Manago--African Americans Living with HIV

AMASSI Health & Cultural Centers
Los Angeles, Harlem, Atlanta, Johannesburg
Prevention with Positives, New Challenges, New Considerations
California Department of Health Services, Office of AIDS (CDHS/OA)
the HIV Care Branch and the HIV Education and Prevention Services Branch
Hilton, Ontario, California
African American Men Thriving With HIV
a Comprehensive Model
(copyright Cleo Manago)
Thursday, October 5, 2006
Cleo Manago, CEO AMASSI Health & Cultural Centers
10/15/2007
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Suggestions:
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Feel absolutely free to interject or ask
questions for clarification at any point
throughout the presentation
Take notes
Afterwards, do your own research
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Workshop Presenter Goals:
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My goal today is to spark critical thinking and
dialogue, and help improve how we attend to
a diversity of males of African descent with
great need for appropriate HIV/AIDS
interventions, and providers with the capacity
to serve them competently. Managing HIV
among Black males reduces the risk to
women, and other Black males.
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Overview of Presentation
C.T.C.A Black Men’s HIV Prevention & Intervention
Project
{ Overview of Black “MSM” Spectrum – “Who Are
These Men?”
{ Recruiting Diverse Black Males at HIV Sexual Risk
and Living with HIV to prevention services
{ Evaluation tools and research findings
{ Review and Questions
{
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Critical Thinking & Cultural Affirmation
(CTCA) Project
Funded by Alliance Health Care Foundation and the
California Institute for Integral Studies – January 1994 to
December 1997
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Purpose: To provide a culturally and sexual behavior
appropriate HIV prevention and intervention service to Black
males at HIV sexual risk and Living with HIV
{
{
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Collaboration between three organizations:
AmASSI Health & Cultural Center
The Black Men’s Xchange (BMX)
Community Mental Health Consortium
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The spectrum of Black males who have sex
with males (BMSM):
Diverse ‘Black males at HIV sexual risk’ (BMSR),
and living with HIV
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BMSR who self-identify (SI) as gay
BMSR who do not SI with or as gay
BMSR who SI as gay, only within gay identified
social networks, not publicly
BMSR with male and female sex partners, e.g.
bisexuals or “freaks” (typically SI as
heterosexual)
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The spectrum of Black males who have sex
with males (BMSM): cont’d
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BMSR who SI as heterosexual; experienced or
involved in male-to-male (MTM) survival sex
(for money, accommodations, or drugs or MTM
sex during incarceration)
BMSR who SI as heterosexual and continue
homosexual behavior after incarceration
BMSR who are injection drug users
BMSR who do not identify as MSM
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Historical Perspective
Barriers to Secondary Prevention and
Treatment of BMSR Living with HIV
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HIV/AIDS Stigma – internalized and societal
Few inclusive services designed to attract
subpopulations
Minimal focus on Black dimensionality
(as if Blacks with HIV are monolithic)
Minimal engagement of societal, cultural and
interpersonal barriers to preventive health
practice
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The CTCA Model
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A culturally relevant model for people of
African descent
Addresses positive mental and sexual health
Encourages self-actualization and
responsibility (for self and community)
Fosters critical thinking, leadership and
preventive health awareness
Acknowledges 3 levels of oppression
[racism/sexual prejudice] (Jones CP, 2000)
Institutionalized (media, pop culture, school, religion, etc.),
Personal mediated (DWB, followed in store, community, family, etc); and
Internalized (low or conflicted self concept)
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The CTCA Model Methodology
Key Components of the Model
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Critical examination of emotional/philosophical
blocks to self and community protection
Addresses mental health, and substance use
(when applicable) issues from a cultural and
historical perspective
Provides services that affirm and celebrate
Black/African culture, diversity and good
health
Avoids “crisis”-based approach to health
Builds community to reduce stigma
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The CTCA Model
Programmatic Implications
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Oppression (internalized and social)
influences risky sexual behavior, and
resistance to treatment
Blacks/African Americans need culturally
and circumstantially relevant coping
strategies and education
Cultural affirmation is used as a
protective factor
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CTCA Theory…. Religion/Masculinity
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For many Black males, anxieties about
manhood, power and/or homosexuality are
linked to ideas of Black male failure – failing
God and/or the Black community
For many Black females self-concept issues,
assumptions about male [partner] sexual
history, and gender power imbalance
impacts risk-reduction capacity
(Peterson et al., 1998; Dowd, 1993; Wright 1993)
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BMSM are a highly diverse population
requiring a fluid and dimensional HIV
prevention and care response, that
addresses behavior and not sexual
identity/labels as a primary focus. BMSM
benefit from HIV programs that explicitly
affirm and include SGL and bisexual
males in its architecture, and that affirm
and create space for BMSR who do not
sexually identify. This can also build
community among these diverse males.
