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.