A culturally tailored HIV prevention program developed and tested by investigators at UCLA and the Charles R. Drew University of Medicine and Science has been shown to significantly reduce unprotected sex among bisexual black men.
The innovative approach, called Men of African American Legacy Empowering Self, or MAALES, is described in an article in the peer-reviewed journal AIDS.
The rate of HIV/AIDS among African-Americans is significantly higher than it is among any other ethnic or racial group. (According to the Centers for Disease Control and Prevention, African-Americans accounted for an estimated 44 percent of new U.S. HIV diagnoses in 2010.) Among men who have sex with men, black men account for the largest estimated number of HIV infections. Yet there are few interventions available to reduce those rates, said the study's principal investigator, Nina Harawa, adjunct assistant professor of epidemiology at UCLA and associate professor of research at the Charles R. Drew University of Science and Medicine.
MAALES takes a holistic approach to minimizing behaviors that could put men at risk for HIV, engaging participants in small-group discussions about popular media, exercises such as negotiating condom use with sexual partners and activities to improve the participants' knowledge of sexual health. Importantly, the intervention is also culturally relevant, addressing participants' shared legacies, including social expectations of African-American men, historical discrimination and disenfranchisement, and societal impacts on individual health and sexual decision-making.
"When we first set out in 2004 to develop an intervention for behaviorally bisexual African-American men, the gap between documented need and services was staggering," Harawa said. "Up to that point, just one prevention intervention tailored for African-American men who had sex with men had been developed and no interventions designed for behaviorally bisexual men of any race or ethnicity had been published."
That gap has since narrowed, but only slightly, she noted. For instance, studies on four other interventions for African-American men who have sex with men have been published. Of those, only two showed evidence of efficacy. In addition, only two of the four studies specifically targeted any specific race or ethnicity.
The Drew-UCLA MAALES study was based on previous research by the authors and others which indicated that African-American men who have sex with men and women have different experiences and concerns from those of men who only have sex with men or men who only have sex with women.
Researchers surveyed 437 bisexual black men, assessing key characteristics and behaviors such as socio-demographics, incarceration history, self-reported HIV status, condom use, gender role expectations, experiences with racism, and use of drugs and alcohol. The surveys were completed at baseline, and again at three months and six months after completing the intervention.
Participants were randomly assigned either to the six-session MAALES intervention or to a control group that provided one session on HIV risk reduction education.
Compared with those randomized to the control intervention, individuals in MAALES reported 49 percent fewer episodes of unprotected intercourse with partners of either gender after six months, as well as 50 percent fewer episodes of unprotected vaginal intercourse with females, and 44 percent fewer female partners.
There were some study limitations that could lessen the generalizability of the study's findings. Participants tended to be over 35 years of age and to report low socioeconomic status. Also, despite efforts to engage men of diverse sexual identities, men who identify as heterosexual may have been less willing than other men who have sex with men and women to engage in a group intervention. Finally, even with intensive retention efforts, loss to follow-up was significant, perhaps due to significant incarceration rates. At least 16 percent of participants who were not retained were incarcerated at their six-month follow-up interview.
"Despite these study limitations, our statistically significant findings demonstrate not only the promise of this intervention but also the ability to bring about important behavioral change through culturally tailored behavioral intervention approaches," said Dr. John K. Williams, associate professor in residence of psychiatry and biobehavioral sciences at UCLA's Semel Institute for Neuroscience and Human Behavior, and the study's co-principal investigator.
"Health interventions that address more than just physical, mental and sexual health may be vital for groups like black men who have sex with men and women whose concerns regarding HIV stigma, biphobia, homophobia and financial hardship may complicate engagement in HIV biomedical prevention and treatment," Williams said.
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