Power, social support and HIV-related service use: the roles of community and homelessness

Retrenchment of the Welfare State is often premised on the assumption that social support or community caring capacity can substitute for formal health and social services. We assert that the nature of this relationship depends on the nature of one's community. This paper examines social support and service use among gay and non-gay, homeless and domiciled people with HIV infection. In general, membership in the gay community is associated with greater use of formal services. Part of this relationship is explained, for homeless people, by one's level of access to social support. This suggests that, for this group, access to formal services can be improved by improving access to social support. Much of the relationship between membership in the gay community and use of services is not explained by social support and may be due to other factors such as the power of the gay community to create services for itself.     

'We never expected this to happen': narratives of ageing with HIV among gay men living in London, UK

The proportion of HIV-positive people over the age of 50 is rapidly increasing in the UK. This reflects the use of antiretroviral therapies and the transformation of HIV from life-threatening disease to chronic treatable illness. In this study a biographical narrative approach was used to explore the lived experience of ageing in 10 HIV-positive gay men aged between 50 and 78. While some participants regarded ageing as an opportunity to continue progressing towards valued life goals, others were more ambivalent about their future prospects. The findings suggest that these differences were particularly influenced by an individual's biographic relationship to the history of the HIV epidemic rather than chronological age. Those with long histories of involvement with HIV were more likely to be disadvantaged by careers interrupted by illness, to be dependent on state benefits and to have social networks damaged by multiple AIDS-related bereavements. The research identifies a cohort of older gay men likely to require additional support in adapting to the challenge of growing older with HIV. The article also explores the construction of moral identities in relation to discourses of 'successful ageing' and the possibility of building supportive communities that are sensitive to the needs of older gay men.     

Sex and the Internet: gay men, risk reduction and serostatus

Access to the Internet has increased dramatically over the past decade as has its use for meeting sexual partners (e-dating), particularly among gay men. Between June 2002 and January 2004, 128 gay/bisexual men living in London were interviewed one-to-one about their experience of e-dating, sexual risk and HIV prevention. The men were recruited both online (through the Internet) and offline (in clinics and the community); 32 men were HIV-positive, 59 HIV-negative, while 13 had never had an HIV test. A key finding was that both identity as well as anonymity are vital to e-dating. Through a process of online filtering and sero-sorting, HIV-positive men are able to meet other positive men for anal sex without condoms. While this does not present a risk of HIV transmission to an uninfected person it does have implications for the potential transmission of other STIs such as syphilis and LGV. Through e-dating, HIV-positive gay men can also avoid abuse, discrimination and sexual rejection. Our findings do not support the suggestion that the attraction of e-dating is that it affords absolute anonymity. We found that the gradual expression of identity is vital for e-dating among gay men. Internet-based HIV prevention campaigns need to take account of the different ways in which gay reflexively manage aspects of their identity online.     

hivstigma.com, an innovative web-supported stigma reduction intervention for gay and bisexual men

An intervention to address stigma directed toward HIV-positive men and to enhance the sexual health of gay and bisexual men was developed through a community-based process involving HIV prevention workers, public health, government and researchers. The intervention aimed to diminish stigma, create greater support for HIV-positive men, make disclosure safer and easier, discourage reliance on disclosure to prevent transmission and encourage testing. The question, 'If you were rejected every time you disclosed, would you?' was widely disseminated in the gay community and supported by the Web site, hivstigma.com, to encourage participation in blog-based discussions. Eight bloggers moderated lively discussions over 5 months. There were 20 844 unique visitors to the site averaging more than 5 min each; 4384 visitors returned more than 10 times. About 1,942 men answered a pre-test survey on a popular gay dating site and 1791, a post-test evaluation. Results show a statistically significant shift among those aware of the intervention toward reduced stigma-related attitudes and behaviors and toward recognition that HIV-positive gay men face stigma in the gay community and that stigma reduces the likelihood of HIV disclosure.     

The Viagra AdVenture: Masculinity,media, and the performance of sexual health

In Canada, there is a paucity of research aimed at understanding Black gay men and the antecedents to risk factors for HIV. This study is an attempt to move beyond risk factor analysis and explore the role of sexual and ethnic communities in the lives of these men. The study utilized a community-based research and critical race theory approach. Semi-structured interviews were conducted with eight key informants to augment our understanding of Black gay men and to facilitate recruitment of participants. In-depth interviews were done with 24 Black gay men. Our data showed that the construction of community for Black gay men is challenged by their social and cultural environment. However, these men use their resilience to navigate gay social networks. Black gay men expressed a sense of abjuration from both gay and Black communities because of homophobia and racism. It is essential for health and social programmers to understand how Black gay men interact with Black and gay communities and the complexities of their interactions in creating outreach educational, preventive and support services.     

