) and the impact on young people. The incidence of HIV among MSM has risen alarmingly by 22% between 2008 and 2010 with most cases involving young men between 13 and 24 years old (CDC Fact Sheet, 2012; HIV and young men, 2012). There is no cure for the infection as HAART only reduces viral titers but do not guarantee complete elimination. There is also no vaccine that provides a high level of protection against HIV as one clinical trial demonstrated a prevention rate of just 31% (Long & Owens, 2011). Without optimum compliance with medications, periodic viral titer testing, and safer sexual practices, the risk of transmission continues to exist among those with HIV. The continuing challenge of infection prevention therefore remains with emphasis on the role of education as a strategy to generate behavior change among MSM.
Health education is indispensable in the effort to prevent HIV and AIDS. This fact is emphasized by statistics showing that in 2008, 44% of those diagnosed with HIV were unaware they had the disease (HIV, 2012). Most of the survey participants who reported lack of awareness were young and racial minority men. Further, individual behaviors and sociocultural factors that increase the risks for infection and impede prompt diagnosis and treatment are modifiable. Effective risk reduction can be achieved through education based on systematic reviews summarizing the results of available studies on HIV, sexually-transmitted disease, and teen pregnancy prevention (Chin et al., 2012). For this reason, it is important for future health educators to have in-depth knowledge about the problem so that they would be in the best position to develop, implement, and evaluate acceptable, appropriate, and cost-effective health education services geared towards effective prevention.
The increasing incidence of HIV and AIDS among MSM and the difficulty of prevention are related to individual lifestyle behaviors which include high-risk sexual practices, drinking too much alcohol, and illicit drug use. HIV is a blood-borne infection with sexual intercourse as the major route of transmission (HIV, 2012). A review of 53 published studies on sexual risk behavior demonstrated that 40% of the MSM who participated in the studies practiced unprotected anal intercourse (UAI) (van Kesteren, Hospers & Kok, 2007). Between 13% and 51% of UAI happened with HIV-negative or unknown status partners. The review also showed that the practice of UAI is significantly more prevalent among HIV-positive men and this increases in frequency over time (van Kesteren, Hospers & Kok, 2007). This trend may be because HIV-positive men perceive no benefits in engaging in protected sex given that they are already infected. With this thinking, the spread of HIV to uninfected partners increases in likelihood. Meanwhile, a study by Rosenberg et al. (2011) showed that of the more than 11,000 sexually-active MSM surveyed, 76% had casual male partners with many having three concurrent partners. HIV-positive MSM were more likely to have more partners, again pointing out that this subset of MSM engage in riskier behaviors than those who are not infected.
The consumption of alcohol is also associated with higher risks of HIV infection. Hess et al. (2015) found that among MSM from 20 cities who took part in a survey, 85% regarded themselves as current drinkers, and nearly 60% of this figure reported one or more binge drinking episode in the past month. Binge drinking was linked with UAI at the latest sexual encounter, having multiple partners within the past 12 months, exchanging sex for drugs or money during the last sex, and engaging with more UAI within the previous year (Hess et al., 2015). Hence, binge drinking among MSM increased the frequency of high-risk sexual behaviors. A study by Baliunas et al. (2010) adds that MSM who reported drinking alcohol had a 77% higher risk of contracting HIV. Those who drank alcohol before or during sexual intercourse were at even higher risk at 87%. Compared to non-binge drinkers, the risk among binge drinkers was double.
At the same time, the use of drugs also raises the chances of HIV infection. Mackesy-Amiti, Fendrich and Johnson (2010) noted that MSM who use drugs, often concurrent with alcohol, report that it increased their self-confidence, facilitated sexual encounters, and enhanced their sexual experience. In a sample of MSM, risky sexual behaviors were found to positively correlate with symptoms of cocaine, prescription drug, and alcohol dependence (Mackesy-Amiti, Fendrich & Johnson, 2010). As such, MSM who are dependent on one or more substances had a higher likelihood of engaging in risky sexual behaviors that similarly raise their chances of HIV and STDs. At the same time, unsafe intravenous drug practices such as the shared use of needles when administering narcotics is a secondary route of HIV and STD transmission.
