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A community-based participatory research partnership explored HIV risk and potentially effective intervention characteristics to reduce exposure and transmission among immigrant Latino men who have sex with men living in the rural south-eastern USA States. Twenty-one participants enrolled and completed a total of 62 ethnographic in-depth interviews. Mean age was 31 (range 18–48) years, and English-language proficiency was limited; 18 participants were from Mexico. Four participants reported having sex with men and women during the past three months; two participants self-identified as male-to-female transgender. Qualitative themes that emerged included a lack of accurate information about HIV and prevention; the influence of social-political contexts to sexual risk; and barriers to healthcare services. We also identified eight characteristics of potentially effective interventions for HIV prevention. Our findings suggest that socio-political contexts must be additional targets of change to reduce and eliminate HIV health disparities experienced by immigrant Latino men who have sex with men.
Subpopulation estimates highlight the severity of the HIV epidemic among men who have sex with men (MSM) of all races and ethnicities. In 2006, 72% of new infections among males occurred from male-to-male sexual contact, including 81% of new infections among whites, 63% among blacks, and 72% among Latinos. In the USA, Latino MSM have twice the rate of HIV infection of white MSM (aCenters for Disease Control and Prevention [CDC] 2008a).
Factors that have been identified as contributing to sexual risk among Latino MSM are numerous and include a lack of understanding of HIV transmission and prevention and of healthcare services (Jarama et al. 2005); discomfort in discussing sex and negotiating condom use (Carrier 1995; Ramirez-Valles et al. 2008); beliefs that condoms sacrifice sensitivity and sexual spontaneity (Diaz 1998; Jarama et al. 2005); and negative peer norms (or perceived peer norms) toward condom use (Ramirez-Valles et al. 2008; Waldo et al. 2000).
Although some Latinos may shy away from discussing sex and sexuality openly with others, including healthcare providers, their orientation or same-sex behaviour may further preclude discussions about sex (Jarama et al. 2005; Ramirez-Valles et al. 2008). Moreover, taking risks may seem to be a way to overcome perceived negative external assumptions and internal feelings about one’s orientation and masculinity (Sandfort, Melendez, and Diaz 2007; Nakamura and Zea 2010) or result from other psychological distress (Chae and Ayala 2009). Higher ethnic identification also has been associated with unprotected sex among immigrant Latino MSM (Warren et al. 2008); however, the interplay between changing sexual values and practices associated with immigration in relationship to sexual risk remains poorly understood, particularly when considering sexual orientation and same sex behaviours (Lescano et al. 2009; Diaz and Ayala 2001). Further, at the systems level, distrust of providers, limited clinic hours, lack of bilingual and bicultural resources, and insufficient public transportation have been identified as reducing access to prevention resources (e.g., condoms, counselling, testing, and treatment) among immigrant Latino MSM (Erausquin et al. 2009).
Despite what is known about HIV and risk behaviours among Latino MSM, studies have focused on urban Latinos who are more “out” about their sexual orientation (Arreola, Neilands, and Diaz 2009; Fernandez et al. 2007; Fernandez et al. 2005; Wilson et al. 2008; Carballo-Dieguez et al. 2005; Ramirez-Valles et al. 2005; Sandfort, Melendez, and Diaz 2007; Flores et al. 2009; Zea et al. 2009; Ramirez-Valles et al. 2010). Less is known about HIV risk among immigrant Latino MSM living in rural communities in the south-eastern USA, like North Carolina (NC), which are disproportionately affected by the epidemic (CDC 2008b). Latinos immigrating to the south-eastern USA reflect the current trend in Latino immigration; they tend to be from southern Mexico and Central America, have lower educational attainment, and have arrived more recently compared to those who traditionally immigrated to Arizona, California, New York, and Texas (Southern State Directors Work Group 2008; Kasarda and Johnson 2006; Rhodes, Hergenrather, Bloom et al. 2009). These immigrants are coming to communities that lack histories of immigration and developed infrastructures to meet their needs (Hayes-Bautista 2004; Rhodes, Hergenrather, Bloom et al. 2009).
Furthermore, effective HIV prevention interventions for Latino MSM are urgently needed. Although interventions exist that provide insight into sound HIV prevention interventions for Latino MSM, none has been evaluated and found effective at reducing sexual risk among Latino MSM living in the USA (Alvarez et al., 2009; Herbst et al. 2007; Johnson et al. 2008).
