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JUST RELEASED! CTCA Curriculum Guide to serve Black/African American MSM

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It is well-documented that African-American men, and in particular African-American men who have sex with men (AAMSM), continue to be over-represented among diagnosed persons living with HIV/AIDS in America and among new, formerly untested, cases in serosurveillance studies. The social and cultural contexts of how African-American men experience the HIV epidemic (e.g., stressors such as stigma, poverty, incarceration) complicate access to testing and care, and compliance with care. (Beltrami, et al. 2005; Millett, et al. 2006). While multiple HIV prevention interventions for men who have sex with men (MSM) have shown success in reducing risky behaviors (Johnson et al. 2002; CDC 1999, revised 2001), few have included large proportions of AAMSM or focused intervention themes on the issues most pertinent to them. For AAMSM, these issues include cultural identity, secrecy and stigma surrounding sexual behavior, racism, social disenfranchisement, and concepts of masculinity, among others (Mays et al. 2004).

This guide addresses the research and intervention gaps noted above by testing the efficacy in reducing the HIV risk behaviors of AAMSM utilizing the Critical Thinking and Cultural Affirmation (CTCA) strategy, a community developed, culturally congruent HIV risk behavior intervention which has been implemented for over a decade in Los Angeles, California, and since 2002, in New York City. The CTCA strategy is an African-American culturally informed model that addresses positive mental health, encourages self-actualization and responsibility, and teaches critical thinking and health education as they apply to AAMSM (Manago 1996). Based in Critical Thinking theory (Crenshaw et al. 1996), and Empowerment theory (Freire 1983), the CTCA curriculum stresses the importance of celebrating positive elements of Black history, life, family, self-concept and culture and of acknowledging how varying levels of oppression contribute to unhealthy attitudes and behaviors (Wright 2001, Jones 2000). It promotes positive self actualization and well-being in African-Americans by incorporating a combination of three racial socialization strategies described by Stevenson et al. (1997): 1) Protective racial socialization, which emphasizes viewing the world as racially hostile; 2) Proactive racial socialization, which encourages individuals to succeed as a function of internal talent and cultural heritage and not to pay much attention to external oppression; 3) Adaptive racial socialization, which recognizes and identifies oppression and racial hostility, then keeps it at bay long enough to create a space for creative self-expression and preservation. Stevenson asserts that, in a culturally relevant and holistic paradigm, all three strategies are necessary for African- Americans to successfully negotiate safer-sex practices.

The CTCA intervention has been pilot tested among a group of diverse AAMSM (who did and did not identify as gay, and some who identified as heterosexual and bisexual) in Los Angeles in the late 1990s. The results of such testing have been recognized in the American Journal of Public Health and by behavioral scientists to be highly promising and deserving of more rigorous study.

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Advancing understanding of the risk behaviors, rates and incidence of HIV/AIDS among AAMSM, and creating interventions that are effective with this population must be part of the agenda to reverse the worsening epidemic among African-Americans in the United States.

Consequently, the CTCA model is a culturally specific and theoretically based intervention that draws upon existing research identifying the unique factors underlying AAMSM HIV risk behaviors and key strategies that are effective in reaching AAMSM.

Knowledge about effective HIV interventions for AAMSM is limited. While many HIV prevention and intervention studies include samples of African-American men and AAMSM, beyond demonstrating disparities in seroprevalence between and among racial groups, few have been specifically designed and evaluated for efficacy among African American men. (Peterson, & Carballo-Diéguez, 2000; Beatty, Wheeler & Gaither, 2004; Mays, Cochran, & Zamudio, 2004; Clarke-Tasker,Wutoh & Mohammed, 2005). Current HIV prevention encompasses a variety of approaches, including Diffusion of Effective Behavioral Interventions (DEBIs), which bring pre-packaged; science-based, community- and group and individual -level HIV prevention interventions to community-based service providers, and to state and local health departments. There are currently 20 interventions in the CDC DEBI portfolio; of these, only 4 either were designed for, or rigorously tested with significant samples of, African-American or African American men populations. In addition, of these 4, only 2 were specifically modified for an AAMSM target population.

Existing interventions are inadequate. The efficacy of the few interventions that have been used with, tailored for, or designed to address HIV prevention with AAMSM is unclear (Myrick, 1999; Beatty, Wheeler & Gaither, 2004). One factor contributing to lack of clarity about the effectiveness of HIV prevention efforts for African- American men (MSM or straight men) is that many of the studies reported in the literature use samples that do not differentiate between self reported sexual identities (e.g., straight, gay, bisexual, homosexual, MSM, down low) and sexual risk behaviors (e.g., sex with men only, sex with men and women). Such an approach fails to take into account both the prevalence of bisexual behavior among AAMSM at risk for of living with HIV/AIDS (Beltrami, Shouse, & African-American, 2005) and the reluctance of many AAMSM to identify with labels such as -gay- or -bisexual. The conflation of identity and behaviors thus creates a situation where men who do not self identify with the label but engage in the behavior are either left out of the intervention framework or -do not see themselves- as part of the described at risk group (Perron, 2004; Millett, Malebranche, Mason, & Spikes, 2005; Wheeler, 2006; Millett & Peterson, 2007). Continued below...

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In a related vein, of the few interventions developed for AAMSM in particular, (i.e., Many Men Many Voices), most have used sexual identity labels [(e.g., gay, bisexual or men who have sex with men (MSM)] to describe the intervention intended audience, and the use of such labels risks alienating men who engage in the sexual behavior but who do not ascribe to commonly used labels (i.e., gay, bisexual, MSM). Among the interventions targeting AAMSM, a nuanced description of the different types of MSM for whom the label -gay- does not resonate is rarely presented. AAMSM includes several distinct subgroups such as situational homosexuals, including those practicing survival sex or sex during incarceration; men who identify with other labels for homosexuality such as -same gender loving-; bisexually identified men who are truly attracted to both men and women; closeted men; men who have sex with male-to-female transgenders; and men who self-identify only with terms such as -sexual freak- (Goldbaum et al. 1996, Mays et al. 2004, Lichtenstein 2000, Manago 1995).

Accordingly, the use of sexual identity labels such as gay and bisexual does not capture a significant group of HIV-infected and at-risk African American men, and for men who shun labeling their sexual behaviors, such prevention efforts are not efficacious. In fact, an environment of increased sexual risk may inadvertently result because the men cannot find effective prevention methods that help them reconcile their behaviors with their self-selected identities (e.g., men who identify as straight, but engage in sexual behaviors with men in exchange for money, housing and/or drugs) (Wheeler et al, In Press).

A further limitation among HIV risk interventions for AAMSM (and indeed African Americans in general) is that extraordinarily few attempt to address the inter-face (Payne, 2005) between internal, social, and cultural arrangements as a means of HIV reduction (e.g., Jana, 2006). Instead, most address individual-level behavior change or, if addressed to the couple, group or community level, seek to effect changes in norms that will support individual behavior change (e.g., Community Promise; Many Men, Many Voices). In other words, these interventions typically focus on the circumstances the men face (e.g. risky sexual encounters, use of substances etc) rather than on the underlying factors that frame how men perceive, understand and respond to these circumstances.

As discussed further in the curriculum guide, the theoretical framework and approach of the CTCA intervention, the subject of the proposed study, focus precisely on such interaction of psychosocial and cultural factors.

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