Further, it has been hypothesized that among MSM, a major reason for the resurgence in HIV incidence is high-risk sexual behavior associated with HAART mainly because of the misconception that antiretroviral therapy eliminates the risk of viral transmission (Hart et al., 2010). In line with this erroneous notion, HIV-positive MSM on HAART treatment no longer see the need for protected sex and so engage again in risky practices such as UAI. However, research revealed that the use of antiretroviral drugs does not completely eradicate the virus and though HIV has not been detected in some of the blood samples from patients on HAART therapy, it was present in varying amounts in 30% of the semen samples obtained from the same patients (Politch et al., 2012). Currently, there are also drug-resistant strains of the virus which, when acquired, will render HAART ineffective further emphasizing the need for protected sexual intercourse even under treatment.
Clearly, the widespread practice of UAI, especially among HIV-positive men, and having multiple sexual partners increase the risk for infection among those who are not yet infected. There is also a need to dispel the notion that HAART removes all likelihood of disease transmission and to highlight the fact that drug-resistant viral strains exist. As such, the promotion of safer sexual practices is imperative even among MSM who are undergoing antiretroviral drug therapy. Finally, the use of drugs and alcohol which are associated with a higher incidence of infection must also be addressed.
However, a gap in knowledge about the causes of HIV/AIDS is the contributory factors to the rise in the incidence of infection in recent years among young MSM. It is my opinion that awareness about HIV is low among teenage and young adult MSM on one hand and on the other, unsafe sexual practices must have become increasingly more common. The 13 to 24 age group where a rise in HIV incidence has been noted corresponds to middle school, high school, and university which means that most of the MSM involved must be students. It is probable that awareness building efforts regarding HIV and AIDS have generally missed schools and universities.
At the same time, social changes may also contribute to this phenomenon. Americans have become more open in regards to the issue of homosexuality with 37 states now allowing same-sex marriages (National Conference of State Legislatures, 2014). As such, younger persons may have become more open about their sexuality but then adopted the risky lifestyles of the MSM subculture. Technology may also have something to do with it. The widespread use of the internet and social networking websites noted among young people for dating and relationships could have had an impact on HIV incidence. These sites, especially those catering to MSM, can strongly influence beliefs and practices related to sex through online advice or peer information which may not necessarily be promotive of health or preventive of HIV infection.
Not only individual behaviors but also mainstream attitudes regarding people who have HIV or AIDS also impact prevention efforts. People who develop HIV or AIDS often experience rejection by and even violence from other people because of the latter’s fear of contracting the disease, their negative judgments based on morality principles, and the need to convey punishment because of what is deemed nonconformity with mainstream sexual behaviors (Earnshaw et al., 2012). The legality of same-sex marriage enacted in many states does not change people’s prejudices overnight in the same way that other ethnic groups, despite their citizen status, continue to experience different forms of discrimination. Specifically, many people continue to believe it is an expected outcome for MSM to develop HIV or AIDS because of their “deviant” sexual orientation and as such, they are blamed for their disease.
These attitudes are also noted among healthcare providers and discrimination leads to less than optimal care rendered to HIV and AIDS sufferers (Rutledge et al., 2011). For fear of suffering discrimination, stigma or violence, MSM may delay or refuse to obtain medical services for screening, diagnosis, and treatment (Earnshaw et al., 2012). Fear also prevents them from openly seeking information about the disease and advice on safer sexual practices. Negative perceptions and attitudes toward MSM may also serve as a barrier for their participation in research that is crucial in determining the health service needs of this population.
Stigma and acts of discrimination against MSM who have HIV and AIDS are not justified especially in health and other human service professions. The code of ethics of health education professionals supports human rights which includes the right to gender. It also upholds equal treatment in the provision of health education services which must be geared towards optimizing health and reducing the risks to disease (Code of ethics, 2011). It further promotes autonomy, which in the case of MSM, includes the freedom to choose a partner and engage in sexual intercourse so long as practices do not negatively affect their health and wellbeing. Negative mainstream attitudes towards MSM who have HIV and AIDS are based on unfounded fears and group differences based on an established societal norm which, through health education itself, can be addressed to reduce stigma and discrimination.
There are many similarities and some differences in the HIV/AIDS situation among MSM in the U.S. and the United Kingdom. Like the U.S., HIV and AIDS incidence and prevalence are disproportionately high among the MSM subpopulation. Similar to the U.S., the incidence rates among MSM have increased with the rate in the U.K. reaching its highest in 2010 at 3,000 new cases (Health Protection Agency, 2011). Like the U.S., the incidence of HIV among younger men in recent years in the U.K was observed with 31% of new infections occurring among males younger than 35 years old (Health Protection Agency, 2011). Majority of the MSM diagnosed with HIV were also White males, but a disparity in incidence and infection outcomes has been noted among Blacks in both countries. Health care utilization is suboptimal among Blacks (Health Protection Agency, 2011) and may partially explain related outcomes. However, unlike in the U.S., the U.K. has a high concern for HIV infections acquired abroad.