This study was designed to qualitatively explore HIV risk among immigrant Latino MSM and to identify characteristics of potentially effective interventions for Latino MSM. To enhance authenticity of study methods and trustworthiness of findings, a community-university research partnership conducted this study applying principles of community-based participatory research.
This study was conceived and guided by a community-based participatory research partnership comprised of representatives from public health departments, AIDS service organizations (ASOs), universities, and the local Latino community (including immigrant Latino gay men) and Latino-serving community-based organizations (CBOs), all of whom have been working together for > 8 years. This partnership is committed to community-based participatory research because blending lived experiences with sound science has potential to develop deeper understandings of phenomena, and interventions are more likely to be more relevant, and thus, successful (Cashman et al. 2008).
Ethnographic in-depth interviews were conducted with immigrant Latino MSM living in rural NC. Each participant was interviewed three times within three weeks because iterative interviews (1) allow rapport and trust building between the interviewer and participant, resulting in greater disclosure; (2) may be more accurate than single interviews because of the opportunities to ask follow-up questions and get feedback on previously obtained information; and (3) offer opportunities for recall and detail (Lee 1993). The interviews were designed to gather narrative context to facilitate understanding of phenomena (e.g., sexual risk), gain more insight into the meaning of these phenomena (Rossman and Rallis 2003), and explore how phenomena can be transformed into intervention approaches and/or activities (Rhodes et al. 2006; Rhodes, Hergenrather et al. 2007).
An Interview Guide was developed, reviewed, and revised by the CBPR partnership. The guide was created in English and Spanish given that partnership members had varying levels of English and Spanish proficiency; however, the guide was finalised in Spanish using a committee approach to translation (Behling and Law 2000). A reconciled version was created and reviewed by an adjudicator before final approval by the community-based participatory research partnership. The guide, briefly outlined in Table 1, was crafted with careful consideration to wording, sequence, and content in Spanish.
All interviews were audio-taped and conducted in Spanish by one of two trained native Spanish speakers; both were men and one was gay. Differences between an interviewer and interviewee can uncover insights that are often omitted as common knowledge if an interviewer and interviewee share the same perspective (e.g., sexual orientation). The strength of this method is that the interviewee offers further detail to a “naïve” observer. Similarities between an interviewer and interviewee can increase the level of comfort that some interviewees may feel and promote more detailed disclosure. By having one gay insider and one outsider, the strengths of each were maximised and the weaknesses minimised (assumed knowledge in the former and discomfort in the latter; Lett 1987; Thomas 1993; Seal, Bloom, and Somlai 2000).
Both interviewers were originally from Mexico. A gay male, Spanish-language proficient notetaker was present during interviews. Interviews ranged 30–90 minutes. Each participant received $15.00 for the first, $30.00 for the second, and $50.00 for the third interview.
Inclusion criteria included self-identifying as Hispanic or Latino; being ≥ 18 years of age; reporting MSM behaviour since age ≥ 18; having been born outside the USA; and providing informed consent. Using purposive snowball sampling, partnership members, who comprised lay community members, suggested eight Latino MSM (two from each county within a four-county catchment area) for participation. Also, at least one was HIV positive and one self-identified as male-to-female transgender. These MSM were approached by an interviewer, screened, provided consent, and interviewed. At the end of the first interview, these participants identified Latino MSM, who met the inclusion criteria, within their social networks whom they could refer to the study. They provided potential participants the study’s toll-free telephone number or brought the potential participant to their second or third interview to meet the interviewer and schedule screening.
After each interview, the interviewer and notetaker listened to the audio-tape and took general notes. This prepared them for the next interview by identifying points for clarification, and revealing areas for further probing, and emerging content areas for exploration. After each audio-recorded interview was reviewed, it was transcribed verbatim in Spanish and English by a professional bilingual and bicultural transcriptionist in Miami who was born in the USA and raised in Guatemala and Mexico. Transcripts were verified by reviewing each while listening to the audio-taped interview. Discrepancies were noted and corrected.
