The HIV/AIDS Epidemic in the Black Community

Introduction to the study

African-Americans represented nearly 51% of the newly diagnosed cases of human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) within the United States between 2001 and 2004 (Centers for Disease Control and Prevention [CDC], 2006). Further, a report on HIV and AIDS diagnoses between the years of 2001-2005 estimated 185,000 adolescent and adult HIV infections, with more than 51% occurring among African-Americans. Of these cases, almost 62% of the newly diagnosed HIV/AIDS cases were between the ages of 25 and 44 years old. Within this group, African-Americans represented 48% of the new HIV/AIDS diagnoses. Since Blacks or African-Americans account for 13% of the United States population; thus, based on the previous figures, addressing disparity is important.

The impact of HIV/AIDS in racial and ethnic minorities is disproportionate. This population represents most of new AIDS cases (71% of new AIDS cases, and 64% of cases living with AIDS) (after, the Henry J. Kaiser Family Foundation report, July, 2007).

Analysis of data from the National household survey displayed more than 2% of the African-American population is HIV positive. Further, the case rate of AIDS (in 100.000) is 9 times higher in African-American than any other racial or ethnic population group. African-Americans accounted for 55% of the death rate because of AIDS in 2003. In addition, HIV is the fourth cause of death for African-American males, and the third for African-American females between 25 and 44 years old (after, The Henry J. Kaiser Family Foundation report, July, 2007).

Mobilization of this community is needed to help foster an environment that supports interventions to lessen the disproportionate impact of this disease on blacks within the United States (CDC, 2007). The African-American community is in need of culturally fitting intervention methods to address this social issue.

Definitions of Terms

1. Definition of AIDS: Definition of AIDS (acquired immune deficiency syndrome) passed through many stages of development. In 1982, the CDC defined AIDS as an infectious disease resulting from a deficiency in the cell-mediated immune mechanisms with no other reason for decreased natural resistance to infections. In the revised definition of AIDS, the CDC, 1993 linked the human immune-deficiency virus HIV to AIDS, and considered AIDS the acquired immunodeficiency syndrome in an individual infected with HIV. The diagnosis of AIDS is to depend on certain clinical indicator illnesses defined by the CDC. In this sense, an HIV positive individual is not necessarily an AIDS patient. The WHO definition of AIDS is different as definitions in other countries like Canada. These differences account for rather higher incidence rates in the USA compared to other countries (Bernstein and Scott, 1993).
2. Defining the term HIV/AIDS: This term refers to cases infected with HIV whether they display AIDS clinical indicator illnesses or not (CDC basic statistics, 2008).
3. Incidence of HIV: This means the number of new cases infected with HIV at a specific time and in a certain population (CDC basic statistics, 2008).
4. Prevalence of HIV: Is the number of living HIV/AIDS cases in a certain year (CDC basic statistics, 2008).
5. MSM: Males who have sex with males (Sullivan, Drake, & Sanchez, 2007).
6. BMSM: Black males who have sex with males (Jones and others, 2008).
7. Down Low: Presumably “secretive” homosexuality among married Black males (Sandfort & Dodge, 2008).
8. UAI: Unprotected anal intercourse (Jones and others 2008).

Review of literature

This critical literature review with proposed research design addresses the current literature on the HIV/AIDS epidemic in the black community. This chapter will review and discuss of the literature that addresses key issues affecting prevention and intervention. These include cultural deafness and denial, the impact of bisexual identity on risk, the role of social and racial discrimination in HIV/AIDS risk, and the impact of economic disparities on health. A section that addresses specific issues in intervention will follow. Finally, the researcher will present the statement of the research problem and purpose of the study.

Literature search strategy

The literature search strategy used was to find peer-reviewed articles covered 17 databases. The databases from Walden University library included Academic Search Premier, Dissertations & Theses, Dissertations & Theses at Walden University, Remove embedded line break

Health & Medical Complete (ProQuest), Health Sciences: A SAGE Full-Text Collection,

Psychology: A SAGE Full-Text Collection, and PsycINFO. The search began with the terms HIV/AIDS and African-American and African-American Gay Community then expanded to other terms, which included Bisexual Black males and Black men who have sex men.

Factors affecting HIV/AIDS risk

Risk factors are behaviors or stances that position individuals at risk of picking up HIV infection. They either connect directly to disease transmission as having unprotected sex, or indirectly related as alcohol abuse. Personality disorders, peers’ influence, and social-cultural environment are predictors to high risk behaviors (Redmond, 2006).

Cultural Deafness and Denial

Often, a gay African-American will hide his sexuality within the close community. However, once outside that community, this person is likely be more open about sexuality. Thus, these African-Americans display deafness at home by refusing to self-identify. Normative focus theory suggests norms will influence behavior only to the extent they are the focus for the individuals involved at the time the behavior occurs (Baron and Byrne, 2003). Many gay African- Americans will deny their sexual orientation and hide behavior to escape social reactions within their community. This lack of access thus helps foster the notion that prevention programs are failing to achieve results. Therefore, the lack of self-identification with the black and gay community is a critical barrier to change high-risk sexual behavior effectively among social groups that include men of color. Many current intervention methods call for the individual to seek the information positively. Within their own cultures, African-American males are not keen to seek such information (Baron and Byrne, 2003).

Several researchers (Earl, 1990; McKirnan, Strokes, & Burzette, 1992) recognize that men who consistently have sex with men but do not identify themselves as gays are more likely to engage in unsafe sex than gay-identified men are. This is presumably because they have not adopted the safer sex norms prevalent in larger gay communities supported by intervention efforts within those communities. Bisexual men may be a case in point, men who labeled themselves “bisexual” but who had male partners only are more likely to engage in unsafe sex. Also, men who labeled themselves straight but who had some male partners would do the same more than those whose self-label was more consistent with their behavior (McKirnan & Stokes, 1995).

Patterns of sexual identification and sexual behavior vary among African-American and Caucasian men. Several writers have noted that urban African-American communities have strongly negative attitudes toward gay men (Peterson and others, 1992). African-American men having sex with men might be less likely to identify themselves as gay or bisexual. The lack of a gay or bisexual identity may increase high-risk behavior. Insofar these men would be less responsive to tailored prevention materials is currently styled. Or such men would be less likely to take part in workshops or academic studies for fear that they should become detected and adversely labeled. However, ethnic differences in HIV risk behaviors have not been examined in larger samples using diverse recruiting sources (Peterson and others, 1992).

McKiman and Stokes (1995) hypothesized that African-American men would show a greater disparity between self-identified label and behavior than would White men. Researchers, therefore, expected a higher proportion of African-American men who had both male and female partners to self-identify as heterosexual rather than bisexual. Also, researchers expected a higher proportion of African- American men with only male partners to self-identify as bisexual rather than as gay. The previous study also expected African-American men to report more HIV-risk behavior than would Whites. McKiman and Stokes interviewed a large, diverse sample of bisexually active men (52% Black, 48% White; aged 18-30 years) who had had sex with a male and a woman in the previous three years. When asked about behaviors in the previous six months, 22% reported multiple instances of unprotected insertive or receptive anal sex with a male and 28% reported multiple instances of unprotected anal or vaginal sex with a woman. Although Black men were more likely to exchange sex for money and drugs, White men who engaged in such exchanges did so more often. Black men were more likely to report being HIV seropositive and were significantly less likely than were White men to disclose their same-sex behavior to their female sexual partners. In this study, contact with a gay community was relatively low among both Black and White men, and risk level was high for men attracted to both sexes. This same group’s lack of participation in gay culture, which provides information and intervention help, makes them prone to outreach or positively affected by current prevention methods and programs within the gay community as a whole.