Both countries have rates of HIV below 1% among MSM compared to the total population although the rate in the U.K. is lower at 0.005% while the U.S. rate is 0.009%. In both countries, HIV transmission is mainly through sexual intercourse and one out of every four infected MSM in the U.K. does not know that he is infected similar to the situation noted in the U.S. (Health Protection Agency, 2011). There is also high-quality health care for HIV and AIDS with wide availability of HAART and various diagnostic techniques in the U.K. and the U.S. Thus, quality of life despite infection is high in both nations with a longer lifespan for HIV and AIDS sufferers.
One organization exclusively working for HIV prevention among MSM since 1998 in the U.K. is the Community HIV and AIDS Prevention Strategy (CHAPS) Partnership. It is currently funded by the U.S. Department of Health and is a public and private partnership of 14 organizations (Our programme of work, n.d.). The CHAPS Partnership provides research-based educational resources and services for the promotion of HIV prevention tailored for the MSM population. One goal is to promote safe sex through nonjudgmental interventions taking into consideration the particular needs and concerns of the sector as a whole as well as specific groups such as the HIV-positive, ethnic minorities, drug users, younger MSM and those with low levels of literacy (Our programme of work, n.d.). These interventions are meant to enhance the quality of life by decreasing the likelihood of disease and recognizing and respecting individual sexuality. The other goal is to correct wrong assumptions about HIV and MSM.
The CHAPS Partnership provides education through print and online media or via counseling, group talks and outreach programs in order to present choices and empower MSM to make the right decisions regarding their sexual practices (Our programme of work, n.d.). Printed literature available to the public are in the form of magazines, booklets, leaflets, posters, and briefing sheets. Written information is also available in the organization’s websites. Group talks and outreach programs develop prevention skills, fulfill individual social needs, and address interpersonal concerns between partners (Our programme of work, n.d.). To increase access to educational resources and services, these are made available in MSM websites, places that MSM frequent, clinics catering to MSM and the community. Resources and services have undergone pretesting to ensure appropriateness and acceptability (Our programme of work, n.d.).
In the U.S., the Institute for Gay Men’s Health (IGMH) is one organization working to promote HIV prevention among gay men in New York. Its aim is to deal with the reasons behind the HIV/AIDS epidemic, modify negative beliefs about the issue and foster behavioral change among MSM and the public (We are GMHC, 2013). Education is seen as a way of empowering MSM so that they can lead healthier lives. Especially among the young, comprehensive sex education is also necessary to reduce risk taking. The IGMH supports research on HIV/AIDS targeted prevention among elderly MSM and MSM in correctional facilities (We are GMHC, 2013). They also raise funds to establish programs for MSM with HIV in New York and other places in the country.
The IGMH launched three different campaigns to prevent HIV. The testing campaign seeks to increase HIV testing services utilization among gay men through the David Geffen Center for HIV Testing and Health Education (Testing campaigns, 2013). It provides free screening services and education on prevention following the screening. The campaign on health awareness involves telephone counseling and HIV prevention education through the organization’s helpline and e-mail (Substance use campaigns, 2013). Finally, the campaign on substance use involves the dissemination of real life stories of MSM who have used drugs. The purpose is to increase awareness about the negative effects of drug utilization among MSM. Links to resources which can assist MSM in stopping the use of illicit drugs are made available as well.
Based on the information available on their respective websites, CHAPS has a wider reach in terms of prevention education because of the greater variety of media it uses and its being active in seeking out MSM in places frequented by the latter. On the other hand, the IGMH provides screening and help line services only for the MSM who seek these services. The CHAPS Partnership also utilizes evidence gained from research participated in by MSM. The use of research evidence permits the organization to develop interventions that cater to MSM in general and also special subgroups of this population. This approach ensures that interventions are acceptable to and needed by MSM as well as effective in addressing the issues there were meant to address.
On the other hand, the IGHM uses research primarily to evaluate and improve its existing services which target MSM in general. Further, the focus of CHAPS is on quality of life with emphasis on empowerment or being able to make choices in the areas of health and sexuality while the IGHM mainly provides a fixed range of services to MSM. Overall, the CHAPS Partnership is more transparent in how it operates because the rationale behind their interventions, the expected outcomes, and the results of data monitoring for progress are made available in their website. This is while IGHM does not make public its program development and evaluation data.