Differences Between HIV-Positive and HIV-Negative African American Men Who Have Sex with Men in Two Major U.S. Metropolitan Areas

Alarmingly high HIV prevalence rates among African American men who have sex with men (AAMSM) require the development of effective prevention interventions. In this study of AAMSM conducted in two cities, we explored similarities and differences between HIV-positive and HIV-negative AAMSM on sociodemographic variables, HIV-related risk behaviors, and attitudinal constructs. Differences emerged in several major life areas: (1) poverty, employment, and use of mental health services, (2) sexual risk behaviors, and (3) self-identification with gay identity and culture. With regard to sociodemographic indicators, HIV-positive AAMSM were doing worse than HIV-negative AAMSM in that they were more likely to be disabled, to be living below the poverty level, and accessing mental health services. With regard to risk behaviors and partner characteristics, HIV-positive AAMSM were acting more responsibly than their HIV-negative counterparts, as they were more likely to have used a condom the last time they had sex. In addition, when compared to their HIV-negative counterparts, HIV-positive AAMSM were more likely to have either no casual partners at all or main or casual partners who were HIV-positive, thus preventing new HIV transmission by partnering with other HIV-positive men. Attitudinally, HIV-positive men were more accepting of their sexual attractions to men and were more likely to identify as gay than their HIV-negative peers. Although causality cannot be determined, the findings of this study can be used to strengthen HIV prevention efforts by improving the selection of targeted behaviors and prevention messages for HIV-positive and HIV-negative AAMSM.     

A pilot study of immigration status, homosexual self-acceptance, social support, and HIV reduction in high risk Asian and Pacific Islander men

This article reports the results of a cross-sectional study that was conducted to describe the sexual behavior and HIV risk reduction behaviors of homosexual and bisexual Asian and Pacific Islander men and to relate immigration status, self-acceptance as a homosexual, and levels of social support to the adoption of safe sexual behaviors in this population. Thirty-one gay and bisexual Asian and Pacific Islander men in San Diego County, California, participated. Generally high levels of knowledge about HIV and transmission risks as well as self-acceptance and social support were found. While most (84%) reported some attempts to increase condom use in the previous 6 months, 42% reported engaging in unprotected intercourse during that same time period. An inverse relationship between self-acceptance and utilization of risk reduction strategies was found. No association was found between immigration status or self-reported HIV status and level of HIV knowledge, level of HIV risk behavior, or level of HIV risk reduction efforts. The findings are discussed within the context of other social network studies and HIV prevention programs for gay and bisexual Asian and Pacific Islander men.     

The MaBwana Black men's study: community and belonging in the lives of African, Caribbean and other Black gay men in Toronto

In Canada, there is a paucity of research aimed at understanding Black gay men and the antecedents to risk factors for HIV. This study is an attempt to move beyond risk factor analysis and explore the role of sexual and ethnic communities in the lives of these men. The study utilized a community-based research and critical race theory approach. Semi-structured interviews were conducted with eight key informants to augment our understanding of Black gay men and to facilitate recruitment of participants. In-depth interviews were done with 24 Black gay men. Our data showed that the construction of community for Black gay men is challenged by their social and cultural environment. However, these men use their resilience to navigate gay social networks. Black gay men expressed a sense of abjuration from both gay and Black communities because of homophobia and racism. It is essential for health and social programmers to understand how Black gay men interact with Black and gay communities and the complexities of their interactions in creating outreach educational, preventive and support services.     

Science,technology, power and sex: PrEP and HIV-positive gay men in Paris

Abstract

The pre-exposure prophylaxis (PrEP) drug Truvada is a new HIV prevention technology that is predominantly promoted as relevant to HIV-negative gay men. This paper explores what PrEP represents for HIV-positive gay men living in Paris, based upon data collected through interviews and ethnographic research. While HIV-positive gay men do not directly consume Truvada through PrEP, they nonetheless hold opinions and understandings of this drug, specifically as it relates to their own sexuality. This paper expands the representations and meanings of this new technology in a different light through the voices of gay men living with HIV in Paris. The main argument of this article is that PrEP as an additional HIV prevention tool blurs the lines between science, technologies and human sexuality.     