Bisexual identities

Recently, the mainstream media has brought greater attention to the down low phenomenon prevalent within the Black community. However, relatively limited scholarly research has examined bisexual identity among black minorities within United States. Sandfort and Dodge (2008, p.683), suggested the study of bisexuality in Black and Latino men is significant in its own entitlement. However, these men have a disproportionate rate of HIV/AIDS. This makes the current shortage of scientific information even more pressing and alarming. Sandfort and Dodge (2008) compiled a diverse collection of observed and hypothetical outlooks on Black and Latino male bisexualities. This included information on the individual, social, and sexual lives of these men, and possible associations to risk behavior.

Defocusing gender: Bisexual identity as an expression of a non dichotomous worldview:

The study of bisexual identity has undergone several theoretical shifts in the past several decades. Moving from the dismissal of bisexuality as a transitional period to treating bisexuality as a legitimate sexual identity based on gendered desire (or attraction to men and women; Parker, Adams, & Phillips, 2007). Understanding bisexuality as an identity contests the dichotomous sex-gender structure (Parker, Adams, & Phillips, 2007).

Health disparity

To understand disparities of the black community will lead to understanding how social, cultural and health factors result in unequal risk of HIV for African-Americans. Health disparity is a term used in the USA; it is a synonym to health inequality or inequity in other countries. Many factors contribute to health disparity of the African-American Community. These factors include poverty, racial and ethnic discrimination, less access to healthcare, and the language barriers among healthcare providers and the targeted population. Other factors that influence health disparity are the physical or geographic location and the social networks. The social stigma and look and negative social attitudes to certain sexual practices created a case of sexual minorities, especially for MSM in black communities characterized by homophobia leading to condition denial. Identifying health disparities is an important step to design a specifically tailored intervention program (Steele and others, 2007).

About economic disparity, most public health prevention models and publicly-funded prevention programs recognize individual human behavior as the main domain of health risk. Therefore, such programs overlook the impact of social factors like discrimination (Raja, McKirnan, & Glick, 2007, p. 56). Sexual transmission of HIV is likely to result from a shortage of knowledge among the African-American community, which leads to misguided assessments of individual risk. The African-American gay understanding of individual invulnerability or lack of motivation to practice safer sex is a core issue. It is important to challenge individual models of risk within the social contexts of groups and communities. African-American’s disease vulnerability links to a history of sexual and racial discrimination, including financial hardships. The CDC statistics explain that African-Americans (Blacks) are more likely to associate with risk for HIV infection, partners being at risk, HIV/AIDS denial, substance abuse, and sexually transmitted diseases. One in four African-Americans (Blacks) lives in poverty (US Census Bureau, 2000).

Social-Racial discrimination factors

Diaz and Ayala (1999) conducted research that challenged individual models of risk by locating risk within the social depth of groups and communities. The foundation of their research is based on information gathered from Latino gay and bisexual men. The research performed on men in three different US cities. Their study design was to collect data and document the correlation. The information correlated subsequently to specific forms of social discrimination. This social discrimination included racism, homophobia, and economic hardship, as it connects to risk factors associated with HIV transmission (Diaz & George, 2001). The work of these researchers challenged individual models of risk. This was done by locating risk within groups and communities, social groups. The findings held from participants in the three cities suggested those with high disease vulnerability link intrinsically to a history of sexual and racial discrimination, financial hardship, and oppression from and starting at childhood (Diaz & George, 2001).

For the next generation of HIV prevention approaches, these findings have a great impact on Latino and African-American men having sex with men. The research supports that HIV prevention and intervention methods should not just focus on adjusting individual behavior; rather, they need to focus on changing the social contexts that influence risky behavior. Discrimination and social oppression are important contexts that need consideration. Prevention methods that are culturally fitting must include strategies to counter racism, sexism, poverty, homophobia, and HIV/AIDS phobia.

Such strategies could result in a dramatic and positive decline of HIV infection rates (Diaz & George, 2001).

African-Americans involvement in sexual activity and HIV/AIDS: Suggestions for future research

AIDS continues to be a health crisis, especially within African-American (Blacks) communities. Accounting for the culture of African-American gay men and their sexuality within a cultural context is significant to reduce the HIV infection and transmission rates within this population (Wyatt, Williams, & Myers, 2008). Wyatt and colleagues noted two major factors affecting HIV/AIDS interventions. The first is confusion about race-based stereotypes, and the second links to historical health disparities and mistrust. Little research conducted on the extent to which such disparities affect HIV/AIDS transmission. There is a need for training of new and settled investigators as well as associative efforts of health, community, religious, political organizations, and historically black colleges and universities. The aim is to spread relevant HIV prevention messages. Conducting research to understand African-American sexuality will make developing behavioral interventions that address health easier (including HIV) and help mental health risk decline within the context of African-American life.

Rural health issues in HIV/AIDS: View from two different windows

Although many researchers advise prevention programs that encourage behavioral change or a shift in individual’s awareness and opinions, yet among African-Americans, such programs did not produce significant changes (Williams and others, 2003). Further, the epidemic nature of the disease in African-Americans especially highlights the issues of emotional, physical, and socio-cultural liability of African-Americans to HIV/AIDS (Williams and others, 2003). Therefore, the authors conducted a questionnaire based study to evaluate sexual knowledge and high risk factors that affect both the incidence and prevalence of the syndrome in this fraction of the black community. They performed their research on urban living and rural areas African-American females. Their results displayed no significant difference between the two groups in risk factors to HIV/AIDS infection. However, knowledge about the syndrome was higher among urban African-American females, but indicators for potential behavioral change did not differ between the two samples. The authors inferred there are two pillars for advancing prevention; first African-American women need an ethnically responsive as well as a gender-specific intervention program. Second is, African-American women leaderships are called for more active involvement. Also, there is a need for parents and spiritual leaders of black community involvement (Williams and others, 2003).

Foster and Frazier (2008) pointed out that planning and implementation for rural areas are important to serving the poor and underserved. Planning and implementation of preventive services are especially challenging in rural communities for various reasons. These include long travel distances to HIV/AIDS services, inadequate supply of HIV/AIDS specialists, limited medical services, and social support services in rural areas. Besides, concerns over greater confidentiality issues that arise due to stigma of the disease which restricts individuals who may be infected from getting tested. Besides, pronounced overall health disparities between rural and urban populations (including chronic diseases and sexually transmitted diseases), poorer economic conditions (including increasing numbers of under-and-uninsured). Finally, limited substance abuse treatment services, which make untreated addiction a barrier in satisfactory treatment for those individuals also infected with HIV. As with the culture of the black community, rural areas have their own set of cultural needs, which can affect prevention strategies. Their research weaves together stories and personal experiences of three contributors aiming to educate and empower the Black community to fight HIV/AIDS.