At the country level, there are strategies being used for HIV/AIDS prevention among MSM. In the U.S., the CDC has launched the Let’s Stop AIDS Together, a five-year campaign involving public health education, HIV testing, and encouraging advocacy at the community level (Act against Aids, 2012). The campaign is based on the principle that HIV and AIDS should be regarded as a public concern and not an issue limited to gay and bisexual men. Promoting HIV/AIDS as a social issue aims to dispel common public misconceptions about the disease and the MSM community. Health education aims to build awareness about HIV and AIDS, its transmission, and prevention measures using online and print media. It further aims for family members and communities to support MSM in seeking better health. Additionally, the Testing Makes Us Stronger campaign for MSM makes testing accessible to them for the purpose of increasing the rates of prompt diagnosis and treatment that is crucial for the secondary prevention of AIDS (Act against Aids, 2012).
The CDC advocacy aims to generate support for MSM and HIV-positive individuals by encouraging them to share their personal experiences in story-telling sessions which convey the main message that HIV-positive individuals are people just like everybody else (Act Against Aids, 2012). Again, this intervention clarifies misconceptions about the disease and MSM. State and local health agencies and health care professionals are also mobilized to provide education, behavior modification, and medical interventions such as HIV testing and promoting condom and microbicide use to ensure safe sex. In summary, HIV prevention in the U.S. is achieved using a multifaceted strategy consisting of mass media educational campaigns, cognitive-behavioral interventions, biomedical approaches, and community-based efforts (Sullivan et al., 2012).
In the U.K., multisectoral coalitions are the main machinery for campaigns and intervention services delivery. This is exemplified by the CHAPS Partnership and also the Halve It initiative by the National Aids Trust, the latter aiming to reduce by half the number of undiagnosed HIV cases through the promotion of early HIV testing (Halve It campaign, 2013). Prevention messages in mass media campaigns is meant not to sound like instructing MSM what they should do but to provide choices and influence MSM to get tested, use condoms, use lubricants, reduce the number of partners or seek treatment as treatment itself is regarded as a method of preventing disease. Help-line educational resources and messages have also been updated to ensure consistency with this prevention approach. The emphasis is on respecting the rights of MSM to choose their sexual partners, practice sex, and express their sexuality while also promoting their rights to health (National Aids Trust, 2010).
Primary care is also being tapped to provide health education and other preventive interventions as it was observed that HIV prevention has not been prioritized in recent years even with the alarming increases in HIV incidence. Further, institutions such as the National Aids Trust are looking into formal collaboration with business establishments catering to MSM to see how health promotion and prevention messages and resources can be advanced in these venues (National Aids Trust, 2010). Policy changes are also being advocated which include the allocation of greater funding for prevention programs and prioritization of HIV prevention at the national level. Support is further being given to continuing research on what prevention strategies work best including new techniques such as pre-exposure prophylaxis (PrEP) and vaccination.
If I were asked to recommend resources about HIV/AIDS among MSM, I will suggest David France’s documentary How to Survive a Plague. The film chronicles the efforts of the AIDS Coalition to Unleash Power (ACT UP), an MSM activist organization, in pressure politics targeting policymakers and pharmaceutical companies. The goal of the group was to hasten the development of drug treatments for AIDS and to make these drugs more accessible to the thousands who were infected. The group succeeded. What is interesting in this movie is its emphasis on the need for collective action to achieve change in the face of political and social discrimination. A major lesson is that gay and bisexual men should not passively hide or stand aside and watch their advocates work on their behalf. Instead, they should be at the frontlines themselves actively working with others in order to achieve improvements in their health and wellbeing.
A good website which I will recommend when asked is http://napwa.org.au maintained by the National Association of People with HIV Australia (NAPWA), a grassroots advocacy group consisting of community-based organizations of HIV-positive people. The website is created by and for HIV-diagnosed individuals and their families and advocates. This attribute is what makes it interesting. The website provides professionally-reviewed and current information on living with and treating and defeating HIV (About this site, n.d.). Information is also available on the online magazine Positive Living. Although NAPWA does not cater exclusively to MSM, the educational resources available for MSM in the website are helpful. Collectively called Real Time, the workbook materials encourage reflection among MSM regarding gay sex and assist them in risk-reduction. Positive Living articles for MSM focus on HIV research, depression, sexual dysfunction, unprotected sex, real life stories, legal battles, and campaigns in the MSM sector.