Transcripts were analysed to identify themes (Miles and Huberman 1994) through the coding of text using an inductive approach to qualitative data analysis: grounded theory (Glaser and Strauss 1967). Rather than beginning the enquiry process with a preconception of what was occurring, the analytic approach focused on understanding a wide array of experiences and building understanding grounded in real-world patterns. The goal of the analysis was to identify common themes through the qualitative analytic technique of coding text. Five coders (comprised of community-based participatory research partnership members) separately read and reread each transcript to identify potential codes. Research suggests that simultaneous, collaborative analysis of qualitative data by speakers of different languages (in this case both native Spanish and English speakers) and with iterative discussion, reflection, and negotiation of codes and themes may yield more accurate findings (Shibusawa and Lukens 2004). Coders created a common coding system and data dictionary, and then separately assigned agreed-upon codes to relevant text. The first author used Nvivo (QSR International, second edition). Similar codes were grouped into concepts. The coders then came together to compare and contrast broad content categories and to revise and develop themes, which were presented to the CBPR partnership for refinement and interpretation to verify theme validity, including rigor, credibility, trustworthiness, and believability. This process was designed to explore the breadth of possible experiences, not quantify participant experiences.
Twenty-one participants were interviewed, for a total of 62 interviews. One participant chose to combine the second and third interviews. Select demographic characteristics are presented in Table 2. The average age of participants was 30 years old. Over 85% reported Mexico as their country of origin. Educational level was low, and use of spoken and written English was minimal. The majority of participants reported their sexual orientation as “gay” or “homosexual;” two self-identified as “bisexual,” and one as “heterosexual.” Four participants reported sex with both women and men during the past three months. Three participants reported being HIV positive; and two self-identified as male-to-female transgender.
The five primary themes that emerged as influencing the sexual health of immigrant Latino MSM are presented in Table 3. Potentially effective intervention characteristics to reduce HIV exposure and transmission are presented in Table 4.
First, participants lacked accurate knowledge about HIV transmission, prevention, and treatment. Amilcar, 32 years old and originally from Guatemala, reported,
“You can tell me you can get AIDS through sex, but I am going to have sex so that doesn’t help me. How do you get it through sex exactly?”
Further illustrating this point, Luis, 23 years old and originally from Mexico, asserted, “You can get AIDS from someone coughing on you.”
Participants also did not know that free condoms were available locally, and as Mario, 30 years old and originally from Mexico, reported, “At the pharmacy they are too expensive.” Arturo, 33 years old and originally from Mexico, reported that he had reused condoms, “washing” them between sexual encounters.
Participants also indicated that some local Latinos believe that medicines available in tiendas (Latino grocers) or from individuals in the community can cure HIV. Carlos, 22 years old and originally from Mexico, noted,
“I have a friend who went to get treatment from a man near here. He thought he might have AIDS so he bought treatment from [a man near here].”
Participants reported that for Latino men manhood can be affirmed through sex. Participants reported that Latino men, particularly younger and unmarried men, are pressured to continually prove their masculinity through having multiple partners and engaging in other risk behaviours, such as heavy episodic drinking.
Participants added that this “need” to prove one’s masculinity may be heightened because MSM are not considered to be “real” men; their self-image and self-esteem suffer, which may contribute to depression and subsequent risk behaviours. Cristian, 30 years old and originally from Mexico, reported,
“I have to cope with being perceived as less than everyone else. I coped by drinking alcohol. It can make you depressed because society thinks less of you because you have sex with men.”
Given the need for men to prove their manhood, pressure not to use condoms among MSM was identified by participants as particularly strong. Daniel, 28 years old and originally from Mexico, noted,
“I already am not a man in my culture’s eyes because I am gay, so I might not use condoms to prove who I am as a man.”
Analysis also suggested that for some Latino MSM using a condom requires recognising and admitting one’s same-sex behaviour and this recognition may reduce one’s sense of masculinity.
Many participants reported a history of being physically victimised by others for identifying as gay or engaging in same-sex behaviour. They reported feeling that being victimised reinforced their negative self-image, which some of them felt led to further risk behaviour. Alejandro, 28 years old and originally from Mexico, explained,
“I have been beaten up for being gay. Whom can you turn to when you are hurt for being yourself? You need love. I used to do anything to be with another man because I felt alone, and I certainly did not worry about AIDS.”
