Sunday, December 10, 2006

The Failure of HIV Prevention Programs to Decrease the Rate of HIV Infection Among Asian American and Pacific Islander MSM - Sara Scott

Currently, there are more than 500,000 men who have sex with men (MSM) diagnosed with AIDS in the United States [1]. In the past 20 years, there were approximately 300,000 AIDS related deaths among the men who have sex with men (MSM) population [1]. Though several public health programs that focused on HIV/AIDS prevention in the gay community were implemented since the spread of the pandemic in the 1980’s, 65% of all HIV diagnosis in 2004 were the result of MSM [1]. Minority MSM are at a particularly high risk of becoming infected with HIV, because they are more likely to participate in riskier behaviors, such as unprotected sex. This is the result of intensified discrimination that minority MSM experience within their families, communities, and even within the gay community [2]. This is especially the case for men of Asian and Pacific Islander (API) decent. The rate of unprotected anal intercourse with multiple partners among Asian American/Pacific Islander (AAPI) MSM has increased from 12% in 1999 to 20% in 2002 [2]. More than 72% of the total diagnosed AAPI AIDS cases are MSM, which is only 2% points lower than white MSM [3]. Though HIV prevention programs have targeted numerous efforts towards preventing the spread of HIV within the gay community, failure to consider and integrate the familial expectations of AAPI men, the stigmatization of homosexuality within their communities, and the stereotypes placed upon them within the gay community into these programs, resulted in failure to decrease the rate of HIV infection among AAPI MSM [4]. Without considering these social and behavioral factors, HIV prevention programs among AAPI MSM will continue to be a failure.

Previous HIV prevention programs failed to account for the fact that in a traditional API family, sexual and personal issues, like homosexuality, are not discussed or even acknowledged [5]. The reason is that respect for the family and carrying out the family name with honor and dignity is considered the highest priority for most AAPI men [5]. AAPI men report that their primary duty is to succumb to parental pressure to get married, have children, and carry on family traditions without bring shame to the family by nonconformity (such as being gay or engaging in premarital sex) or individual misbehavior [4]. Because homosexuality is not acknowledged or discussed within a traditional AAPI family, AAPI MSM experience difficulty with sexual identity development [4]. The confusion surrounding sexual identity and fear of bringing shame to the family results in increases in shamefulness due to a perceived inability to be “a man,” decreased self-esteem, and feelings of isolation. These feelings lead to an increased likelihood of performing risky sexual behaviors, because AAPI MSM will have less regard for their health and well-being than heterosexual AAPI men [4]. Familial avoidance of issues surrounding homosexuality may also prevent AAPI MSM from obtaining information regarding HIV prevention and support services.

AAPI MSM who adhere to their traditional family values are less likely to know how HIV is transmitted and prevented, because they are raised with the belief homosexuality is a taboo subject that should not be discussed. According to the AIDS Risk Reduction Model, individuals must pass through three general stages called labeling, commitment, and enactment in order to make necessary behavioral changes that protect one from becoming HIV infected [6]. During the labeling stage, an individual must have knowledge of how HIV is transmitted and prevented, perceive themselves as susceptible for HIV, and believe that HIV is undesirable [6]. The commitment stage is when the individual attempts to decrease risky behaviors by understanding what puts him at risk for HIV infection [4]. The enactment phase is the final phase whereby an individual must take direct action to reduce risky behaviors by acquiring behavioral skills to complete the task [4]. A study performed on Asian American college students showed that most of them lacked basic information about HIV transmission, risk, and prevention [7]. This leads to a snowball effect throughout the commitment and enactment phases of the AIDS Risk Reduction Model, because the lack of knowledge about HIV transmission, risk, and prevention leads to an inability to decrease high-risk sexual behavior [4]. Familial avoidance, internal shame, and lack of self-esteem also deter AAPI MSM from taking direct action to reduce risky behaviors through seeking out information, obtaining remedies, or enacting solutions [6].

