How successful we are in altering the current patterns and rates of HIV infection in African American MSM depends, in part, on the conceptual frameworks that we employ in our collection and interpretation of data as well as on our design and implementation of programs and policies (Zierler & Krieger, 1997). The purpose of this article is twofold. First, we will develop a rationale for reframing the conceptualization of risk of HIV infection in Black men who have sex with other men from an individualized perspective to a social and interpersonal paradigm drift (Trickett, 2002) that takes into account the multiple sources of influence on their behaviors and points of needed interventions (Cochran & Mays, 1993, 1994; Mays, 1992; Mays & Cochran, 1990b, 1990c, 1995, 1998; Mays & Jackson, 1991; Peplau, Cochran, & Mays, 1997). Factors that impact the relationships of African American men who have sex with men on a personal and individual level (i.e., choice of sexual partners, sources of information, emotional and social support) drive HIV-related behaviors. In addition, larger, macropublic relationships (power, privilege, and position in society) play a role in shaping the context and precursors for those behaviors. Patterns of both dyadic and social relationships have significant implications for the design of HIV-prevention approaches in this population.

Second, and equally important, we seek to focus the research agenda on questions to which answers may help us to reduce the burden of HIV disease among African American MSM. We suggest that research is needed to examine sources of influence, interpersonal factors, and contextual vulnerabilities that go beyond simply documenting traditional HIV-related disease parameters and individual risk behaviors. We begin by reviewing the racial disparities found in the epidemiology of HIV/AIDS in African American MSM. Our goal is to illuminate what it is that we now know and provide guidance for future directions for data collection.

In the CDC’s seven-city epidemiologic study of 3,492 young MSM aged 15 to 22 years old, African American MSM were almost six times more likely than their Whites counterparts to be infected (CDC, 2001). The prevalence rate of HIV infection for African American MSM was 14%, which is higher than all other groups of MSM regardless of ethnicity or race. A later phase of this same study conducted in six of the seven cities with older MSM (23 to 29 years of age) observed similar disparity in HIV infection rates. Of the 2,942 men surveyed, HIV prevalence was 7% among Whites, 14% among Latinos, and 32% among African Americans (CDC, 2001). In yet another CDC epidemiologic six-city study of men visiting sexually transmitted disease clinics for HIV testing, African American gay and bisexual men were two times more likely to be infected than White gay and bisexual men (CDC, 2002). An examination of blood samples in this study revealed that 11% of the infections in African Americans were recent (within the last 4 to 6 months). Comparable rates among Whites and Latinos were 6.5% and 7.7%, respectively.

Although findings of consistently higher rates of seroprevalence in African American MSM emerge from these studies, findings of differences in actual risk behaviors that can account for these higher HIV infection rates are not consistently found. Bingham et al. (2003) review this issue and find that there are studies finding higher, similar, and lower levels of unprotected anal sex by African American MSM as compared to White MSM (Easterbrook et al., 1993; Heckman, Kelly, Bogart, Kalichman, & Rompa, 1999; Lemp et al., 1994; Mays & Cochran, 1987, 1990b, 1993; Rotheram-Borus, Reid, & Rosario, 1994; Ruiz, Facer, & Sun, 1998). In the recent young men’s studies cited above (CDC 2001, 2002, 2003), rates of risky sexual behavior by African American MSM as compared to their White counterparts were not higher despite the higher rates of seroprevalence (Bingham, Harawa, Ford, & Gatson, 1999). Bingham et al. (2003) argue that this lack of convergence in findings should lead us to look beyond individual-level behavioral-risk data. As an example, they examined partner characteristics in a Los Angeles County Young MSM study and concluded that the young African American MSM who were HIV infected tended to have older and predominantly African American partners. Older men may be more likely to be HIV infected given their longer histories of risk exposure. African American men are also more likely to be HIV infected given the higher prevalence in this population. The risk in particular risk behaviors is greater when partners have a greater likelihood of infection. Prevention approaches for African American MSM would benefit from research that seeks understanding of the ways that relationships, as well as behaviors, of African American MSM affect their HIV risk. Indeed, Bingham et al. (2003) found that the sexual partner choices of young African American MSM were better predictors of the higher rates of seroprevalence than individual behavior histories.

Research focused on social and interpersonal factors is clearly needed. This type of research captures elements of behaviors that are a function of the individual in concert with others or their environment. As an example, an individual may be quite committed to using condoms, and this intention may be bolstered by use of condoms in past sexual interactions. Nevertheless, these intentions and typical behavioral scripts can be disrupted by powerful emotions, sexual attractions, or interpersonal power differentials (Gagnon & Simon, 1973). Men may falter, substituting an alternative, deferential script that allows one’s partner to steer the course of the sexual experience even to include behaviors that the individual might not normally perform.