The study of Williams and others (2003) recognized a few key similarities and differences between rural and urban African-American populations. First, the majority of respondents to survey question were between 15 and 44 years in both communities. Second, education level influences awareness of the disease in both communities, also, their result showed that differences in economic status among individuals of both communities influence awareness and risk behavior. On the negative side, mistrust in healthcare providers and negative social attitudes were more prevalent in rural areas. They inferred there is a need for setting up networks of public health providers and African-American rural community groups to work for negative attitudes mending (Williams and others, 2003).

Challenges facing African-Americans with HIV infection

Rawlings and Masters (2008) identified the challenges that face African-Americans with HIV infection. First is the noticeable disparity in health outcomes which lead to disproportionate incidence and prevalence rates among African-Americans. Second are the medical disorders prevalent in the black community like hepatitis, and diabetes, that influence the course of disease or increase the complexity of treatment. Further, the prevalent psychological problems like depression and societal barriers to suitable medical care increase the rates of morbidity and mortality among African-Americans. Thus, the challenges facing the black community are interconnected and should all be given suitable consideration to achieve a successful prevention program outcome (Rawlings and Masters, 2008).

Intervention issues

There are two popular theories involved in HIV interventions, which are the reasoned action theory, and the planned behavior theory, and both theories aim to understand human behavior and actions (Redmond, 2006). The reasoned action theory provides a scope to try predicting behaviors based on an individual’s intents linked to thoughts or beliefs or commanded individual’s norms. An example is what the family and friends (local community) think of these intents. The theory of planned behavior adds considering the idea of realized behavior control, in other words it considers internal and external risk and protective factors (Redmond, 2006).

Despite the recognized need for culturally tailored HIV prevention interventions, few studies have examined if predictors of unprotected sex vary for youth from different ethnic groups (Warren and others, 2008). In the study by Warren and colleagues, they recruited 189 participants, including gay, bisexual, and questioning youth between the ages of 15 and 22. The participants were from three racial-ethnic backgrounds, including African-American, Hispanic, and White. The participants were located in Chicago, Illinois and in Miami-Dade and Broward counties in Florida. The researchers found that African- American adolescents who engage in long-term relationships and whose families rejected because of homosexual practices were at a younger age when engaging in unprotected sex. However, for Hispanic youth, higher ethnic identification and older age at the start of sexual behavior linked to unprotected sex. The researchers found that for White youths, there were no predictors associated with unprotected sex. The findings show how significant understanding the varying predictors correlates to unprotected sex. Also, they show how important is integrating the predictors into prevention and intervention methods tailored to the apt population.

Racial discrimination may be an item of many intervention methods and programs; often, African-American culture was not considered in their development. Wallace (1998) conducted a study to address this issue designed to explore the experiences and views of gay Black men who took part in HIV/AIDS infection prevention intervention. In addition, Wallace (1998) examined the social structure of the gay Black Community. Wallace sought to understand the meaning the HIV/AIDS epidemic has for gay Black men. Further, they displayed how this meaning influences opinions of gayness, notions about HIV, and ideas of safe sex, and awareness about educational materials in the Black community.

Wallace (1998) noted that Black gay men have not been involved in the process of developing AIDS educational programs and campaigns. Also, neither gay Black men nor the Black community recognized the need for such involvement. Gay Black men are afraid of exposure and subsequent reprisals by the Black community. This has also figured prominently in the lack of gay Black male involvement in HIV/AIDS infection educational programs and or campaigns. Further, the pamphlets and brochures developed for the gay community targeted primarily at gay White men. Few brochures address gay Black men and the cultural and sexual behavior differences that exist.

Fisher and Fisher (1992) found that AIDS risk behavior reduction interventions are only effective if the targeted audience embraces them culturally. In a review of the literature, Fisher and Fisher identified some intervention methods with characteristics that are likely to have a positive influence o declining risk within this population. The most effective interventions have two critical parts: They are theoretically based and group-specific. These intervention methods must focus on providing HIV/AIDS risk behavior reduction information, and behavioral skills to motivate positive change.

Careful evaluation of these interventions must follow to produce an effective outcome. Fisher and Fisher incorporated these parts into their information-motivation-behavior (IMB) model of HIV/AIDS risk. Kalichman, Tannenbaum, and Nachimson (1998) noted that some features of the models are powerful determinants for particular populations and some determinates are more powerful than others. The variations should provide significant data for understanding and adjusting AIDS risk behavior in specific populations like the African-American (Black) gay community towards specific HIV/AIDS preventive behaviors within these social groups.

Fisher and Fisher (2002) identified critical determinants of AIDS risk behavior reduction. The three stages to apply this interpretation to promote HIV/AIDS risk behavior reduction within a population are as follows. First, for each population, it is necessary to research and identify the population’s current HIV/AIDS risk behavior reduction knowledge base. Identification of factors that control the population’s motivation to reduce AIDS risk behavior, as well as the population’s current HIV/AIDS prevention behavioral skills is of importance. Second, in using population specific data, they found it necessary to create population suitable intervention methods to produce changes in knowledge levels, behavioral skill levels, motivation, and thus HIV/AIDS preventive behavior. Lastly, to infer the intervention methods produced short and long-term changes in multiple indicators of knowledge, motivation, and behavioral skills, there is a need to carry satisfactory evaluation (Fisher & Fisher, 2002, p. 115).

Interventions that focus on peer norms are important as well. Jones et al. (2008) surveyed 252 BMSM attending nightclubs in three North Carolina cities. Results showed that 45% of the respondents reported UAI in the previous two months. In a secondary analysis of the data, men who reported experiencing discrimination based on their race, as well as non-gay identified men reported favorable peer norms for condom use. However, men who reported that their families disapproved of them being homosexual were more likely to have been confined within the past two months as compared to other participants. The study found, HIV/AIDS prevention methods for Black men who have sex with men must promote supportive peer norms for condom use. Besides, the need to address confinement issues, racial discrimination, and family disapproval and nonsupport (Jones and others, 2008).

A look at risk and protective factors

It is noticeable that incidence, prevalence, mortality rates of HIV/AIDS are higher in African-American communities. A fact that points to overall higher risk of the black community members, an examination of the social networks, in HIV intervention terms, this means a look to how members of the black community are sexually connected. Factors that influence the burden of HIV/AIDS in African-American community include (Redmond, 2006):

1. Density, or in other words, the number of individuals in a social network who make sexual contact with one another.
2. The extent of involvement of individuals with high risk behaviors.
3. The tendency of individuals sharing the same characteristics (age, gender, beliefs…) known as sorting. Sorting can be a risk or a protective factor depending on the socio-cultural backgrounds of the network.
4. A number of risk behaviors can introduce HIV infection into low risk social networks. These behaviors are: mixing with other social networks individuals with different cultural backgrounds. A second risk behavior is joining more than one social network by mutual members (bridging). A parallel concomitant partnership is a third risk behavior that introduces infection into a low risk social network.

