Latino Gay Men and HIV

Culture, Sexuality, and Risk Behavior

Rafael M. Diaz

• Publisher: Routledge
• Year: 2013
• Print ISBN:
  9780415913874
• eBook ISBN:
  9781317795704
• Topic: Social Sciences
• Subtopic: AIDS & HIV
• Index: Social Sciences

With research based on focus group and individual interviews in the United States, as well as a thorough and integrative review of the current literature, LatinoGay Men and HIV discusses the six main sociocultural factors in Latino communities -- machismo, homophobia, family cohesion, sexual silence, poverty and racism--which undermine safe sex practices. In an attempt to explain the alarmingly high incidence of unprotected intercourse in this population, this in-depth cultural and psychological analysis shows how an apparent incongruence between knowledge or intention and behavior can possess its own sociocultural logic and meaning.

1.

Findings of Epidemiological Research

Based on epidemiological studies of HIV, I would like to assess the degree of risk that Latino gay men in the U.S. experience with respect to HIV transmission. Whenever possible, the assessment will be done in comparison to groups of non-Latino gay and bisexual men. First, I will review both the absolute numbers and the rates of increase of diagnosed AIDS cases among Latino men who have sex with men, as reported by the CDC and other government health agencies. Second, I will review the current estimates of HIV infection in our community, as determined by studies of HIV seroprevalence (i.e., studies that involved testing of blood samples). Finally, I will review self-reported rates of sexual risk behavior, such as unprotected anal intercourse, that continue to threaten many members of this community with new infections.

The statistics that follow will give us a clear and unequivocal indica-tion that our community of Latino gay men, in comparison to other communities in the U.S., has been severely affected by the AIDS epidemic. The numbers tell us that for many years we have been, and remain, a group at an extremely high risk for the transmission of HIV.

AIDS Cases among Latino Men Who Have Sex with Men

As overlapping members of two high-risk groups (Latinos and men who have sex with men), Latino gay men in the U.S. have been highly and disproportionately affected by the AIDS epidemic. During 1990, death rates (per 100,000) for HIV-related causes was 22.2 for Latinos compared to 8.7 for Whites (NCA, 1992). By June 1996,18% of all diagnosed AIDS cases in the country were Latino, an ethnic group that constitutes only about 9% of the U.S. population (CDC, 1996). Similarly, since the beginning of the HIV epidemic, men who have sex with men have carried the largest and most disproportionate share of AIDS cases in the nation; as of June 1996, 67% of all male diagnosed AIDS cases in the U.S. have been among MSM.

Also as of June 1996, a total of 40,243 AIDS cases have been diag-nosed among Hispanic/Latino men who have sex with men; Latino MSM thus constitute 51% of all reported Latino male AIDS cases in the nation (CDC, 1996). Percentages of Latino AIDS cases accounted for by MSM vary substantially across the three major ethnic subgroups. In 1992, for example, 70% of Cuban, 59% of Mexican, and 18% of Puerto Rican AIDS cases were among MSM (CDC, 1993a). The relatively low percentage of MSM among Puerto Rican AIDS cases reflects the higher incidence of HIV transmission through injection drug use in this population. Many of the Puerto Rican drug-related cases, however, could also be MSM, though not coded as such by the CDC.

The number of diagnosed AIDS cases in the nation continues to increase at a faster and disproportionate rate among Latino than non-Latino White men who have sex with men. For example, by March 1993, a total of 21, 021 AIDS cases had been diagnosed in Latino MSM (CDC, 1993b); by June 1994, 15 months later, the number of diagnosed Latino MSM AIDS cases had risen to 29,432. Thus, in the 15 months between March 1993 and June 1994, AIDS diagnosed cases increased about 40% among Latino gay and bisexual men (CDC, 1994). This large percentage increase should be examined in comparison to a much slower, though also painfully dramatic, 29% increase of AIDS cases in non- Latino White MSM during the same time period. The most recent statistics show that, in the two year period between July 1994 and June 1996, the number of diagnosed AIDS cases among Latino gay and bisexual men in the U.S. increased by 37%.