Lastly, a good book on the topic of HIV/AIDS among MSM is Aging with HIV: A Gay Man’s Guide by James Masten and published in 2011. With a longer lifespan afforded by HAART, more and more HIV-positive men find their way into older adulthood. This stage of life poses physical and psychological challenges as body functions begin to deteriorate, job roles are relinquished during retirement, and long-term partners die with new ones difficult to find. HIV-positive gay men face the additional challenge of living with a chronic disease. The book assists older adult gay men navigate this life stage by discussing common changes, the challenges they might encounter, and strategies they can use to cope so that they can have the best possible aging experience despite infection with HIV (Masten, 2011).
A specific educational approach developed to address this issue is the internet-based counseling called the Prevention Organization with Empowerment Resources on the Net which provides services to MSM in Kansas City (PowerON) (Moskowitz, Melton & Owczarzak, 2009). The counselors created their own profiles in Gay.com, a social networking site for MSM, and thus were able to chat with MSM users about various topics pertaining to testing, high-risk sexual behaviors, HIV and STD, coping with infection, and sexuality (Moskowitz, Melton & Owczarzak, 2009). Whenever the opportunity arose, the counselors provided information about HIV prevention consistent with the public health information being disseminated by the city.
Based on need, the counselors referred the MSM clients to testing and medical consultation services. They also posted messages which let users know they can ask for HIV/STD-related information by sending instant messages. Transcripts of 245 chat sessions or 90% of those included in the study showed that health education and counseling were provided to clients (Moskowitz, Melton & Owczarzak, 2009). The benefit of this approach is that MSM can have immediate answers to their most pressing concerns from a member of their own community, albeit online, through a medium that is acceptable, convenient and upholds their privacy. This approach can be adapted to other social networking sites for MSM which have a chat feature.
As a health educator in the future, I can contribute to HIV and AIDS prevention by advocating for MSM’s right to health information regarding HIV and AIDS. Seeing the rise in HIV cases among adolescent and young adult MSMs, I will seek out and work with advocate groups to promote HIV prevention education in this subpopulation. Partnering with school nurses would be a start. In order for me to work effectively as an advocate for young MSMs, I would need to have in-depth information about them including trends in infection rates, sexually risky behaviors, factors influencing these behaviors, sources of sexual health information, common concerns and education needs. I will obtain the knowledge by referring to the literature and interacting with MSMs to gain first-hand information that will validate and enhance what has been published.
At the national level, I can help in the drafting and pilot testing of educational materials in print or video form or as resources for online information dissemination and counseling. Pilot testing is important as it determines the appropriateness of the content, format, graphics, reading level, language, and other characteristics of the material. I can also volunteer as an online or offline counselor. At the international level, I can assist in the conduct of research about the HIV and AIDS situation of less developed countries where infection rates are highest and communicate findings to governments so that they can formulate appropriate public health responses. I can also aid in raising funds to help organizations in those countries sustain and expand their HIV/AIDS prevention efforts especially among young persons.
About this site (n.d.). Retrieved from http://napwa.org.au/living-with-hiv/gay-and-bisexual- men?page=1
Act Against Aids (2012, Dec. 21). Retrieved from http://www.cdc.gov/actagainstaids/index.html
Baliunas, D., Rehm, J., Irving, H., & Shuper, P. (2010). Alcohol consumption and risk of incident human immunodeficiency virus infection: a meta-analysis. International Journal of Public Health, 55(3), 159-166.
CDC fact sheet: New HIV infections in the United States (2012, Dec.). Retrieved from http://www.cdc.gov/nchhstp/newsroom/docs/2012/HIV-Infections-2007-2010.pdf
Chin, H.B., Sipe, T.A., Elder, R., Mercer, S.L., Chattopadhyay, S.K., Jacob, V., Santelli, J. (2012). The effectiveness of group-based comprehensive risk-reduction and abstinence education interventions to prevent or reduce the risk of adolescent pregnancy, human immunodeficiency virus, and sexually transmitted infections: Two systematic reviews for the Guide to Community Preventive Services. American Journal of Preventive Medicine, 42(3), 272-294. doi: 10.1016/j.amepre.2011.11.006.
Earnshow, V.A., Smith, L.R., Chaudoir, S.R., Lee, I., & Copenhaver, M.M. (2012). Stereotypes about people living with HIV: implications for perceptions of HIV risk and testing frequency among at-risk populations. AIDS Prevention and Education, 24(6), 574-581
Halve It campaign (2013). Retrieved from http://www.nat.org.uk/Our-thinking/Prevention- and-testing/Halve-it-campaign.aspx
Hart, T.A., James, C.A., Hagan, C.M.P., & Boucher, E. (2010). HIV optimism and high-risk sexual behavior in two cohorts of men who have sex with men. Journal of the Association of Nurses in AIDS Care, 21(5), 439-443.