Nearly 25% of African-Americans live in poverty (compared to 11% of the white population), this predisposes to increased rates of substance abuse, unstable neighborhoods and unstable transient relations. Unawareness of HIV infection and difficult access to healthcare are other factors associated with poverty (Redmond, 2006).

Protective factors, on the other hand, are those behaviors that protect African-Americans from infection with HIV. Based on Redmond analysis (2006), these protective factors are:

1. Self-discipline and self-efficacy (abstinence).
2. Peer influences in a social network which can be a double bladed factor influencing behaviors as a risk or a protective factor.
3. Awareness of how important is the regular and consistent use of condoms.

A well constructed intervention program should aim at reducing risk factors and promoting protective factors (Redmond, 2006).

Summary of the review

Clearly, there are many factors, including individual, social, and cultural, that influence the effectiveness of HIV/AIDS interventions. Wallace (1998) recommended that HIV/AIDS education programs for gay African-American men be culturally fitting. The approach to prevention must engage many segments in the African-American community, including spiritual leaders, community leaders, and health professionals. Wallace also noted the complex nature of the gay African-American community needs that education and prevention efforts be done in various settings and should always protect confidentiality. Jemmott, Jemmott, Sweet, and Fong (1992) confirmed that suitable interventions could help to decrease risky sexual behavior that can result in a reduction in HIV/AIDS rates. In the Jemmott and others (1992) study, adolescent African-American, Black men were randomly assigned to receive HIV/AIDS risk reduction intervention methods. Interventions aimed to increase HIV/AIDS related knowledge levels and to weaken uneducated attitudes toward risky sexual behavior. In this study, the participants that received the intervention reported greater HIV/AIDS knowledge and less favorable attitudes about risky sexual behavior and lesser intents to engage in risky sexual behavior. However, there are factors that are likely to increase the risk for participation in risky sexual behavior. Sullivan and others (2007) found a positive correlation between risk and treatment optimism. Fifteen percent of 1477 HIV-negative or untested MSM in the study reported optimism-related risk behavior. Interestingly, Black and Hispanic MSM reported this optimism-related risk behavior more often than did White men and more often than MSM with a high school education or less. Thus, HIV prevention programs should address treatment optimism and related behavioral risks by providing culturally fitting information about the limits of current therapies to MSM with less education (Sullivan and others, 2007).

As HIV/AIDS continues to affect African-American communities disproportionately, there is a growing need for empirically based, culturally suitable, tailored interventions for this community (Raja, McKirnan, & Glick. 2007). It appears that peer interventions may also be specifically helpful. Raja and colleagues (2007) developed a treatment advocacy program to help participants increase medication compliance and decrease risky behavior. The intervention was tailored specifically to those participants reporting low socio-economic status as well as those who live in urban areas.

Statement of the problem

While there is ample theoretical and empirical literature that addresses HIV/AIDS intervention, less research examines the specific impact of culture on intervention efforts. Specifically, the review of the literature revealed a separation between current intervention methods and approaches and their effective implementation in the community of gay Black men.

Therefore, the researcher will address the following research questions. First, why has the African-American community not embraced current intervention methods? Second, how do attitudes displayed by the African-American community about gay men affect intervention methods? Finally, is current intervention methods culturally biased? Activists and scholars believe that African-Americans are less tolerant of gay men (Lemelle & Battle, 2004). However, not much research has contributed to the understanding of the correlation between church attendance, income levels, education levels, and urban living on attitudes and views toward gay men (Halton, 1989; Rose, 1998; Waldner, Sikka, & Baig 1999).

Purpose of the study

The purpose of the proposed research is to examine qualitatively the reasons the African-American community has not embraced current HIV/AIDS interventions and the extent to which those who take part in such interventions realize discrimination.

Methods

Research design and approach

This chapter addresses literature on self-identification and includes a proposed qualitative research design. Quantitative examples represent inquiry into human or social issues that assess and analyze data employing statistical methods. This discovers whether the predictive generalizations of a theory can hold true. Qualitative patterns focus on understanding the meaning of a social phenomenon. The qualitative tool is interview or other text data to build a complex picture, which considers all factors using information and actions of informants gathered from participants in natural settings (Creswell, 1994).

Although there are many types of qualitative paradigms available, this paper will use grounded theory. Grounded theory allows researchers to develop theory from empirical data using multiple stages of data collection and a method of refinement by which the researcher settles the interrelationship of categories of information (Strauss & Corbin, 1990, p. 3). There are two main characteristics of grounded theory design, which makes it different from other forms of qualitative research. First is the constant comparison of data and emerging categories to which the data is compared. Second is the theoretical sampling of different groups to maximize likenesses within the comparison (Creswell, 1994). There are other qualitative paradigms available to compare to the grounded theory approach such as phenomenological, ethnographic, or case study. Studies that focus on the meaning of an experience are phenomenological in nature. Phenomenological studies include studying a few participants with detailed and prolonged engagements, to develop patterns of meaning in the data (Dukes, 1984; Oiler, 1986). The study where the researcher studies an intact cultural group within the group’s normal or natural setting during a given time and collects mainly observational data is an ethnographic study (Wallen & Fraenkel, 1991). In the case study approach, the researcher explorers a single entity and collects complete information using various methods of data collecting practices during a fixed period of time (Merriam, 1988; Yin, 1989).

Thus, grounded theory is fitting for the present study because of the desire to produce theory to test later. Given the need for a satisfactory theory to drive the development of culturally suitable interventions, grounded theory is likely the best paradigm for the present proposed study.

The researcher’s role is personal considering that qualitative research is interpretative research and in that opening the door to biases, and the researcher states personal judgments plainly. Locke, Spirduso, and Silerman (1987) considered such openness useful and positive. The researcher needs to secure permission to study the informants and or their circumstances. The research should have a method developed for collecting data at minimum. For this thesis, the method of data collection will include setting boundaries for the study, collecting information through observation. Data collection may also be through interviews and visual materials followed by setting up the protocol for recording and documenting information.

In planning data recording, this researcher will respond to two primary questions before data entry. (1) What to record, then (2) how to record? To the first question, the record will show the responses to direct questions whether open-end or with yes or no responses. In a try to take the mass of information and reduce it to certain patterns or themes lending its content to interpretation. The researcher will use a coding scheme to reduce the information into the patterns and themes mentioned before. A1 code will be for African-American males who self-identify as gay and reported having sexual relations only with men within the last year. A2 code will identify African-American men who report having sexual relations with both men and women within the last year but self-identify as heterosexual. A3 code will point to African-American men who report having sexual relations with men and women within the last year and self-identify as bisexual. This coding process will foster the objective of this research to compare data continuously, so achieve the primary purpose for employing the grounded theory. A4 code will be for African-American men who have had sexual relations with men and have stated their female partners know. Code A5 will be for African American men who have had sexual relations with men and have not told their female partners.

Code B1 will be for African men who have engaged in unprotected (oral, vaginal, or anal) sex in the past year. Code B2 will be for African-American men who have had a least one casual sexual meeting with a male within the last year. B2a code refers to African-American men who have had 2 or 3 casual sexual meetings with males or a male within the past year. Code B2b will be for African-American men who have had 4-6 casual sexual meetings with men or a male within the past year. Code B2c refers to African-American men who have had 7+ casual sexual meetings with men or a male within the past year.