The Health Belief Model, much like the AIDS Reduction Risk Model, states that behavioral changes depend on perceived susceptibility, perceived severity, perceived benefits of performing a behavior, and perceived barriers of performing a behavior [4]. According to the CDC in 2004, approximately 90% of Asian and Pacific Islanders perceived themselves of being at risk for HIV, yet only 47% had been tested during the past year [8]. This shows that API may not truly perceive themselves as being susceptible to HIV or that fear familial abandonment and stigmatization by the family far outweighs the perceived benefits of taking action to reduce the threat of HIV infection, thus they do not modify risky behavior.
Another factor that previous HIV prevention programs failed to consider for is the extreme stigma attached to homosexuality within the AAPI community. Aside from parental expectations of “the son,” there are high expectations for men within the AAPI community to be leaders and role models for younger generations [4]. The cultural avoidance of discussing issues such as sexual behavior, illness, and death, not only prevent AAPI MSM from seeking information about HIV prevention, but also force them to keep their sexual identity closeted [9]. AAPI MSM develop their sense of self in a social and cultural environment that is marked by racism, homophobia, and immigrant status [10]. The lack of social support causes decreases in self-esteem, depression, and feelings of being unworthy of help in AAPI MSM [5].

Given the strong familial and cultural norms, it is essential that an HIV prevention program incorporate the family and community values to be effective [9]. Unlike previous HIV prevention programs that focused solely on the individual, The Social Cognitive Theory or Social Learning Theory, maintains that behavioral changes are influenced by observing others who are motivated and have knowledge of the steps necessary to avoid risky behaviors [4]. Many AAPI MSM remain closeted, ashamed about their sexuality, and unlikely to discuss their sexuality; therefore observing others is difficult. According to the Diffusion Theory, which states that community members are most likely to make behavioral changes when the message is delivered by other members within their social networks who are perceived to be similar to them, this was an ineffective approach to dealing with the AAPI MSM community [4]. In essence, AAPI MSM are most likely to adopt the idea of practicing safe sex when the idea is communicated by other AAPI MSM. This is why a majority of HIV prevention programs utilize heterosexual and/or Caucasian males or females to deliver the message that the use of condoms is essential in protecting oneself from HIV.

AAPIs are one of the fastest growing populations in the US today [11]. The AAPI populations grew approximately 72% between 1990-2000 [11]. Immigrant AAPIs with limited English proficiency are at a disadvantage in obtaining necessary information, because most HIV prevention programs in the US were delivered in English [9]. According to the Diffusion Theory [4], the likelihood of changing the risky behaviors of the immigrant AAPI MSM community will increase if messages are delivered by health care professionals to whom they can linguistically and culturally relate. HIV prevention programs fail to account for the lack of healthcare providers with appropriate linguistic and cultural competencies regarding the AAPI community that could direct AAPI MSM towards needed preventative services [11].

A major factor that HIV prevention programs failed to address is the discrimination AAPI men experience within the entire gay community [4]. Most Americans identify the quintessential “all-American” male as being tall, blonde haired, blue-eyed, and strong [4]. AAPI MSM are stereotypically labeled as submissive, monogamous, and are perceived to be at low risk for HIV infection [4]. AAPI MSM are typically uneasy with discussing sexual issues, especially in the presence of a non-Asian MSM [10]. The cultural need to be non-confrontational in hierarchical systems and placing higher value on making sure their partner is comfortable takes precedence over their own feelings and prevents many AAPI MSM from aggressively challenging the stereotypes placed upon them [10]. As a result, many AAPI MSM report being the recipient of unprotected anal sex, which increases the likelihood of becoming infected with HIV [12]. Other AAPI MSM claim that they are excluded from programs or activities, such as HIV prevention, pertaining to the gay community as a whole [4]. The lack of social support within the gay community results in low self-esteem and feelings of worthlessness among AAPI MSM. This is why many AAPI MSM have a high chance of practicing risky sexual behavior [4].

