Community-based approaches to HIV prevention that address antigay stigma

School-based interventions, social marketing on family acceptance and community connectedness

Despite 3 decades of advances in HIV testing technologies and medications, HIV continues to burden gay and bisexual men disproportionately, especially within communities of color in the United States. One key structural driver of vulnerability to HIV infection is antigay stigma. To counter the detrimental effects of pervasive antigay stigma, widespread implementation of innovative and replicable HIV prevention interventions that affirm and cultivate the healthy formation of gay identities is strongly needed. This article outlines current community-based HIV prevention approaches addressing antigay stigma being used in the field, often with little or no funding.

LGBT-affirming school-based interventions

Antigay bias is rampant in schools and in urgent need of redress. Several studies show that lesbian, gay, bisexual and transgender (LGBT) youth experience higher rates of harassment and violence from their peers because of their actual or assumed sexual orientation (Bontempo & D’Augelli, 2002; Espelage, Aragon, Birkett, & Koenig, 2008; Swearer, Turner, Givens, & Pollack, 2008; Rivers, 2004). Many LGBT students feel unsafe at school and report higher rates of social isolation, depression, suicidal ideation and unprotected sex (Russell, Ryan, Toomey, Diaz, & Sanchez, 2011).

A number of school-based, LGBT-affirming and antibullying interventions are emerging across the country. One such program is the Gay Straight Alliance (GSA). GSAs are support groups where LGBT students, those questioning their sexual orientation or gender identity, and their straight friends can gather to discuss issues associated with their sexual orientation or gender identity and foster communication with others (Ginsberg, 1999). Currently, 4,000 GSAs are registered throughout the United States. The spate of suicides that occurred in late 2010 among gay men who were victims of anti-gay harassment and bullying underscores the importance of GSAs. Research shows that these interventions are a key resiliency factor for gay youth; young gay and bisexual men in schools with pro-gay interventions report fewer risky behaviors associated with HIV transmission, including unprotected sex (Goodenow, 2007).

One study in Salt Lake City found that students’ academic performance improved, their sense of belonging to the school community was enhanced, and their school attendance increased if they were involved with the GSA (Lee, 2002). Replicating programs such as these is critical to preventing the development of risk behaviors that increase vulnerability to HIV among young gay and bisexual men and transgender women.

Social marketing campaigns promoting family acceptance of gay sons and challenging antigay stigma

Family acceptance of LGBT persons is also central to addressing HIV. Research shows that the greater the extent to which one experiences family rejection because of one’s sexuality during adolescence, the poorer the health outcomes for LGBT young adults (Ryan, Huebner, & Sanchez, 2009). In addition to exhibiting higher rates of substance use, depression, and attempted suicide, participants in the study who were rejected by their families were 3.4 times more likely to report having engaged in unprotected sexual intercourse, compared with peers who reported little to no experiences of family rejection (Ryan et al., 2009).

Gay Men’s Health Crisis (GMHC) has implemented a series of social marketing campaigns that draw on a strength-based intervention model. Strength-based campaigns are effective in changing an individual’s behavior (Detweiler, Bedell, Salovey, Pronin, & Rothman, 1999; Devos-Comby & Salovey, 2002; Rothman, Salovey, Antone, Keough, & Martin, 1993). One 2008 campaign, titled “My Son Is My Life,” models behavior in which a Black father supports his gay son. Informational palm cards and ads in print media and in bus shelters highlight reactions parents can have when they learn their son is gay and illustrate steps they can take to provide support and love. “I know he is gay, and I don’t always understand, but that doesn’t change my love for him,” the image reads.

Another campaign, titled “I Love My Boo,” depicts young Black and Latino men in loving, affectionate embraces in public settings — a portrayal of gay men of color rarely seen in mainstream media. “We’re about trust, respect and commitment,” the image reads. “We’re PROUD of who we are and how we LOVE.” The campaign ran in 1,000 subway trains and 150 subway stations in New York City in 2010 to promote positive, strength-based images of Black and Latino gay men, encourage gay men to aspire to committed, long-term relationships, and counter antigay stigma.

A 2008 campaign titled “I know my rights… Do you?” focuses on combatting the stigma transgender women experience in public accommodations by explaining a New York City nondiscrimination ordinance passed in 2002 covering gender identity. Palm cards addressed access to health care, homeless shelters and employment. Research to date on public health issues affecting men who have sex with men (MSM) has largely neglected transgender persons. There are no national data on transgender women and HIV. However, independent studies report that transgender women are among the most vulnerable to HIV infection (Clements-Nolle, Marx, Guzman, & Katz, 2001). Addressing HIV among transgender women requires better surveillance and culturally competent and effective HIV prevention campaigns.