Code C1 will refer to African-American men who have paid for sex with a male or a woman within the past year. In the coding scheme, C2 refers to African-American men who used a professional escort service and paid for sexual contact with the escort. About religious beliefs, code C3 will be for African-American men who consider themselves religious, while code C4 will be for African-American men who do not consider themselves religious. C5 will be for African-American men who consider their church and community understanding and support. C6 will be for African-American men who consider their church and community hostile and or non-supportive.

Code D1 will be for African-American men who state they are aware of the HIV/AIDS epidemic among African-Americans in the United States. D2 will be African-American men who state they are not aware of the HIV/AIDS epidemic among African-Americans in the United States. D3 code will be for African-American men who state they have had and read HIV/AIDS intervention materials within the past year. Code D4 will point to African-American men who state they have no chance to have HIV/AIDS intervention materials within the past year.

Economically, code D5 will refer to African-American men who state they have had to borrow money within the last six months for basic items like food and shelter. While code D6 will be for African-American men who state they do not have health insurance. Code D7 is for African-American men who state they have practiced sex for money. Code D8 is for African-American men who state they have engaged in sexual practices for other types of consideration (like favors, or employment).

Procedures

Seeking participants will be at gay social clubs, nightclubs, and gay professional organizations (that I Gay political and Gay business groups) that cater to African-Americans located in metropolitan areas of the Midwest. The researcher will first approach the organization’s management and disclose the complete nature of the study. Next, the researcher will seek permission to be on-site recruiting for the study. Once permission is received, the researcher will give out flyers that describe our study. For those who consent to take part in the study, the researcher will arrange an agreeable time to conduct the interview.

The researcher will conduct interviews individually and in a neutral location, such as a local library or community center. The interviewer will take detailed notes and will audiotape all sessions. The interview procedure is as follows. First, the interviewer will read an opening statement that includes instructions, an outline of the research questions, and a review of how the researcher would use the results. Next, the researcher will ask key research questions and participants will try to answer the questions in an unstructured format. Including probes will be as needed to help guide each participant. Finally, participants will have time to add closing statements or comments.

The research will employ safeguards to protect the informant’s rights in performing the research project. The researcher will clarify the research objectives in written and verbal formats aiming to make sure of complete understanding of the informant. This information will include a detailed description on how the information will be used. In addition, the researcher will seek written permission from the informant to advance with the research and gathering of information as described to the informant. The Walden University Institutional Review Board (IRB) will give permission to conduct research with human participants, and research will halt until the receipt of such permission. The researcher will explain all data collection tools and procedures to all informants. Finally, at all-time the informant’s full consideration of the rights and wishes of participants will be a focal point.

Factors of sample size are critical in applying grounded theory because the sample size must be large enough to produce enough data to clarify patterns, categories, properties, and dimensions of a phenomenon. In this case, the reasons the African-American community has not embraced current HIV/AIDS interventions and the extent to which those engaged in such interventions feel and recognize discrimination.

Theoretical saturation will help decide the suitable sample size. Theoretical saturation occurs when (Strauss & Corbin, 1998, p. 212):

1. No new or relevant data are likely to emerge about a category,
2. The category becomes well developed about its properties and dimensions, displaying variation, and
3. Well created and confirmed relations among categories.

The criteria for selecting participants includes African-American men between the ages of 18 and 44 who report having engaged in oral sex, anal sex, or mutual masturbation with a male during

their lifetime. Participants will be assigned to one of two categories: those who are openly gay and those who are on the down-low (as previously defined). The aim for having two groups is to provide information available to cross-reference data between groups to provide content-appropriate interventions methods for both groups. This should allow for greater generalizability to the population and to make inferences about the characteristics or behavior of the population studied.

This study will start with 20 participants and will continue expanding the sample size until data collection reveals no new information. It is not possible to predict when theoretical saturation occurs. Participants’ selection will be random for each group in which they fit to ensure that each individual has an equal chance of selection (to improve representativeness of the sample and so external validity). In this study, the researcher will choose participants who have experienced or are experiencing the prodigy under study. The researcher understands that theoretical sampling is cumulative and each interview provides the researcher with a piece of the data to build the theory foundation. The researcher will perform an iterative analysis of all collected interviews to observe the emerging patterns, categories, and dimensions as they link to the research topic. This new insight of the emerging patterns, categories, and dimensions should lead to a point of saturation.

Research limitations

Theoretical saturation will help decide the apt sample size, but it can also be a research limitation (Maxwell, 1992). A broader research scope needs more data, thus, more data collection. This translates into more interviews, interviewees, and in some cases, may need alternative types of data to be collected. Therefore, the researcher needs to control the scope of the study. Another factor that may dictate sample size is the nature and sensitivity of the issues studied; it may be difficult to find a large sample enough to ensure good representation.

The qualitative paradigm has five categories to judge the validity of qualitative research, which include interpretive validity, descriptive validity, generalizability, theoretical validity, and evaluative validity. Achieving interpretive validity needs accurate data recording (Maxwell, 1992). Satisfactory descriptive validity is dependent on collecting accurate data. Generalizability is the ability to apply the drawn theory to the larger population (Auerbach & Silverman, 2003, Maxwell, 1992). Achieving saturation and careful theoretical sampling should improve generalizability. Theoretical validity directly addresses the theoretical frames the researcher brings to the study or occasionally developed during the study (Maxwell, 1992, p. 50). Theoretical sampling and the use of constant comparative analysis should help with improving theoretical validity.

The possible shift of using sensitizing concepts instead of definitive concepts is another inherent ambiguous issue in grounded theory qualitative research. A definitive concept points directly to common characteristics in a subgroup by clearly defining terms of traits or having clear fixed standards. A sensitizing concept is short of such precise definition of traits and standards, although it does not allow researchers to move directly to the case content, yet it provides a more general outlook to guidance in approaching observed cases (Bowen, 2006). In social research, sensitizing concepts are interpretive tools that commonly serve as a starting point for qualitative research. It points to important characteristics of social relations and generally provides guidelines for research in specific sceneries. Further, as grounded theory research starts with no predetermined ideas, and then it is suitable to start with sensitizing concepts. In simple terms, sensitizing concepts are the background notions that enlighten the whole of the research problem. A researcher must be aware that sensitizing concepts provide starting points to research but are not the ending points to prevaricate for. Researchers may also use sensitizing concepts to examine codes aiming to develop stemmed categories from obtained data. As sensitizing concepts may increase awareness to important features of research, they may also distract attention away from significant research outlooks (Bowen, 2006).

Finally, to come up with recommendations on specifically designed intervention programs for African-Americans, it needs reflective, assorted, developing, and non-linear approaches to complement grounded theory analysis. Because of this, the transferability of recommendations to other African-American subgroups may be limited. To overcome this limitation, the unit of data analysis may be ideas instead of cases, and to group cases based on wider structural conditions as cultural values or social status. Working with clear methods and procedures helps to overcome the transferability limitation (Misco, 2007).