The numbers are even more striking when one examines those for cities with a high concentration of Latinos and homosexuals. In San Francisco, for example, the number of Latino AIDS cases diagnosed annually increased from 168 cases in 1989 to 334 in 1992; approximately 80% of these cases were Latino gay and bisexual men. These numbers are the lowest estimates possible because they are from the period before the CDC’s major change in the diagnostic definition of AIDS, and are not corrected to include the broader, more inclusive current definition. The dramatic increase in AIDS cases among Latino gay and bisexual men stands in contrast to the slower, though also unfortunate, increase of cases for non-Latino Whites in the city during the same time period (an increase from 1,533 cases in 1989 to 2,239 in 1992; of these cases, 87% are gay and bisexual males). In other words, the number of yearly reported AIDS cases in the city increased 99% for Latinos but only 46% for non-Latino Whites within the same four-year period.

It should be noted that the statistics for Latino gay and bisexual men presented throughout this section are most likely conservative estimates for two important reasons. First, Lindan et al. (1990) have shown that, in California, about 20% of Latino AIDS cases were incorrectly reported and recorded as non-Latino Whites. Second, as recently recognized by the National Commission on AIDS (NCA, 1992), different definitions of homosexuality and gay identity among Latinos “may skew statistics dealing with homosexual/bisexual infection rates since there are Hispanic/Latino men who fit these categories but do not identify themselves accordingly” (p. 40).

HIV Prevalence and Seroconversion

While the epidemiological trends are somewhat clear for diagnosed AIDS cases, there are no reliable epidemiological studies of HIV sero-prevalence, seroconversion, or both among Latino gay and bisexual men that involve probabilistic, representative samples. Seroprevalence refers to estimates of how many persons are HIV positive in a given population, while seroconversion refers to the proportion of men from the population who become HIV positive (“convert”) during a given time period. Seroprevalence and seroconversion studies estimate the prevalence and incidence respectively, of HIV based on analysis of blood samples rather than on participants’ self-report.

Data from two seroprevalence studies in the U.S. clearly show that Latinos (regardless of risk category or sexual orientation) are more likely to be infected with HIV than are non-Latino Whites. One study, done with economically disadvantaged Job Corps entrants, revealed that Latinos were infected at a rate two and a half times higher than Whites (St. Louis et al., 1991). In a second study, done with activeduty members of the U.S. army, Latinos were three times more likely than non-Latino Whites to be HIV infected (Kelley et al., 1990). Even though these two seroprevalence studies did not distinguish gay and bisexual from other types of cases, the data are consistent with the findings that Latino gay and bisexual men are highly and disproportionately affected by the HIV epidemic.

Most of what we know about HIV seroprevalence and seroconversion, specifically among Latino gay men, comes from studies of (mostly) White gay men that have included relatively small numbers of Latinos. One important longitudinal study of seroconversion among gay men (Kingsley, 1991) is indicative of both the seriousness of the problem and the limitations of our current data on Latino gay men. The Multicenter AIDS Cohort Study (MACS) followed the temporal trends in HIV seroconversion among gay males in five major urban centers in the U.S. between 1984 and 1989. The study included a total of 3,262 originally HIV-negative gay men, of whom approximately 90 were Latino. Overall, when compared to White gay men, Latino gay men showed a higher HIV seroconversion rate in the city of Los Angeles and a much higher rate—330% higher!—in the city of Chicago. However, the small proportion (2.7%) of Latinos in the study, the English-only questionnaires, and the fact that Hispanic Blacks were categorized as African Americans make the findings difficult to interpret. If at all valid, the reported rates for Latinos are most likely conservative estimates of true seroconversion rates in our communities. Nevertheless, because epidemiological studies of seroconversion rates are difficult and expensive to do, the present data constitute highly prized information on the largely unknown and understudied population of Latino gay males.

Based on numerous epidemiological studies in the region, the AIDS Office of the San Francisco Department of Health has estimated the HIV seroprevalence among Latino gay and bisexual men in San Francisco at 43% (SFDH, 1993); that is, close to one-half of Latino gay and bisexual men in San Francisco are infected with HIV! Seroprevalence for non-Latino White gay and bisexual men in the city is slightly lower, estimated at 41%. Considering that the HIV epidemic first started and rapidly spread in San Francisco’s White gay community, a seroprevalence of 43% among Latino gay and bisexual men indicates not only that HIV infection has caught up with the Latino gay and bisexual community but also that it is increasing at a faster rate in this population. This observation is confirmed by a 1992 seroprevalence study of young gay and bisexual men, ages 18 to 29, in San Francisco, involving a multistage probability sample. The study showed a sero-prevalence rate of 25% among the Latino young men, in contrast to a rate of 15.5% among the White young men (Osmond, Page, Wiley, et al.,1994).