Psychological states raised within the context of interpersonal interactions can include fears of abandonment or isolation, feelings of inadequacy, perceived challenges to masculinity, loneliness, love (Greene, 1998; Mays, Chatters, Cochran, & Mackness, 1998; Mays, Nardi, Cochran, & Taylor, 2000), fears of isolation, discrimination, threat, and violence that accompany being a minority within a minority status (Mays & Cochran, 2001). These states can influence whether an individual will engage in safer sex practices.

Some men perceive less freedom or permission to be open about themselves in the world, and this, too, is both interpersonal in nature and important for HIV prevention. In the CDC six-cities study described above, African Americans were least likely to disclose their sexual orientation (CDC, 2003). Similar studies of nondisclosure have found that such behaviors are based on fears of isolation, discrimination, and verbal and physical threats (Kennamer, Honnold, Bradford, & Hendricks, 2000; Stokes & Peterson, 1998). One in three of the nondisclosing young men in the six-city study above reported having female sex partners; of the African American nondisclosers, one in five was infected with HBV, and one in seven was infected with HIV (CDC, 2003). Many of these young men also indicated that the majority of persons in their community disapproved of homosexuality (CDC, 2003).

Building on the work of Bingham et al. (2003), researchers who focus on partner choices might seek to identify the cultural proscriptions and psychological states that occur in the relationship interactions between older and younger African American MSM. Explorations of the men’s sexual scripts (Gagnon & Simon, 1973) and how sexual scripts can be used or modified for risk reduction are needed. Questions in this interpersonal/social research approach could be as basic as the determination of what younger African American MSM seek in their relationships with older men, or whether power differentials based on culture and age result in risky dyadic behaviors (Adams & Kimmel, 1997; Cheng, 1999; Kurtz, 1999).

Perhaps now is the time to go beyond what we can learn from traditional public health surveillance and epidemiologic studies, with their focus on infection rates, risk behaviors, and attitudes of gay men aggregated by ethnic/racial and age strata. Instead, we might consider a focus on better understanding the social influences in interpersonal interactions of African American gay men, MSM, bisexuals, or any other variant of African American men who have sex with other men (e.g., brothers on the down low [Constantine-Simms, 2001; Denizet-Lewis, 2003; Hardy, 1997; Lee, 2001] or homo thugz [Hardy, 2001; Keyes, 2002; Trebay, 2000]). To date, much of the research on HIV risk and risk reduction on African American MSM has been epidemiologic in nature, with a focus on individual-level mediators of risk behaviors. Whereas at the individual level there have been several attempts at understanding the role of internal processes or mediators such as self-esteem (Peterson et al., 1996) or sexual/racial identity (Crawford, Allison, Zamboni, & Soto, 2002), a comprehensive focus on interpersonal factors (e.g., close and intimate relationships, neighborhood and community ties, sources of social support; Mays et al., 1998; Mays et al., 2000) or social constructs (e.g. definitions of Black MSM masculinities/sexuality, social inequalities, experiences of discrimination, and prejudice and Black MSM role expectations and norms; Cheng, 1999; Kurtz, 1999) has been slow to come. But this focus is the type of research domain that seems quite appropriate for exploration by mental health researchers (Peterson, 1998; Trickett, 2002). In general, over the course of the HIV epidemic, men have been studied from an essentialist perspective, as if the properties that we use to classify them for a particular study are stable, reliable, and valid (Kurtz, 1999). Although mainstream society tends to think of homosexuality as homogenous, it is more accurate perhaps to think of these diverse populations we are concerned with as representing homosexualities (Cheng, 1999). African American MSM consist of a diverse group not only in their socioeconomic status but also as a function of their ways of construing their relationships (Cheng, 1999). This translates into differences in the natures of their relationships, their environments, and their access to HIV-related prevention efforts. Research that can help identify how these differences foster higher risk environments, vulnerabilities, or reduced access to supportive mechanisms for HIV-related risk protection is greatly needed if we are to decrease the rate of new infections in African American MSM. It is the experiences that these men have in their interpersonal and social relationships that form the cornerstones for understanding HIV-related risk-taking and/or protective behaviors (CDC, 2003; Cochran & Mays, 1994; Mays & Cochran, 2001).