Summary and critique

Discussion on the reviewed literature

The literature review showed the impact HIV/AIDS has had on the Black community. It included current literature on the epidemic of HIV/AIDS in the black community. It showed also how cultural deafness, economic disparity, racial discrimination and culturally unsuitable intervention methods foster the disease epidemic in the black community. These topics specifically link to black gay males and their community. This critical literature review analyzed each of these areas by reviewing the literature; showing the differential impact of the HIV/AIDS epidemic on black gay males and their community.

Discussion of cultural deafness and denial addressed the ways gay African-American men hide their sexuality within the community and how, once outside that community, they become more open about their sexuality. Thus, these men display deafness at home by refusing to self-identify. Normative focus theory suggests that norms will influence behavior only to the limit they are the focus for the individuals involved at the time the behavior occurs (Baron and Byrne, 2003). Many gay African-American men deny their sexual orientation and hide behavior to escape social reactions within the African-American community. Thus, they are less likely to engage in prevention programs. So this lack of access can help foster the notion that such programs are failing to achieve results.

Economic disparity is a major obstacle to understanding and addressing the social impact of discrimination on health within a group. However, research should include economic disparity in the wider frame of health disparity. Health disparity means differences in incidence and prevalence of a disease influenced by differences in education, income, access to medical or health facilities, geographic location, or ethnic socio-cultural beliefs. Until now, there is little understanding of how to measure health disparities among different population groups. Should health outcome be the measure of health disparity that is should research compare health outcome for total health disparity. This approach ignores differences among groups, alternatively, should research measure group disparity (based on economic or socio-cultural differences) with an ethnic community. This approach has the advantage of providing an apt measure to size, quantity, and extent of relation of a health outcome to a specific population. Finally is the choice should research measure both total and subgroup (differential disparity) (Steele and others, 2007).

Many of the publicly funded prevention programs continue to locate the source of health risk within the domain of individual behavior and the factors that influence those behaviors (Raja and others, 2007). This is the case with sexual transmission of HIV. Risk behaviors and actions result from shortfalls in individuals’ knowledge level. Often, there is a lack of motivation to practice safer sex. It is important to challenge models of individual risk and look to social context.

Within communities whose disease vulnerability essentially links to sexual and racial prejudice, this issue should be at the forefront. The work of Diaz and Ayala (1999) challenged such individual models of risk.

There is a recognized need for culturally apt HIV prevention interventions for gay and bisexual youth. However, despite this, few studies have examined if predictors of risk levels for engaging in unprotected sex vary for youth from different ethnic groups (Warren and others, 2008).

Practice implications

A successful HIV/AIDS prevention education program targeting African-American population has to consider the following. First, the problem volume is significant and represents a prevention emergency. Second, the previously carried out programs did not specifically target the African-American community considering the social and cultural characteristics. Third, the choices of strategies for HIV/AIDS prevention programs targeting African-Americans are outreach strategy, special groups targeting strategy, or Individual targeted intervention strategy. Based on Rose’s analysis (2004), the best strategy that suits the African-American Community is outreach intervention strategy. A prevention education HIV/AIDS program has to address barriers specific to the black community. Based on Roses’ analysis (2004), besides culture, African-American linguistics has been neglected in most HIV/AIDS prevention programs; this has created a communication gap between health providers and targeted African-American population. Also, including African-American leaderships in the stage of program design is a must as they are able to tell how to approach and how to overcome barriers. Funding is a major problem that needs suitable ways to overcome (Rose, 2004).

The implications of this research for practice are twofold. First, the research implies the current method of intervention may be ineffective in that they are not tailored specifically to the needs of African-American men. Second, it is unclear why the Black community as a whole does not embrace the current intervention methods and often refuse to self-identify as gay or bisexual. Thus, the issues raised in this thesis support the notion that effective interventions for this community need to be relevant to the specific cultural norms and based on theory that incorporates social as well as individual contexts. This will enable practitioners to be more effective with these populations in minimizing risk due to HIV infection.

Future Directions

Given the landscape of the HIV/AIDS epidemic, it is critical that interventions to reduce the spread of infection be effective. There are many areas that future research needs to highlight. First, there is a need for research to explore deeply the African-American sexuality. This should provide a better understanding to specific risk factors of the African-American community. Second, there is still a need to understand the sociocultural background of African-American male-male or male-female relations and its influence on sexual health. This is important because effective interventions stems from a model that aptly assesses the complex relations with the African-American Community. Third, there is still a need to recognize the influence of diversity within the African-American community. This includes many variables, gender and age related risk protective factors, sociodemographic risk factors, and how HIV serostatus influence sexuality and sexual decision-making. Fourth, future studies should incorporate how African-Americans look at their culture that is ethnocentric. Fifth, education and prevention HIV/AIDS programs should target both genders and different age groups of African-Americans in a suitable cultural, social, and religious context. Finally, because of the characteristic cultural deafness and denial among African-Americans, health providers face difficulties in setting up proper communication channels for education. The question is how to provide proper training to health providers to make them able to reach and gain the trust of African-Americans (Wyatt and others, 2008).

Implications for social change

An effective approach to the prevention of HIV/AIDS should look carefully at the diversity of the African-American community. The black community differs in culture, values, and norms from other ethnic minority communities in the US. Further, within this community subgroups differ in immigration status, and culture absorption. These differences have to be in the background in addressing the implications for social change as they strongly link to HIV risks. Therefore, for future prevention planning, researchers should have the skills to carry out culturally and socially oriented research (Wyatt and others, 2008).

This paper gives attention to the HIV/AIDS epidemic within the Black community. There are several factors, including individual, social, and cultural, that influence the effectiveness of HIV/AIDS interventions. Wallace (1998) recommended that HIV/AIDS education programs for gay African-American men be culturally apt for this population. The approach to prevention has to engage many segments in the African-American community, from spiritual leaders to community leaders and health professionals. The complex nature of the gay African-American community needs that education and prevention actions performed in various settings and should always protect confidentiality (Wallace, 1998). Creating such effective interventions would improve the quality of life for African-American men by recognizing the unique understandings of sex and sexuality. It would also reduce the risk for HIV transmission, and thus reduce the costs (financial and other) that HIV/AIDS epidemic has incurred.

Integrative summary

Statistical figures display the growing AIDS epidemic in the gay African-American community. Research suggests that several factors contribute to the growing number of HIV/AIDS cases among this population. A realized hostile environment in the African-American community may discourage African-American men who have sex with men from self-identifying as members of the gay community. Besides, this environment perpetuates sexual behaviors that place these men at higher risk for HIV/AIDS infection. Research further suggests that models for AIDS reduction intervention can only be effective if aligned to specific, targeted audiences. Although much of AIDS reduction information exists in the gay community, gay African-American men are unlikely to seek or internalize this information if they do not identify themselves first as gay.

Therefore, AIDS reduction intervention can best reach gay African-American men if these men can be encouraged to self-identify as gay without fear of reprisals from the African-American community.

Continued research is essential. Scholarly research is lacking in studies that deal specifically with the social reality of gay African-American men. Data must be gathered to measure the degree of success or failure of AIDS prevention and intervention programs in the gay African-American community. Such studies may be effective in helping gay African -American men take full advantage of AIDS reduction intervention programs, in that way addressing the crisis of AIDS in the African-American community as a whole.