Negotiating cultures: disclosure of HIV-positive status among people from minority ethnic communities in Sydney

Because of the multiple stigma attached to HIV/AIDS, disclosure of HIV-positive serostatus is a considerable social risk for those who disclose. While HIV/AIDS-related stigma affects all HIV-positive people, for people from minority cultures additional cultural factors may play a significant role in self-disclosure. This paper draws on data from semi-structured, in-depth interviews with HIV-positive people from minority cultures in Sydney. Disclosure decisions were influenced by gender, sexual orientation, as well as cultural background. Gay men drew on both collectivist and individualist notions of interdependence and self-reliance in different socio-cultural contexts. This enabled them to accommodate the imperative to maintain harmony with the family and meet their individual needs for support. Heterosexual men who had disclosed voluntarily or involuntarily experienced discrimination and avoidance, and interdependence with family and ethnic community was disrupted. Heterosexual women disclosed to no one outside the health care system and were anxious to avoid any disclosure in the future. For all participants, voluntary and involuntary disclosure caused potential and actual disruption of relationships with their families and ethnic communities. The paper concludes by arguing for an ecological perspective of health in which decisions are not located in rational decision making alone but in the broader context of family and community.     

Providing support to caregivers and self-care

The evolution of HIV/AIDS care has resulted in a wide range of caregivers who work out of public and private hospital facilities, nongovernmental organizations (NGOs) and community-based facilities. Others are volunteers and community health and social workers based at facilities or community sites. Many caregivers are family members or part of a client's close social network. Additionally, people living with HIV/AIDS (PHA) themselves engage in self-care and provide support to other PHA through support groups. In the best-case scenario the services of these caregivers are sometimes provided free of charge at one site by a specialized NGO. In many cases, however, a person wishing to gain access to care and social services may need an understanding how the systems and procedures of various institutions operate. Many PHA are unprepared for the administrative, financial, and legal barriers that they may encounter. To cope with this need, a new type of support service called the "buddy" system has emerged. Buddies are individuals who are less directly involved with, but who know about HIV/AIDS, the services available and the rights of PHA. A buddy is close enough for the PHA to approach, has sufficient time to devote to him/her and can be asked almost everything. The article on the Rio de Janeiro Buddy Project provides an example of a project for gay men in Brazil. In other parts of the world where the buddy system is non-existent, the PHA must often rely on support provided by family and friends.     

Focusing on the negative

A San Francisco HIV prevention group has started a series of programs focusing on keeping HIV-negative gay men uninfected. The group, Invention, began the programs in September in response to city-funded studies showing gay men returning to unsafe sexual practices. The San Francisco AIDS Office estimates that 650 gay or bisexual men seroconvert each year, up from 250 in 1987. Infection is sometimes regarded as a rite of passage into the gay community, where half of all gay men are already HIV-positive, and those with HIV are perceived as having a superior social service network for health and counseling needs. The HIV-negative men regard infection as inevitable, and are not as fearful of HIV since those who are positive are living longer. Programs will discuss how to build a meaningful life, help the HIV-negative develop a sense of the gay community apart from AIDS, and encourage dialogue between negative and positive men.     

Gay men and ambivalence about 'gay community': from gay community attachment to personal communities

The concept of 'gay community', and gay men's attachment to and involvement in gay community activities, has held both a symbolic and practical role in understanding and guiding responses to HIV in developed world contexts. In the West, the HIV epidemic has disproportionately affected gay men. Being involved in and connected to gay community activities (what, in Australia, is described as 'gay community attachment') predicted the adoption of safe sex practices. However, the meaning of gay community is changing. This presents a challenge to those working in HIV prevention. With reference to previous research, the meaning of gay community is analysed in qualitative interviews conducted with Australian gay men. The interview data indicate that gay men are often ambivalent about gay communities, suggesting a need for subtlety in the ways we think about and address gay men in HIV education and health promotion. The concept of 'personal communities' may better reflect the ways in which gay men engage with each other and their social networks. Recognising and responding to the changing nature of gay life will ensure that the flexibility and pragmatism of HIV programmes aimed at gay men are maintained.     

'It's like the treasure': beliefs associated with semen among young HIV-positive and HIV-negative gay men

This paper examines cultural and social meanings associated with semen, along with related issues of unprotected receptive anal intercourse, HIV seroconversion, treatment optimism and viraemia. The findings are derived from qualitative interviews conducted with 12 HIV-positive young gay men and 12 HIV-negative counterparts who participated in a prospective cohort study in Vancouver, Canada. Focussing on the narratives of young gay men, the analysis reveals a diverse range of knowledge, values and functions of semen, especially in relation to its exchange. Beliefs about semen appeared to differ by HIV serostatus and were linked with intimacy, identity and pleasure, particularly among the HIV-positive men. Against dominant representations of semen in relation to issues of loss, anxiety and infertility, this unique study sheds much needed light on its role within the cultural construction of sexuality among gay men. As such, these narratives are of direct importance to primary and secondary HIV prevention, including condom promotion and the development of rectal microbicides.     