Participants reported being lonely because they cannot be honest about their sexual orientation, feel disconnected from others, and/or lack a sense of community with other MSM. Cristian, who reported having had sex with men and women, also shared,
“I get lonely. I do not have anyone I can turn to. So I know that influences me to do things that I should not do.”
Participants noted that few “healthy” options for social networking exist in rural communities. They reported meeting men in public places such as adult bookstores, public parks and lakes, and heterosexually oriented Latino bars and nightclubs. Participants noted these were common venues for meeting men who may not identify as gay but have sex with other men, either regularly or occasionally. Jesús, 41 years old and originally from El Salvador, noted,
“You can go into these places in rural areas. The type of place with hundreds, maybe thousands, of Latinos from the area. You can find men who sometimes have sex with other men. They may prefer women, but they do what they have to do!”
Karina, a 28-year-old male-to-female transgender participant originally from Mexico, noted that she goes to a non-gay Latino nightclub in rural NC. She explained,
“I get a man for the night, a man who usually has sex with women. He might even be married, and his wife is home [in his country of origin]. He has sex with me. That is where I meet men.”
Participants with established gay social networks described how they found sexual partners through these networks. They reported hosting and attending house parties that include men with varying levels of openness about their sexual orientation. Alejando shared, “Some of us might get together to socialise, you know, as friends, but people pair up too.” Almicar noted,
“I attended a party where we hired a man to come over and have sex with some of us at the party. I do not know if my friends used condoms but I do not always use condoms when the man says he is not gay.”
Although not all participants identified or reported feeling a sense of a community, some participants noted after arriving in the USA they discovered sexual freedom. Raul, 39 years old, commented, “You arrive and have hidden who you are [in Mexico], but here you can have sex with all types of people and often.” Some participants also described feeling objectified by others as being “hot blooded,” “exotic,” and “super sexual.” Francisco, 36years old and originally from Mexico, noted, “For some men, it is about being desired; that is what matters.” He added that the attention he receives from other MSM is appealing, but can yield negative outcomes such as multiple partners and inconsistent condom use.
Participants also shared that among some groups of men, there is competition for sex partners. As Gabriel, 41 years old and originally from Mexico, shared, “I have seen it, where men are competing for partners and having sex with one man after another, and bragging about it.”
Finally, some participants noted that using condoms early in a relationship may make sense, but sex can be about trusting one’s partner. As a participant reported,
“How can people think that I am supposed to use a condom when loving someone means being close, without a condom between you?”
Participants felt that discrimination has profound emotional and behavioural effects, including depression and inconsistent condom use. As Carlos noted,
“When I feel bad about myself, when we are afraid because people do not trust us, see me as illegal, that is when I am not going to be thinking about protecting myself.”
Some public health department staff also were perceived as discriminating against Latino MSM based on ethnicity/race, perceived documentation status, economic status, and/or MSM behavior. However, it was not clear to participants what the cause of the discrimination was (e.g., race/ethnicity, economic status, or MSM behaviour).
Moreover, participants reported high levels of distrust of the US healthcare system and providers, and many did not believe that their health information would be kept confidential. Participants reported believing that whether they were documented or not their records could be used against them.
We also identified seven primary barriers that prevent immigrant Latino MSM from accessing health care and related services. First, participants lacked knowledge about available services and eligibility. Participants did not know where they could go for HIV testing; whether they were eligible for testing services; whether they had to be “documented,” meaning having legal permission to be in the US, to access services; and what the processes of testing included.
Those who had used services felt that agencies lacked expertise in the health of MSM. They were hesitant to talk openly with providers, in part because they did not perceive providers to be comfortable with their sexual orientation and behaviour. Some participants also reported that interpreters held negative beliefs about same-sex behaviour. Participants also noted that agencies lack bilingual and bicultural expertise.
Other barriers identified included lack of health insurance, fear of deportation if they are found to be HIV positive, sense of fatalism, and denial of risk and potential infection. As Cristian noted,
“I cannot have AIDS. It would make my life even more difficult. Life is not easy in the US, and we tell ourselves that we cannot have it.”
Because the research partnership was committed to moving towards action, the Interview Guide explored potential intervention approaches. Eight characteristics that should be considered for inclusion in HIV prevention interventions targeting immigrant Latino MSM (Table 4) were identified.