A briefing on creating a theory by grounded theory qualitative research

Most theories are the result of logical inferences from previous studies and research, however, grounded theory has the advantage of producing a theory from available data. Producing a theory from grounded research passes in three stages, which are:

1. Comparative analysis of data sets, which may result in a substantive theory (to answer a specific question) or a formal theory.
2. Identifying the different population categories of the study and their characteristic traits.
3. Developing a generalized relation between various categories and their characteristics.

This needs the researcher to be theoretically oriented in analyzing the data about what it would lead to. It also need the researcher to have a consistent method in analyzing the data both category and characteristic wise. When theory begins to form, the researcher has to compare his analysis results with more incidents, a step known as delimiting the theory. Finally, the researcher has to base the research on many comparison groups to achieve better credibility (Corbin and Strauss, 2007).

Conclusion

The HIV/AIDS epidemic problem in African-American population represents an emergency. The disproportional incidence and prevalence rates, especially among African-American MSM are the highest in the US. In community high risk subgroups for infection transmission, African-Americans show the highest risk. Several social, cultural, and economic factors are responsible for high risk and are barriers to healthcare or prevention programs implementation. Further, prevention programs did not specifically target the African-American population in many features. There is a need for research to clarify the complex nature of the epidemic in the black community. Further, to come up with recommendations and plan for an HIV/AIDS prevention program that specifically address the multifaceted African-American environment that lead to this epidemic. The epidemiological figures of HIV/AIDS incidence and prevalence in African-American community especially for black MSM, point to the lack of effective intervention programs. This in turn labels breaks in prevention research targeting this African-American subgroups populations. First is there are few studies on black MSM that look into social and cultural predictors of HIV risk and fewer studies addressing overcoming obstacles. Second is, the lack of social organization’s interventions aiming for black MSM. A third and equally important research gap is the lack of constructed interventions specifically designed for black MSM.

In case research covers these gaps, there remains the question of diversity in African-American subgroups. This means that a program designed for an MSM subgroup in one black community is not directly applicable to another MSM subgroup in another African-American community. The procedure of developing a prevention program designed for the African-American community is neither easy nor expected in short time. However, with rising numbers of new HIV cases, especially among black MSM make time a crucial factor. Therefore, a suitable compromise is adopting available intervention programs while developing new specifically tailored programs for black MSM. Black community leaderships have to engage effectively and with harmony in researchers efforts. Future prevention programs should reduce black MSM risk factors, enhance protective factors, look deeply into sociocultural traits, and be cost-effective; otherwise, they will be neither effective nor accepted by the African-American community.

The black community HIV/AIDS epidemic reflects the nature of the African-American community. It displays the social, cultural, health and economic burden on the African-American community and clearly identifies that prevention is the key to lessen the impact of HIV/AIDS on the black community. With increasing awareness of the problem, and in addition to prevention, health organizations, social, and psychological counseling infrastructures must be available to support African-Americans living with the disease. Besides research in defective areas, a successful HIV/AIDS prevention program targeted to African-Americans needs strategic resources allocation, policy education, strategic alliances among federal, state authorities, and community leadership.