Identity management and sense of belonging to gay community among young rural Thai same-sex attracted men: implications for HIV prevention and treatment

Young Thai men who have sex with men continue to have high HIV prevalence and incidence in spite of much investment in community-based prevention approaches. To make HIV services more appropriate for same-sex attracted young men in Thailand, it needs to be considered how target groups view themselves and manage their identities. This paper derives from a qualitative study of 25 same-sex attracted rural young Thai men. It identifies five tactics men employed to manage the discrepancy between their preferences and parental/societal expectations regarding gender and sexuality, and discusses how the young men viewed themselves in the wider context of Thai society, including whether they felt part of a separate gay community. Participants usually did not adopt a gay social identity and were reluctant to join in gay community activities beyond dating. Hence, they would likely experience barriers in accessing gay community-based HIV services. HIV services targeting young same-sex attracted Thai men need to be diversified if they are to be more inclusive, appropriate and effective.     

Original Research: Sexuality, Perceived Illness, and Quality of Life in Spanish Gay and Bisexual Men Living with HIV

The experience of living with HIV can be associated with different subjective perceptions in each person, and these can change across the HIV illness trajectory. In the early AIDS epidemic, the gay community was stigmatized and blamed for spreading HIV. Consequences of being gay and coping with HIV resulted in self-blame and higher psychological distress. Since the early 1990s, the gay community has actively combated AIDS and HIV transmission in gay people, promoted support for those affected, and provided education in HIV issues throughout the gay community. This paper presents a cross-sectional study carried out in Spain with 25 Spanish gay and bisexual men living with HIV. Results show a significant association among frequency of sexual intercourse, risk behavior, perceived illness, and quality of life. To enhance the well-being of people living with HIV, researchers and professionals will have to take into account sexuality in relation to quality of life and perceived health.     

Enacting personal HIV disclosure policies for sexual situations: HIV-positive gay men's experiences

Given successes in treating HIV/AIDS, there are increasing numbers of sexually active HIV-positive people. Although there is a current public health emphasis on testing interventions to reduce HIV transmission by people who know they are HIV positive, understanding how people enact decisions to disclose their HIV seropositivity is needed. HIV Disclosure Decision Making in Sexual Situations, a grounded theory based on interviews with 15 HIV-positive gay men, hypothesizes and interprets a two-part process wherein HIV-positive gay men form personal disclosure policies that they contextualize to various dating and sexual situations. In this article, the author depicts the second part of the grounded theory with its five interlocking components of the process of enacting HIV disclosure in sexual situations.     

Social factors associated with Major Depressive Disorder in homosexually active, gay men attending general practices in urban Australia

Objectives : Social factors associated with Major Depressive Disorder (MDD) were identified among gay men attending high HIV caseload general practices in Sydney and Adelaide.
Methods : Men who visited four participating practices were invited to self-complete a survey. A self-screening tool (PHQ-9), based on the Diagnostic and Statistical Manual of Mental Disorders, version four (DSM-IV), was used to measure depressive disorders.
Results : The rate of MDD (PHQ-9 score 10 or above) among the 195 HIV-positive gay men was significantly higher than that among the 314 non-HIV-positive gay men (31.8% vs 20.1%, p=0.002). Current MDD was independently associated with younger age, lower income, recent major adverse life events, adopting denial and isolation as coping strategies, less social support, less gay community involvement and recent sexual problems. HIV-status, however, was not independently associated with MDD.
Conclusion : Socio-economic hardship, interpersonal isolation and personal withdrawal were significantly and independently associated with major depression in this population of gay men.
Implications : The study provides further evidence of health inequity affecting gay men in Australia. Structural health promotion approaches focused on homophobia and discrimination, as well as community-engaged primary health care responses are called for to mitigate this inequity.     

Seropositivity,homosexuality and identity politics in Brazil

The decade since highly active anti‐retroviral therapy (HAART) arrived has been a time of change for gay men in the West. HIV incidence rates have been levelling off—and in some cities, increasing markedly—for the first time since the early years of the pandemic. New sexual subcultures have found expression, including Internet chat rooms, ‘poz‐only’ sex parties, ‘barebacking’ and crystal methamphetamine use. These circumstances force a re‐evaluation of HIV prevention targeting gay communities. We examine the antecedents of current HIV‐prevention dilemmas in findings from a qualitative study of gay men who were personally and professionally engaged in HIV/AIDS in Sydney, Australia, in 1997–1998, immediately after the ‘protease moment’. The men's lives were characterized by constant and difficult negotiation of gay subjectivities. They did not find a place of uniform belonging in the gay community; rather, ambivalence—toward the gay community and HIV prevention—and fragmentation emerged as themes. Our findings suggest that by the late 1990s, the ethos of safe sex developed in the early HIV/AIDS period was no longer a unifying cultural value. We explore the conditions that led to this shift and the implications for HIV prevention in the 21st century.