According to the Social and Cognitive Theory, behavioral changes are made through outcome expectations, the extent to which the person values the expected outcome of a specific behavior, and depends on the level of self-efficacy, the belief in his ability and confidence in performing such behaviors [6]. AAPI MSM who are subjected to familial and communal discrimination, as well as discrimination within the gay community, may lack the self-confidence to demand the use of a condom, even if they know better. As discussed previously, AAPI MSM value their partners’ comfort level over their own, especially when their partners are non-AAPI, thus placing little value on the benefits of using protection. The feeling of being subservient and submissive also decreases their level of self-efficacy in practicing safe sex. Previous public health HIV programs placed little to no emphasis on the discrimination that AAPI MSM suffer at the hands of other non-AAPI MSM.

Until recently, HIV prevention programs did not adequately address the sociocultural and behavioral issues that influence sexual risk taking among AAPI MSM. According to San Francisco’s survey of gay men (aged 18-29) in 1992-1993, 26.9% of AAPI MSM were tested HIV positive compared to 15.5% of white MSM [4]. The rate of HIV among AAPI MSM is rising every year. In order to implement an effective HIV prevention program that targets AAPI MSM, one must understand the social influences that impact their behavior. The Empowerment Theory states that people change through populations for change at both the individual and group level, participating in education of the community, and in focus group strategies [6]. In order to make these necessary changes in behavior, public health professionals must consider what prevents AAPI MSM from feeling a sense of empowerment over their own well-being. The sense of empowerment, along with high self-esteem, and a social support network, is key to preventing HIV among AAPI MSM.

References

1. CDC. CDC HIV/AIDS fact sheet: A glance at HIV/AIDS among men who have sex with men. January 2006. Available at: http://www.cdc.gov/hiv/resources/factsheets/PDF/MSM_Glance.pdf

2. Truong H.M, McFarland W., Folger K., Owen C., Chen S., Kohn R., Klausner J. Increases in Rates of Unprotected Anal Intercourse and Sexually Transmitted Diseases in Asian MSM in San Francisco. Conference for Retroviral Opportunistic Infections in San Francisco, California 2004: Abstract no. 844.

3. Wong, FY. HIV-Related Risks Among Asian American Pacific Islander (AAPI) Men Who Have Sex With Men (MSM). National HIV Prevention Conference in Atlanta, Georgia 2005: Abstract no. M2-D1401.

4. Choi K., Yep GA., Kumekawa E. HIV Prevention Among Asian and Pacific Islander Men Who Have Sex With Men: A Critical Review of Theoretical Models and Directions For Future Research. AIDS Education and Prevention 1998; 10(Supplement A): 19-30.

5. Asian/Pacific Islanders and HIV/AIDS In The United States. November 2006. Available at: http://hab.hrsa.gov/history/api/

6. HIV/AIDS Prevention and Education Services Effective Interventions and Strategies-Definitions of Theories and Models. November 2006. Available at: http://www.doh.wa.gov/cfh/hiv_aids/Prev_Edu/Effective_Interventions/6_def_theor_models.htm

7. Dominicus S., Frank Y., Wong F., DeLeon J. Sex, HIV Risks, and Substance Use Among Asian American College Students. AIDS Education and Prevention 2005, 17(5): 457-468.

8. CDC. HIV/AIDS Among Asians and Pacific Islanders. November 2006. Available at http://www.cdc.gov/hiv/resources/factsheets/PDF/API.pdf

9. Asian Americans and Pacific Islander and HIV/AIDS. October 2006. Available at: www.apiahf.org

10. What Are Asian and Pacific Islander HIV Prevention Needs? October 2006. Available at: http://www.apiahf.org/programs/hivcba/resources/facts/apifs.pdf

11. HIV/AIDS Among Asian/Pacific Islanders. November 2006. Available at: http://www.omhrc.gov/hivaidsobservances/api/AAPI_fs_5_9_06.pdf

12. Poon M., Ho P., Wong J., Wong G, Lee R. Psychosocial Experiences of East and Southeast Asian Men Who Use Gay Internet Chatrooms in Toronto: An Implication for HIV/AIDS Prevention. Ethnicity and Health May 2005, Vol. 10: 145-167.

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