The act of living in American society as a Black man leaves little room to avoid an engagement with the inequalities that are attached to race and minority status (Hunter & Davis, 1994; Oliver, 1989). As is true with other societies, American society has a set of ideas and an ideology by which life is made understandable (Hunter & Davis, 1994; Oliver, 1984, 1989; Staples, 1982; Vander Zanden, 1986). American ideology directs individuals as to how to behave (as an American), how to define oneself (as an American), and how to make sense of experiences (in the American tradition) (Oliver, 1984, 1989; Vander Zanden, 1986). Ideology allows individuals to have a sense of the nature of their society, and it often serves as an intellectual foundation for group identity and solidarity (Oliver, 1984, 1989; Vander Zanden, 1986; Wildman, 1996). For Black men living in American society, what they are or should be and their definitions of manhood are measured against the status and privilege, both real and imagined, of White males (Boykin, 1996; Hunter & Davis, 1994). Much has been written about the marginalization of African American men in American society (Baldwin, 1963; Hunter & Davis, 1994; Oliver, 1984, 1989; Staples, 1982). For these men, making sense of being American and creating a sense of solidarity and group identity within the Black community and within the larger society is difficult (Wildman, 1996). Whether HIV risk taking is more closely associated with ethnic cultural values or gay cultural values is an open question, although there is evidence that the experiences that accompany the race, culture, and class status of African Americans may play a more prominent role in risk for HIV infection (O’Donnell et al., 2002). Marginalization arising from racism, poverty, and homophobia also add to the risk (Cochran & Mays, 1994; Diaz, 1998; Diaz et al., 2001; Marin, 2003; Stokes & Peterson, 1998; Zea et al., 2003).

Traditionally in America, manhood and masculinity are characterized by role attributes of competition, aggression, and success (Hunter & Davis, 1994; Spraggins, 1999; Wise, 2001) and are best summarized by the expectation that high-status men possess power, position, and privilege (Greene, 2003). In a parallel fashion, for some African American gay men, the perceived status, culture, and privilege of White gay men is also an important touchstone in defining what they expect for themselves (Boykin, 1996). Much also has been written in contemporary literature about the cool pose, the tough guy, the player, and now the homo thugz and brothers on the down low as if they are only stereotypes or affectations (Byrd & Guy-Sheftall, 2001; Majors & Billson, 1993; Smith, 2000). Yet, these roles manifest complex relationships among cultures, communities, and social inequalities. Power, position, and privilege shape both their roles and their behaviors (Greene, 2003). Being Black, male, and a man who has sex with other men in America is territory with few widely accepted role models, cultural proscriptions of behavior, or foundations of support (Boykin, 1996).

The field of HIV prevention developed some similar insights regarding heterosexual women in terms of how interpersonal relationships, social networks, culture, race/ethnicity, and social inequality could confer greater HIV-related risk to women as a function of their status as women and in their social interactions (Amaro, 1995; Mays & Cochran, 1988; Reid, 1992; Zierler & Krieger, 1997). Investigators identified the role of gender and sexual scripts, relationship power, violence, poverty, and economic and social inequalities in HIV risk for women (Amaro, 1995; Cochran & Mays, 1988; Pulerwitz, Amaro, De Jong, Gortmaker, & Rudd, 2002; Zierler & Krieger, 1997).

Although the study of interpersonal relationships of gay men is a relatively underdeveloped area in psychology (Peplau & Cochran, 1990), research has begun to examine how close and intimate relationships influence their sexual risk taking (Trussler, Perchal, & Barker, 2000). For example, in a recent study of gay men’s interpersonal lives, researchers were able to identify a number of culturally constructed HIV vulnerabilities. These included the challenges of personal development over gay men’s life course, the unspoken ground rules of gay relationships, and the relationship between gay culture, society, and local culture.

What research has not yet revealed is the cost of the choices that these men make in constructing lives that straddle the borders of African American community life and gay community life or the stresses and strains of trying to maintain integration of the two communities. There are a host of issues that are salient here. One is the question of the emotional toll that results from commitment to maintaining a presence only in the African American community or an integrated presence also in the White gay community. In a study conducted several years ago, we observed that African American lesbians who attempted to do this paid an emotional price (Mays, Cochran, & Rhue, 1993). Those African American lesbians who were committed to only having same race partners had a harder time because of the difficulty in finding these relationships as the African American lesbian community tended to be less openly gay or accessible through gay/lesbian networks and organizations. Relationships with White women were impacted by racism, discrimination, and marginalization. Women who tried to maintain ties with both communities found it to be difficult. Those women who had more contact with the White lesbian community had higher levels of depressive distress (Cochran & Mays, 1994).

