1. Wheeler/HIV Testing Black MSM IOM 1 HIV Testing: Issues for Black & African American MSM Darrell P. Wheeler, Ph.D., M.P.H. Hunter College School of Social Work Presented April 15, 2010 Institute of Medicine of the National Academies Workshop to Identify Facilitators and Barriers to HIV Testing Washington, DC

2. Wheeler/HIV Testing Black MSM IOM 2 Why are we having this discussion? Disproportionate rates of infections among men who are categorically identified as  MSM  Black and/or African American Disparate rates of testing among these men Stage of disease progression among these men who are testing positive Central role of testing in HIV & AIDS arsenal

3. Wheeler/HIV Testing Black MSM IOM 3 Emerging thoughts on disparate testing Negative encounters with medical institutions Need to promote social awareness and acceptance of male bisexuality Racial discrimination Social isolation and sero-prevalence within a social network/environment Sexual discrimination Role of sexual & social networks Emphasis on behavioral only approaches to understanding risk Stigma Religion Class Etc.

4. Wheeler/HIV Testing Black MSM IOM 4 One view of current approaches to HIV Testing for BMSM

5. Wheeler/HIV Testing Black MSM IOM 5 Contextual & Structural Factors Poverty & Employment Housing & Homelessness Criminal Justice System, Incarceration and Re-Entry Racism and presumptive rationality of racial constructs; including manifestations of this from the health and public health care systems Heterosexism & Homophobia

6. Wheeler/HIV Testing Black MSM IOM 6 Relationship as Intervention: A Socio-cultural model Darrell P. Wheeler, Ph.D., M.P.H. Antecedent ProximalMediatingOutcome Variables Variables VariablesVariables Socio- Cultural and Demographic Variables racial identity sexual identity SES values orientation Socio- Cultural and Demographic Variables racial identity sexual identity SES values orientation Client’s Psychosocial Factors Worker’s Characteristics Multicultural competence Style of Interaction Setting related factors Service mix Arrangement for seeing clients Interactions That effect The Quality of Relationship with Worker Trust Communication Satisfaction Perception of Testing Testing Experience Outcome Process

7. Wheeler/HIV Testing Black MSM IOM 7 Personal Context Person + Partner + Sexual Context SEXUAL CONTEXT Person + Partner Social-Cultural Sex in Context Structural Cultural Context Person + Partner + Sexual + Structural Context

8. Wheeler/HIV Testing Black MSM IOM 8 “Whether sensational or mundane, the inappropriate responses to the health ailments that disproportionately affect the Black community are deeply imbedded in the structure and culture of America’s health care system. Such chronic problems are not amenable to simple reforms…” (Byrd & Clayton, 2000, p. 16)

9. Wheeler/HIV Testing Black MSM IOM 9 Closing Thoughts Providers/Systems will need to increase their understanding of and advocate for interventions that target basic needs (i.e., housing, income and education) Need for deeper examination of the factors which impact the lives of BMSM (social isolation, and negative life experiences including sexual abuse) There is a need for community anchored services that build on relationships established with men over time to ensure that the special needs of men are appropriately assessed, linked and sustained to (but not limited to) mental health, substance use, social service, and medical services. The need for REAL structural and contextual level interventions and not just individual behavioral interventions. Including confrontation of pejorative use of labels like MSM, Black without confronting normative understanding of these terms.

10. Wheeler/HIV Testing Black MSM IOM 10 References Byrd, W. M. & Clayton, L.A. (2000). An American Health Dilemma: A Medical History of African Americans and The Problem of Race Beginnings to 1900. New York, NY: Routledge. Dodge, B., Jeffries, W., & Sandfort, T. (2008). Beyond the Down Low: sexual risk, protection, and disclosure among at-risk Black men who have sex with both men and women (MSMW). Archives Of Sexual Behavior, 37(5), 683-696. Fanon, F. (1967). Black Skin White Masks. New York, NY: Grove Press. MMWR: Morbidity & Mortality Weekly Report, (2009). HIV infection among young black men who have sex with men -- Jackson, Mississippi, 2006-2008. 58(4), 77-81. Retrieved from CINAHL database; 4/7/2010. Malebranche, D., Peterson, J., Fullilove, R., & Stackhouse, R. (2004). Race and sexual identity: perceptions about medical culture and healthcare among Black men who have sex with men. Journal Of The National Medical Association, 96(1), 97-107. Millett, G., Flores, S., Peterson, J., & Bakeman, R. (2007). Explaining disparities in HIV infection among black and white men who have sex with men: A meta-analysis of HIV risk behaviors. AIDS, 21(15), 2083-2091.

11. Wheeler/HIV Testing Black MSM IOM 11 References Nanín, J., Osubu, T., Walker, J., Powell, B., Powell, D., & Parsons, J. (2009). "HIV is still real": Perceptions of HIV testing and HIV prevention among black men who have sex with men in New York City. American Journal Of Men's Health, 3(2), 150-164. Smith, D.B. (2002). Health Care Divided Race and Healing a Nation. Ann Arbor, MI: University of Michigan. Wilton, L., Herbst, J., Coury-Doniger, P., Painter, T., English, G., Alvarez, M., et al. (2009). Efficacy of an HIV/STI prevention intervention for black men who have sex with men: findings from the Many Men, Many Voices (3MV) project. AIDS And Behavior, 13(3), 532-544. Wheeler, D.P. (2006). Exploring HIV prevention needs for non-gay identified Black and African American men who have sex with men: A qualitative study. Sexually Transmitted Diseases, 33(7 Suppl), S11-6. Wheeler, D.P. (2007). HIV and AIDS today: Where is social work going. Health and Social Work, 32(2), 155-7.