Rates of Unprotected Intercourse

For clearly established biological reasons, and as confirmed by clear epidemiological findings, anal intercourse without condoms (i.e., un-protected anal intercourse) is recognized as one of the most efficient routes for the transmission of HIV. Unfortunately, studies done to date converge on the finding that Latino gay and bisexual men have had enormous difficulties adjusting to condom use and adopting less risky forms of sexual behavior. In fact, five studies that have measured rates of unprotected anal intercourse in gay and bisexual men (Doll et al., 1991; Fairbank, Bregman, and Maullin, 1991; Lemp, 1994; NTFAP, 1993; Richwald et al., 1988) show that Latinos had the highest rates of unprotected anal intercourse when compared to samples of non-Latino Whites, African Americans, or men from other minority groups.

For example, in a survey of knowledge, attitudes, and behavior conducted in the summer of 1990 in San Francisco’s American Indian, Fil-ipino, and Latino gay and bisexual male communities, Latinos reported the highest rate of unprotected anal intercourse (35%) during the last thirty days as compared to 25% of Filipinos and 12% of American Indians (Fairbank, Bregman, and Maullin, 1991). This situation has not changed much for Latinos in San Francisco during the last few years, even though AIDS education and prevention programs in the city are well established and are often regarded as state-of-the-art programs. In Lemp and associates’ (1993) recent study of young gay men in San Francisco, 40% of Latinos reported engaging in unprotected anal intercourse during the last six months, as compared to 38% of African Americans and 28% of non -Latino Whites.

A similar situation has been found in Southern urban cities, not considered AIDS epicenters, as evidenced in a recent study of gay men of color sponsored by the National Task Force on AIDS Prevention (NTFAP, 1993). Sampled in eight urban centers, in five different states ranging from Texas to Florida, Latinos reported the highest rates of both insertive and receptive anal intercourse without condoms. For insertive anal intercourse, 38% of Latinos reported engaging in this activity without condoms during the previous month, as compared to 32% of African Americans and 29% of non-Latino Whites. Differences were even more striking for receptive anal intercourse: 37% of Latinos, 21% of African Americans, and 25% of non-Latino Whites reported engaging in this activity without condoms during the previous month.

Studies of special groups, such as bathhouse patrons or STD patients, have replicated the findings regarding the HIV vulnerability of Latino gay and bisexual men. In a relatively early study of patrons exiting gay bathhouses in Los Angeles, Richwald et al. (1988) found that, of all ethnic groups interviewed, Latinos accounted for the greatest proportion of men practicing anal sex without condoms. Approxi-mately 25% (20/81) of Latinos interviewed reported engaging in unprotected anal intercourse during the bathhouse visit, as compared to 10% (10/99) of African American, and 9% (50/576) of White men. Finally, when predicting anal sex without condoms in predominantly Hispanic and Black clients of urban STD clinics, Doll et al. (1991) found three major predictors: number of drugs each month, sex within a steady relationship, and being of Latino/Hispanic ethnicity.

In the three most recent studies of Latino gay and bisexual men (Carballo-Diéguez, 1995a; Díaz et al., 1996; Ramírez, Suarez, de la Rosa, Castro, and Zimmerman, 1994), participants have reported extremely high rates of unprotected intercourse. Ramírez et al. (1994) surveyed 200 Mexican men in the border Mexican town of Juarez; because these men reported frequent contact with the gay community in the nearby U.S. town of El Paso, the data are informative about Latino gay and bisexual behavior in the U.S. Ramírez inquired about condom use in two different ways: (a) the number of times that condoms were used in the last 10 sexual encounters, and (b) the frequency of condom use in anal intercourse and oral sex rated on a three-point scale of “never,” “occasionally,” or “frequently.” For the whole sample, the mean number of times they used condoms in the last 10 encounters was 6.47. For insertive anal intercourse, 45% reported condom use as “frequent,” 30% as “occasional,” and 25% as “never.” For receptive anal intercourse, 46% reported condom us as “frequent,” 27% as “occasional” and 27% as “never.” These data suggest that more than 50% of Mexican gay and bisexual men who are sexually active in border U.S. towns, and who have a relatively high knowledge about HIV and AIDS, continue to practice both receptive and insertive anal intercourse without condoms.