First, participants asserted that HIV prevention interventions should build on existing informal social networks. Participants reported that as they rely on one another for support to find a job or a car, they could help one another learn about HIV, prevention, and accessing care. Participants also indicated that identifying those men who are dedicated, have the potential to be trained to be comfortable talking and offering sound advice about sensitive issues and remain discreet, come into contact with many men, have some level of literacy, are trustworthy, and are helpful to others may be appropriate to train to serve as community health workers, peer educators, or lay health advisors.
Other intervention characteristics that emerged included filling knowledge gaps and correcting misconceptions; offering safe spaces for supportive dialogue about living with HIV and the meanings and expressions of love and intimacy between men; and skills building around using condoms, negotiating safer sex, and communicating with providers.
Participants reported feeling isolated from gay communities and identified the need for positive social outlets in rural communities. Participants also reported the need for practical guidance on resources and how to access them, including HIV prevention, testing, care, and treatment.
Participants emphasised the importance of understanding how “being a man” affects behaviour. As Mario suggested,
“I know that I feel the pressure [to take risks], but understanding the bad side of what my culture tells me, and why, and what I can do about it would help me.”
Participants reported needing interventions to help them reconcile their roles as men and their same-sex behaviour.
Both transgender participants wanted interventions that help them but also target their peers. Riki, a 22-year-old male-to-female transgender participant from Mexico, shared,
“I face a lot of challenges and want my friends to understand and help me, not run from me.”
Finally, participants acknowledged that interventions must include advocacy training. As Jesus said, “Society needs to change, and I need to be part of that fight.”
Through the qualitative analysis of transcript data using grounded theory, we identified five main themes related to HIV risk among immigrant Latino MSM. First, participants clearly lacked basic and accurate information about HIV and prevention. Although knowledge does not imply behaviour change, having a context in which to place prevention messages is required for those messages to be understood. The finding that these participants reported low knowledge of, and high misconceptions about, HIV is similar to other findings among heterosexual Latinos immigrating to the south-eastern USA from similar communities in Mexico and Central America (Rhodes, Hergenrather, Bloom et al. 2009). Culturally congruent programming is needed to reduce the risk of HIV transmission among Latinos, particularly among Latinos who are immigrating from communities that do not have HIV prevention activities being currently implemented (Bastos et al. 2008; Hernandez-Rosete et al. 2008).
Second, the social context of the Latino community affects Latino MSM who feel the need to hide their orientation and behaviours to maintain relationships with family, who may label those who engage in same-sex behaviour as not “real” men. Because immigrant Latinos living in rural communities tend to have limited resources and must rely on family (most often fathers, brothers, male cousins, and uncles), Latino MSM may feel intense pressure to hide their orientation to maintain their limited social support networks in the USA.
The social context also fosters objectification of Latino men as hypersexual and promotes competition for increased numbers of partners among some MSM. Lacking other social support resources, some immigrant Latino MSM engage in sex to feel human connection, approval, and affirmation with another. Condom use was found to be less of a priority in this context.
Findings also indicated that unprotected sex may be linked with intimacy, trust, and commitment. A strategy to positively affect the risk of Latino MSM may be to focus on knowing one’s HIV serostatus within the context of one’s relationship through the promotion of counselling and testing within the relationship. Messages that focus on consistent condom use and do not include considerations related to intimacy may miss an opportunity to reduce risk and affirm same-sex orientation.
Fourth, two ways in which the political context may influence risk were identified. First, Latino MSM may feel discriminated against for being Latino, immigrants, and gay. They also may not trust the US healthcare system, providers, and the confidentiality of medical records. Policy interventions may include increasing community outreach to build trust and sensitising healthcare staff and providers in, and overcoming, their biases.
Finally, this study identified barriers that limited access and utilisation of health care and related services among immigrant Latino MSM. Barriers included lack of bilingual and bicultural services for Latinos and limited agency expertise in MSM health. NC, like many states in the south-eastern USA, is experiencing unprecedented growth of Latino communities and currently lacks the infrastructure, and the resources (Rhodes, Hergenrather, Griffith et al. 2009), to make the necessary system changes (e.g., sufficient staff training and after-hour and offsite clinics). The current local and national debates surrounding Latino immigration are not conducive to prioritisation and reallocation of resources. In fact, political sentiment in rural communities in the south-eastern USA are strongly anti-immigration (Rhodes, Hergenrather, Griffith et al. 2009). Such sentiment is likely to continue to contribute to limited access to needed prevention education and resources among immigrant Latinos.