Health Protection Agency (2011). HIV in the United Kingdom: 2011 Report. London: Health Protection Services, Colindale.
Hess, K.L., Chavez, P.R., Kanny, D., DiNenno, E., Lansky, A., & Paz-Bailey, G. (2015). Binge drinking and risky sexual behavior among HIV-negative and unknown HIV status men who have sex with men, 20 US cities. Drug and Alcohol Dependence, 147, 46-52. Retrieved from http://dx.doi.org/10.1016/j.drugalcdep.2014.12.013
HIV among gay and bisexual men (2012, May 18). Retrieved from http://www.cdc.gov/hiv/topics/msm/
HIV and young men who have sex with men (2012, June). Retrieved from http://www.cdc.gov/healthyyouth/sexualbehaviors/pdf/hiv_factsheet_ymsm.pdf
Long, E.F., & Owens, D.K. (2011). The cost-effectiveness of a modestly effective HIV vaccine in the United States. Vaccine, 29, 6113-6124. doi:10.1016/j.vaccine.2011.04.013.
Mackesy-Amiti, M.E., Fendrich, M., & Johnson, T.P. (2010). Symptoms of substance dependence and risky sexual behavior in a probability sample of HIV-negative men who have sex with men in Chicago. Drug and Alcohol Dependence, 110(2010), 38- 43.
Masten, J. (2011). Aging with HIV: A Gay Man’s Guide. New York, NY: Oxford University Press.
Moskowitz, D.A., Melton, D., & Owczarzak, J. (2009). PowerON: the use of instant message counseling and the internet to facilitate HIV/STD education and prevention. Patient Education and Counseling, 77(2009), 20-26.
National Aids Trust (2010). Partnership patterns and HIV prevention amongst men who have sex with men. Retrieved from http://www.nat.org.uk/Media%20library/Files/Policy/2010/MSM%20Parternship%20 Patterns%20FINAL-1.pdf
National Conference of State Legislatures (2013). Same-sex marriage laws. Retrieved from http://www.ncsl.org/research/human-services/same-sex-marriage-laws.aspx
Office of Disease Prevention and Health Promotion (2015). HealthyPeople 2020 topics and objectives: HIV. Retrieved from https://www.healthypeople.gov/2020/topics- objectives/topic/hiv/objectives
Our programme of work (n.d.). Retrieved from http://www.chapsonline.org.uk/Who-we- are/Our-programme-of-work
Politch, J.A., Mayer, K.H., Welles, S.L., O’Brien, W.X., Xu, C., Bowman, F.P., & Anderson, D.J. (2012). Highly active antiretroviral therapy does not completely suppress HIV in semen of sexually active HIV-infected men who have sex with men. AIDS, 26(12), 1535-1543.
Rosenberg, E.S., Sullivan, P.S., DiNenno, E.A., Salazar, L.F., & Sanchez, T.H. (2011). Number of casual male sexual partners and associated factors among men who have sex with men: Results from the National HIV Behavioral Surveillance system. BMC Public Health, 11(189), 1-9. Retrieved from http://www.biomedcentral.com/1471- 2458/11/189
Rutledge, S.E., Whyte, J., Abell, N., Brown, K.M., & Cesnales, N.I. (2011). Measuring stigma among health care and social service providers: the HIV/AIDS Provider Stigma Inventory. AIDS Patient Care and STDs, 25(11), 673-682.
Substance use campaigns (2013). Retrieved from http://www.gmhc.org/learn/gmhc- campaigns/substance-use-campaigns
Sullivan, P.S., Caballo-Dieguez, A., Coates, T., Goodreau, S.M., McGowan, I., Sanders, E.J., Sanchez, J. (2012). HIV in men who have sex with men 3: successes and challenges of HIV prevention in men who have sex with men. Lancet, 380, 388-399.
Testing campaigns (2013). Retrieved from http://www.gmhc.org/learn/gmhc- campaigns/testing-campaigns
van Kesteren, N.M.C., Hospers, H.J., & Kok, G. (2007). Sexual risk behavior among HIV- positive men who have sex with men: A literature review. Patient Education and Counseling, 65(2007), 5-20.
We are GMHC (2013). Retrieved from http://www.gmhc.org/learn/we-are-gmhc