Exploring the nature of the intimate and close relationships of African American gay men and MSM may also be an avenue to begin to address the growing numbers of studies finding high rates of depressive distress in this population (Cochran & Mays, 1994; Myers, Javanbakht, Martinez, & Obediah, 2003; Peterson, Folkman, & Bakeman, 1996). As far back as 1994, we reported that African American gay and bisexual men had higher rates of depressive distress than those found in the literature for White gay men, heterosexual African American men, or Blacks in general (Cochran & Mays, 1994). Peterson et al. (1996) found that psychosocial resources and, most significantly, social supports were important in moderating the effects of a depressive mood in African American gay men. We know from a number of studies that positive interpersonal and intimate relationships are important to maintaining good mental health and can serve as a protective factor in the development of depression (Brown & Harris, 1978; Cowen, 1973). Therefore, we should not underestimate the importance that interventions designed to enhance and strengthen the interpersonal, intimate, and social relationships may play in reducing HIV-related risk behaviors.

In moving from an individual focus to a social/interpersonal focus of HIV prevention, we can enhance communities through bolstering economic development, improving work opportunities, developing skills, improving access to affordable education, and creating greater tolerance for diversity (Peterson, 1998; Trickett, 2002). These community-level enhancements, if they are to be effective, should not be targeted merely at the men themselves but also at the development of community-based infrastructures that can deliver the needed resources.

Sometimes we even try to fit people into our finely articulated categories even though many African American gay men, MSM, or brothers on the down low cannot connect with or recognize themselves in those boxes. Here, prevention efforts tend to fail. For traditional public health disease eradication to be successful, we need to find ways to meet our needs for categorization while interfacing with individuals in ways that resonate with their own experiences.

A reality for many African American men who are gay, bisexual, MSM, or on the down low is their experience of a dynamic, evolving, and interactive nature of their race, their maleness, their sexuality, their social class, and other intertwining social statuses. This makes categorization difficult. Yet, in our best attempts at prevention, we need informed categories that can provide a way to outreach, organize, and evaluate activities that engage and address the interactive nature of their complex identities. There is a race-based consciousness about maleness; it is a Black maleness. It may be a Black maleness that is associated with Southern culture, an urban flavor, or a culture of poverty or middle-class experiences. No one model of prevention will be sufficient to address the entire community of African American men who have sex with men. Unfortunately, HIV prevention of the last 2 decades has treated African American gay men as gay men who are Black or gay men in the Black community, an additive model that negates the complex experiences of African American gay and bisexual men, MSM, and down low men.

The perceived contradictions of Black men’s identities in American society create difficulties for researchers because our work is facilitated by the use of simple, mutually exclusive categories or labels. In an anonymous piece written by a Jamaican gay man, he says, if the Black church were to remove every homosexual from its ranks there would be no more choir, half the pastors would vanish, and some of the sisters would not be getting it as regularly as they currently do. This is a model of male homosexuality that inherently includes heterosexual sexual behavior. This model in not prominent in the White gay community. Understanding that the African American MSM expressions of homosexuality may be different from the essentialist binary identity models of the White gay community will help us to generate more useful categorizations for prevention work with African American MSM.

Perceived contradictions seem to lie at the heart of homo thugz experience. This is a population that is seldom mentioned in published prevention efforts, but those who work in the African American community are well aware of their existence. As described by Trebay (2000), these are young African American men who sport do-rags, Fubu jackets, platinum and gold necklaces, Timberlands or neonerd Wallabies, sideway knotted bandannas, and army fatigue trousers that hang off the hips. These young men are easily mistaken for thugs or gangstas, hence the term homo thugz. Scholar Cheryl Keyes (2002), in her book on rap and hip-hop music, discusses the relationship among gay men/MSM, HIV, and the rap/hip-hop communities, giving us insight to the longevity that this subgroup has had within the hip-hop community. Novelist James Earl Hardy (1997, 2001) also writes about the phenomenon of homo thugz, defying the perception that they just recently emerged on the scene. The rap and hip-hop world of the homo thugz, with its crews and posses, has been characterized as appealing to a sense of male-with-male attraction (Thomas, 1999; Trebay, 2000). The contradiction for some is the mistaken expectation that homosexuality is incompatible with the gangsta/thugz experience. In reality, the portrayal is yet another variation on hegemonic masculinity; it is young Black men expressing their masculinity through a specific portrayal of masculinity in the gangster image.