Participants indicated the need for creative intervention strategies to reach immigrant Latino MSM to reduce their risk for HIV. Participants suggested that traditional venues and delivery channels used for other vulnerable populations and communities may not reach immigrant Latino MSM who are most at risk for, and carry disproportionate burdens of, HIV. The Internet has been identified as invaluable for social and sexual networking among MSM, especially in rural areas in the USA (Bowen, Horvath, and Williams 2007; Rhodes 2004), but findings suggest that immigrant Latino MSM in these communities are not using the Internet as regularly as other MSM communities. Although providing access to the Internet as a structural intervention may help some Latinos develop and maintain social support networks, literacy levels in both Spanish and English were low in this sample.
Participants, however, did suggest that HIV prevention interventions should be built on existing informal social networks and be natural helper-based. Latino MSM may benefit from interventions designed to enhance sexual health through identifying and training trusted and willing community members with large social networks to be community health works or lay health assistants. These workers and assistants could serve as sources of HIV information, prevention, and referral; opinion leaders to reframe negative and bolster positive socio-cultural expectations; and community advocates to work with local organisations to better address the needs of Latino MSM. Although the literature around natural helper approaches to affect the health outcomes of immigrant Latino communities in the USA is limited (Rhodes, Foley et al. 2007; CDC 2009; Elder et al. 2009), there is promise in the approach. Natural helping also may build community capacity to successfully address other community concerns.
Regardless of the intervention approach, these findings indicate that interventions must fill knowledge gaps and correct misconceptions about HIV and its prevention; offer guidance on accessing available resources, communicating with providers, and successful approaches to negotiating safer sex with partners; address the challenges faced with being an immigrant Latino MSM and the various meanings sex plays among partners.
This study used purposive snowball sampling. Thus, the findings may not be generalisable to all rural immigrant Latino MSM. Furthermore, the initial eight Latino MSM who chose to participate in these interviews may differ from Latino MSM who were not connected to community members involved with the CBPR partnership. The 13 participants who were approached to participate by one of the initial participants also may differ from other samples of Latino MSM who may have more distal and/or less trusting relationships with initial participants. However, for the purposes of formative research, which followed the CBPR approach, these findings can inform future efforts to explore risk among Latino MSM and the design of an HIV intervention with these men or men like them. Moreover, immigrant Latino MSM in rural communities are particularly difficult to identify and recruit given stigma related to being an immigrant (whether documented or not) and engaging in same-sex sexual behaviour. Furthermore, given the small sample size, the impacts of age, country of origin, or level of openness about participant’s sexual orientation could not be explored. Clearly, these distinctions should be explored in future research.
As the HIV epidemic has evolved, prevention efforts must evolve. With increasing disproportionate rates of HIV, a need exists to explore, understand, and intervene upon factors associated with exposure and transmission among Latino communities. Nowhere is this more urgent than in the south-eastern USA, which is experiencing the most rapid growth of Latino residents and bears a disproportionate burden of HIV and AIDS. This study provides preliminary insight into the salient beliefs of a group of immigrant Latino MSM toward sexual health; more research is warranted to further identify and explore the factors affecting their risk.
The study identified the potentially effective use of a male-centred approach to HIV prevention, using natural helpers within informal social networks to provide prevention education and referral and skills building. Although intervention strategies building on social networks among men remain uncommon, such an approach must be explored and empirically tested, especially given findings from prospective studies that suggested that social support may have greater health effects for men than women (Shumaker and Hill 1991).
Exploring and identifying effective approaches for disease prevention, including HIV prevention, is especially important because the health of men of colour has been traditionally neglected in the USA. As a result, they constitute a significant part of the population most in need of health promotion and disease prevention.
Human subject oversight was provided by the Institutional Review Board of Wake Forest University Health Sciences. This study was supported by the United States National Institute of Child Health and Human Development (NICHD) grant # R21HD049282 (to Scott Rhodes). Special thanks to the participants of this study. We also thank Karen Klein (Research Support Core, WFUHS), for her editorial contributions to this manuscript.