References

1. Amaro H. Love, sex, and power: Considering women’s realities in HIV prevention. Am Psychol 1995; 50(6):437-447.
2. Auberbach, C. F, & Silverstein, L. B. (2003). Qualitative data: An introduction to coding and analysis. New York: New York University Press.
3. Baron, R. A., & Byrne, D. (2003). Social Psychology (10th ed.). Boston: Pearson Education, Inc.
4. Bernstein, R., and Scott, R. (1993). Rethinking AIDS: The Tragic Cost of Premature Consensus. New York: Free Press
5. Blaise Astra Parker, Heather L. Adams, Layli D. Phillips. (2007). Decentering Gender: Bisexual Identity as an Expression of a Non-Dichotomous Worldview. Identity, 7(3), 205-224.
6. Centers for Disease Control and Prevention (CDC). (2000). HIV/AIDS among racial/ethnic minority men who have sex with men—United States, 1989-1998. MMWR 2000; 49:4-11.
7. Centers for Disease Control and Prevention (CDC). (2003). Late versus early testing of HIV—16 Sites, Unites States, 2002-2003. MMWR 2003:52(25)581-586.
8. Centers for Disease Control and Prevention (CDC). HIV/STD risks in young men who have sex with men who do not disclose their sexual orientation—six US cities, 1994-2000. MMWR 2003; 52;81-100.
9. Centers for Disease Control and Prevention (CDC). Racial/ethnic disparities in diagnoses of HIV/AIDS-33 states, 2001-2004. MMWR 2006;55:121-5
10. Centers for Disease Control and Prevention (CDC). Racial/ethnic disparities in diagnoses of HIV/AIDS-33 states, 2001-2004. MMWR 2006;55:121-5
11. Centers for Disease Control and Prevention (CDC). Racial/ethnic disparities in diagnoses of HIV/AIDS-33 states, 2001-2005. MMWR 2007;56(09):189-193
12. Centers for Disease Control and Prevention (CDC). Racial/ethnic disparities in diagnoses of HIV/AIDS-33 states, 2001-2004. MMWR 2006;55:121-5
13. Centers for Disease Control and Prevention (CDC). Racial/ethnic disparities in diagnoses of HIV/AIDS-33 states, 2001-2005. MMWR 2007;56(09):189-193
14. Centers for Disease Control and Prevention HIV/AIDS Surveillance Report, 2004. Vol. 16 Atlanta: US Department of Health and Human Services, CDC; 2005:1–46.
15. Centers for Disease Control and Prevention (CDC). HIV/ AIDS surveillance report 2005.
16. Centers for Disease Control and Prevention (CDC). Basic Statistics. Web.
17. Corbin, J., and Strauss, A. (1990). Qualitative Sociology, Spring90, Vol. 13 Issue 1, p3, 19p
18. Corbin, Juliet M., and Strauss, Anselm C. (2007). Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory. Sage Publications, Inc. Thousand Oaks.
19. Diaz T, Chu SY, Buehler JW, Boyd D, Checko PJ, Conti L, et al. (1994). Socioeconomic differences among people with AIDS: Results from a multistate surveillance project. American Journal of Preventive Medicine, 10(4), 217-222.
20. Earl, W. L. (1990). Married men and same-sex activity: A field study on HIV risk among men who do not identify as gay or bisexual. Journal of Sex and Marital Therapy, 16(471), 251-257.
21. Ekstrand, M. L., Coates, T. L., Guydish, J. R., Hauck, W. W., Collette, L., & Hully, S. B. (1994). Are bisexually-identified men in San Francisco a common vector for spreading HIV infection to women? American Journal of Public Health, 84 Vol 84(6), 1994. pp. 915-919.
22. Fleming D. T., Wasserheit, J. N. (1999). From epidemiological synergy to public health policy and practice: The contribution of other sexually transmitted diseases to sexual transmission of HIV infection. Sex Transm Infect 1999;75:3-17.
23. Fisher, J. D. & Fisher, W. A. (1992). Changing AIDS – risk behavior. Psychological Bulletin, Vol 15(2), 1996. pp. 114-123.
24. Gagnon, J. (1989). Disease and desire. Daedalus, 118, 46-77.
25. Harder, S., Smith D,, Moore J., & Holmberg S. (2001). HIV infection in women in the United States: Status at the millennium. Journal of the American Medical Association, 285(9), 1186-1192.
26. Herek, G. M., Gillis, J., & Cogan, J. (1999). Psychological sequelae of hate crime victimization among lesbian, gay and bisexual adults. Journal of Consulting and Clinical Psychology, Vol 67(6), 1999. pp. 945-951.
27. HIV/AIDS Surveillance Report. (1994). Center for Disease Control and Prevention CDC, Vol 5(8), pp. 4.
28. Peterson, John L., Marín, Gerardo, Issues in the prevention of AIDS among Black and Hispanic men. American Psychologist, 0003-066X, 1988, Vol. 43, Issue 11
29. Jemmott H., John B III, Jemmott, Sweet L., Fong H, Geoffrey T. (1992). Reductions in HIV Risk-Associated Sexual Behaviors Among Black Male Adolescents: Effects of an AIDS Prevention Intervention. American Journal of Public Health, 82(3), 372.
30. Jones K. T., Johnson W. D., Wheeler D. P., Gray P., Foust E., Gaiter J. (2008). Nonsupportive Peer Norms and Incarceration as HIV Risk Correlates for Young Black Men who have Sex with Men. AIDS and Behavior, 12(1), 41-50.
31. Jones, Kenneth T.; Johnson, Wayne D.; Wheeler, Darrell P.; Gray, Phyllis, et al. The North Carolina Men’s Health Initiative Study Team; AIDS and Behavior, Vol 12(1), 2008. pp. 41-50.
32. Kalichman, Seth C.; Tannenbaum, Libby; Nachimson, Dena; Psychology of Addictive Behaviors, Vol 12(4), 1998. pp. 262-271.
33. Leigh B, Stall R. Substance use and risky sexual behavior for exposure to HIV: Issues in methodology, interpretation, and prevention. Am Psychol 1993; 48(10):1035-1045.
34. Lemelle, A., & Battle, J., (2004). Black Masculinity Matters in Attitudes Toward Gay Males. Journal of Homosexuality,Vol. 47(1) 2004
35. Maxwell, J. A., 1992, Understanding and validity in qualitative research. In A. M. Huberman & M. B. Miles (Eds.), The qualitative researcher’s companion, (pp. 37-64). Thousands Oaks, CA: Sage Publications (Reprinted from Harvard Educational Review. 1992, 62, 3; 279-300).
36. McKirnan, D. J., Strokes, J. P., & Burzette, R. G. (1992). Self-identification among bisexual men: Efforts on psychological well being and HIM risk. Paper presented to VIII International Conference on AIDS, Amsterdam, July.
37. McKirnan, D. J., & Stokes, J. P. (1995). Bisexually Active men: Social Characteristics and Sexual Behavior. Journal of Sex Research, 32(1), 65, 12.
38. National Center for Health Statistics. National vital statistics report. 2002;50(16).
39. O’Leary, Purcell, Spikes, Gomez (2007). Correlates of Risk Patterns and Race/Ethnicity Among HIV-Positive Men. Web.
40. Pamela H Foster, Ellis Frazier. (2008). Rural Health Issues in HIV/AIDS: Views from Two Different Windows. Journal of Health Care for the Poor and Underserved, 19(1), 10-5.
41. Sullivan P. S., Drake A. J., Sanchez T. H. (2007). Prevalence of treatment optimism-related risk behavior and associated factors among men who have sex with men in 11 states, 2000-2001. AIDS and Behavior, 11(1), 123-9.
42. Peterson, J. L., Coates, T. J., Catania, J. A., Middleton, L., Hillard, B., & Hearst, N. (1992). High risk behavior and condom use among African-American gay and bisexual men. American Journal of Public Health, 82, 1490-1494.
43. Rawlings, M., K., and Masters, H., L. (2008). Comorbidities and Challenges Affecting African Americans with HIV Infection. Journal of the National Medical Association, 100 (12), 1477-1481
44. Redmond, M. L. (2006). Reducing the Risk of HIV Infection in African American Adolescents in the Midwest: A Look at Self-Efficacy and Condom Use in Adolescent Population. Unpublished Doctoral Thesis. College of Liberal Arts, Wichita State University.
45. Rose S., Derlerlega, V., & Barbee, A. P. (1998). Searching for the meaning of AIDS: Issues Affecting Seropositive Black Gay Men. HIV and Social Interaction (pp. 56-82), U Missouri, St Louis, MO, US: Sage Publications, Inc, 1998. x, 269 pp.
46. Sheela Raja, David McKirnan, Nancy Glick. (2007). The Treatment Advocacy Program-Sinai: A Peer-Based HIV Prevention Intervention for Working with African American HIV-Infected Persons. AIDS and Behavior: Supplement, 11, pp. 127-37.
47. Sandfort, Theo G. M.; Dodge, Brian. Archives of Sexual Behavior, 2008, Vol. 37 Issue 5, pp. 675-682, 8p
48. Stokes, J. P., McKirnan, D. J., & Burzette, R. G. (1992). Paper presented to VIII International Conference on AIDS, Amsterdam, July. Behavioral versus self-labeling definitions of bisexuality: Implications for AIDS risk.
49. The Henry J. Kaiser Family Foundation (2007). HIV/AIDS Policy Fact Sheet: The HIV/AIDS Epidemic in the United States. Washington, DC: Author.
50. U.S. Census Bureau. (2000). Poverty status of the population in 1999 by age, sex, and race and Hispanic origin. See APA Publication Manual for missing components in reference to U.S. Government reports.
51. Waldner, L.K., Sikka, A., & Baig, S. (1999). Ethnicity and Sex Differences in University Student’s Knowledge of AIDS, Fear of AIDS, and Attitudes toward Gay Men. Journal of Homosexuality, 37(3), 117-133.
52. Wallace, C. E. (1998). AIDS/HIV Infection Prevention Interventions: The Experiences and Perceptions of Gay African American (People of Color) men (Doctoral Dissertation, University of Michigan, 1998). UMI Company.
53. Warren, Jacob C.; Fernández, M. Isabel; Harper, Gary W.; Hidalgo, Marco A.; Jamil, Omar B.; Torres, Rodrigo Sebastián; AIDS and Behavior, Vol 12(3), 2008. p. 459-468.
54. Williams. B., P., Ekundayo, O., Udezulu, I, E. and Omishakin, A. M. (2003). An Ethnically Sensitive and Gender-Specific HIV/AIDS Assessment of African American Women A Comparative Study of Urban and Rural American Communities. Fam. Community Health, 26 (2), 108-123.
55. Williams J.K., Wyatt G. E., Resell J., Peterson, J., & Asuan-O’Brien, A. (2004). Psychosocial issues among gay and non-gay-identifying HIV-seropositive. Missing Journal, volume, issue, and page numbers.
56. Wyatt G E, Williams, J. K., & Myers, H. F. (2008). African-American Sexuality and HIV/AIDS: Recommendations for Future Research. Journal of the National Medical Association, 100(1), 44-8, 50-1.