Community connectedness

Community connectedness has also been proven to protect against HIV infection. Greater community involvement counters the negative effects of antigay bias on safer sex practices among gay men by providing social support, enhancing feelings of self-efficacy and positive self-identity, and reinforcing peer norms supporting safer sex practices (Ramirez-Valles, 2002). Greater emphasis on prevention among older adults is also necessary. The Centers for Disease Control and Prevention (CDC) reports that most new infections among white gay and bisexual men occur among those who are 30-49 years of age (CDC, 2008). In 2007, 16 percent of new HIV infections were among people 50 and older (CDC, 2007). Evidence suggests that in addition to experiencing anti-gay bias, older gay men also experience issues related to aging and self-esteem. Some older gay men experience aging differently than their heterosexual counterparts, a concept referred to as “accelerated aging” (Rosario, Schrimshaw, Hunter, & Braun, 2006). This experience of feeling older at an earlier age than one’s chronological age presents issues of social isolation for gay men over 40 who are single and equate physical attractiveness with youth. These men may put themselves at risk for HIV by meeting anonymous partners on the Internet and coupling these experiences with substance use.

Identifying the need for HIV prevention among older gay men in 2008, the Fenway Institute in Boston piloted a group intervention to reduce HIV sexual risk, depression-related withdrawal, and anxiety-related social avoidance in gay and bisexual men 40 and older. The intervention, titled “40 and Forward,” was a series of 2-hour weekly sessions that brought together groups of gay men, ranging from 49 to 71 years of age and of multiple races, to socialize and discuss topics like safer sex. Men who participated in the intervention reported a significant decrease in depressive symptoms, as well as a significant increase in condom use self-efficacy (Reisner et al., 2010). It is notable that the intervention also helped socially isolated older gay men develop social support networks, a critical resiliency factor against HIV.

International efforts

Globally, public health specialists are also recognizing the importance of combatting antigay bias to stem the spread of HIV, especially among MSM. The full scope of the global HIV pandemic among MSM is unclear, as most countries fail to gather surveillance data for MSM. However, evidence suggests that the 86 countries which criminalize homosexuality render MSM highly vulnerable to HIV infection because they are forced underground and face multiple barriers to HIV prevention and treatment (amfAR, 2008). In many African countries, the exclusively heterosexual content of HIV prevention campaigns causes gay and bisexual men to think they are not at risk for HIV. A number of studies show a disproportionate impact of HIV on MSM in sub-Saharan Africa (Beyrer, 2008; Saavedra, zazola- Licea, & Beyrer, 2008). One study reported that in middle-and lower-income countries, MSM are 19 times more likely to contract HIV than the general population (Baral, Sifakis, Cleghorn, & Beyrer, 2007).

In 2008, the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) was reauthorized and included language calling for prevention with MSM and research to understand the impact of HIV on MSM. Also in 2008, the former presidents of Zambia and Mozambique, chairing the United Nations’ Economic Commission for Africa, issued a report calling for HIV prevention with MSM and opposing legal discrimination against them. The Global Fund for HIV, Tuberculosis and Malaria is also promoting MSM concerns. In May 2011, the U.S. Office of the Global AIDS Coordinator issued field guidance on MSM (see U.S. President’s Emergency Plan for AIDS Relief, 2011). The guidance gives suggestions for providing HIV prevention to MSM in Africa, the Caribbean, and elsewhere.

Doctors say experimental treatment may have rid man of HIV

A Brazilian man infected with the AIDS virus has shown no sign of it for more than a year since he stopped HIV medicines after an intense experimental drug therapy aimed at purging hidden, dormant virus from his body, doctors reported Tuesday.

The case needs independent verification and it’s way too soon to speculate about a possible cure, scientists cautioned.

“These are exciting findings but they’re very preliminary,” said Dr. Monica Gandhi, an AIDS specialist at the University of California, San Francisco. “This has happened to one person, and one person only,” and it didn’t succeed in four others given the same treatment, she said.

Another UCSF specialist, Dr. Steven Deeks, said: “This is not a cure,” just an interesting case that merits more study.

The case was described at an AIDS conference where researchers also disclosed an important prevention advance: A shot of an experimental medicine every two months worked better than daily Truvada pills to help keep uninfected gay men from catching HIV from an infected sex partner. Hundreds of thousands of people take these “pre-exposure prevention” pills now and the shot could give a new option, almost like a temporary vaccine.

If the Brazil man’s case is confirmed, it would be the first time HIV has been eliminated in an adult without a bone marrow or stem cell transplant. Independent experts want to see whether his remission lasts and for the intense drug combination that he received to undergo more testing.

“I’m very moved because it’s something that millions of people want,” said the 35-year-old man, whose spoke to The Associated Press on condition that his name not be published. “It’s a gift of life, a second chance to live.”

Transplants are how two other men, nicknamed the Berlin and London patients for where they were treated, were cured previously.

“I’m the living proof it’s possible to be cured,” Adam Castillejo, the London patient, said in a news conference at the AIDS meeting, which is being held online because of the coronavirus pandemic.

He and the Berlin patient, Timothy Ray Brown, had donors with a gene that confers natural immunity to HIV infection. Such transplants are too medically risky and impractical to attempt on a large scale, so doctors have been trying other approaches.