In a study of mostly gay and bisexual Puerto Rican men in New York City, Carballo-Diéguez (1995) examined the rates of unprotected insertive and receptive anal intercourse by different partner types within a 12-month period. For insertive anal sex, 37% reported unpro-tected intercourse with lovers, 32% reported unprotected intercourse with one night stands, and 22% reported unprotected intercourse with other types of partners. For receptive anal sex, 34% had unprotected intercourse with lovers, 22% with one night stands, and 18% with other partner types.

In a recent study of 159 Latino gay men recruited from gay bars in Tucson, Arizona, Díaz et al. (1996) surveyed participants’ sexual practices with both monogamous and non-monogamous partners during the previous 30 days and during the past year. Questionnaires were available only in English; this Latino sample is likely to over-represent highly acculturated, English-speaking men. The results showed that, during the previous 30 days, 22% of the sample engaged in unprotected intercourse with non-monogamous partners. In addition, 51% of the men reported at least one instance of unprotected anal intercourse during the previous year.

Díaz et al. (1996) also estimated the frequency of unprotected intercourse in the sample by examining the proportion of condom use only among those men who reported any anal intercourse during the last 30 days. For the month prior to testing, 61 men (or 38%) of the sample reported engaging in anal intercourse with their primary partners, and 45 men (or 28%) reported engaging in anal intercourse with casual (non-primary) partners. Taking these numbers as the base denominator, the reported proportion of unprotected anal intercourse in the sam-ple was alarmingly high: 67% (41/61) of the men who reported anal intercourse with primary partners were unprotected, and 44% (20/45) who reported anal intercourse with casual partners were unprotected during the previous 30 days.

Research findings in Tucson suggest that the majority of Latinos who are being safe are perhaps remaining so by abstaining, at least temporarily, from anal intercourse. However, when the men engage in anal intercourse, especially with primary partners, they typically have unprotected sex. The main concern with this strategy is that safety through abstinence might be a fragile way to maintain safer sex behavior over time. It is possible that abstinence from anal sex might mask a deeper aversion and inability to use condoms in an effective yet plea-surable manner.

An important finding in Díaz et al. (1996) study was that HIV risk behavior correlated negatively with both education and income, that is, within this sample there was more risky behavior in men that had less education and income. Because the men sampled were highly acculturated, English-speaking, and mostly well-educated, we should then expect higher rates of unprotected intercourse in less acculturated, Spanish-speaking men of lower socioeconomic status and lower education. This concern is based not only on the correlations between socioeconomic variables and risk behavior obtained in the Tucson study, but also on the documented relationship between acculturation and positive attitudes toward condom use among Latino heterosexuals (Marín, Tschann, and Gómez, 1993). Unfortunately, there are at present no systematic studies on the relationships among poverty starns, education, acculturation, and HIV risk behavior among Latino gay and bisexual men.

In summary, studies have shown that Latino gay and bisexual men engage in extremely high rates of unprotected intercourse; that is, within a one-year period, about one-half of Latino gay and bisexual men in the U.S. engage in behavior that puts them at risk for HIV infection. The rates of men who practice risky sexual behavior vary, according to the window of time observed, from 23% to 35% (within one month) to about 40% (within six months) and about 50% (within a year). Although the largest proportion of unsafe sex appears to occur within steady-partner relationships, the data also show that the majority (about two-thirds) of those relationships are non-monogamous (Díaz, Morales, Dilán, and Rodríguez, 1997) and that there are also substantial amounts of risky sex with casual partners. These high rates of unprotected anal intercourse are possibly due to difficulties with or negative reactions to condom use, rather than lack of knowledge or lack of desire, intentions, or both to protect oneself and others against HIV infection....

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• Acknowledgments
• Preface
• Introduction: “We Now Have the Knowledge . . ” Do We?
• 1. Findings of Epidemiological Research
• 2. Findings of Behavioral Research
• 3. Cultural Barriers to Behavior Change
• 4. Machismo and Homophobia: The Wounding of Self-Esteem
• 5. Family Loyalty and Sexual Silence: Splitting Off Sexuality
• 6. Poverty and Racism: The Fueling of Fatalism
• 7. Acculturation Groups
• 8. A Psycho-Cultural Model of Sexual Self-Regulation
• 9. Hennanos de Luna y Sol: A Model for HIV Prevention with Latino Cay Men
• References
• Index