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In-Forming the CTCA intervention
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Identify and train diverse BMSM, over 18, to
recruit and interview Black men to inform the
CTCA prevention strategy
Select recruits who fit criteria (BMSM with
adequate HIV literacy levels, and who report
practicing protected (anal and/or vaginal)
intercourse as “Very Difficult [not sexually
protected most of the time]”
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CTCA Pilot – Inclusion Criteria
SUBJECT RECRUITMENT:
Random-Via Focus Groups/Informants/Social Networks/Cultural Activities
INCLUSION CRITERIA:
Self-identified (SI) Black or African American
Self-identified (SI) (behaviorally) as MSM or MSM/W
Over 18 years of age
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MSM who SI as gay
MSM who do not SI with or as gay
MSM who SI as bisexual
MSM who SI as heterosexual; experienced or involved in: MTM
survival sex, MTM sex during incarceration, or who identify as a
“sexual [super] freak”
Involved in unprotected sexual activity in the last 12 months
History of Incarceration (not strict criteria)
History of substance use (not strict criteria)
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In-Forming the CTCA intervention
Recruitment
Palm cards for recruitment/awareness
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In-Forming the CTCA intervention
Population
Average age of men recruited – 24.8
150 men recruited
67 reported behaviorally as MSM (homosexual,
bisexual, gay identified, heterosexual identified
with incarcerated or survival MTM sexual experience)
39 (26% of the sample) reported practicing protected
anal sex as “Very Difficult (not sexually protected
most of the time)”
32 agreed to participate in CTCA Pilot
Self described sexual behaviors:
59% “versatile”
31% “bottom” (receptive)
9%
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“top”
(insertive)
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In-Forming the CTCA intervention
Themes
SEMI-STRUCTURED INTERVIEWS (N = 32):’Barriers to Safer Sex
Practice’ - Themes [Among BMSR with 100% HIV competency]:
Conflict with same sex desire/behaviors
Concern about perceived compromised manhood
(masculinity)
Disorientation about societal value as a Black male
and/or as a male with same sex desire
Sexual shame (guilt)
Low value (and low planning) for long life
Loneliness/Isolation (no feeling of community)
Mental/Emotional fatigue
Substance Use
“I don’t know”
History of sexual assault
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Presentation of researched-based
behavior change methodology
CTCA: An Evidence-Based Intervention
z The Critical Thinking and Cultural Affirmation (CTCA)
model, uses a Cognitive-Behavioral approach to
prevention and risk reduction.
Social Cognitive Theory (SCT) is at the foundation of
CTCA. CTCA is a culturally based approach that
addresses the impact of societal challenges (i.e. race and
gender based self-concept dilemmas, peer pressure,
negative social influences, being – or the perception of
being - disenfranchised, etc.) on Black males. And
addresses identified barriers to retention of or access to
HIV prevention messaging and behavior change.
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Presentation of researched-based
behavior change methodology
Social Cognitive Theory
z Social Cognitive Theory (SCT) focuses on how
people acquire and maintain behavioral patterns,
while providing a basis for intervention strategies.
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Presentation of researched-based
behavior change methodology
SCT is rooted in the view of human agency where individuals are
proactively engaged in their own development and can make things
happen by their actions. According to Albert Bandura (1986) key to
the sense of agency is the fact that, among personal factors,
individuals possess self-beliefs that enable them to exercise a
measure of control over their thoughts, feelings, and actions and
that “what people think, believe and feel affects how they behave.”
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Mental Health Themes - HIV
STATES OF MIND THAT DEMAND INTERVENTION–
HIV+/HIV-:
Among HIV positive Black men interviewed some considered
knowing that they were positive as a stress reliever (because
now they could stop "worrying about it”). Assuming that
other Black men share the same anxiety, some may
encourage partners to have unprotected sex with them. Not
by sharing that they were positive, but by helping - through
seduction and manipulation - to ensure that the sexual
interaction is not safe; to bring on “the inevitable” and
eliminate having to disrupt sexual expression and release
with diversions like condom use and preparatory thought.
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Mental Health Themes – HIV, contd.
TEMPORARY MOTIVATIONS FOR TREATMENT:
“If I get HIV, I can just take some drugs, and look and do
just fine.”
With treatment, some HIV positive people can still
successfully invest in a healthy appearance. HIV+ Blacks
need interventions that empower them to value their well
being at least as much as their appearance. Without such
intervention, unsafe sexual practices often continue, and
drug regiments are sometimes abandoned when the drugs
begin to negatively impact personal appearance.
The majority of Black men interviewed don't prepare to live a
long life; they just “hope” (in many cases) that they do.
Rarely do they consciously plan to live a long life.
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CTCA: Selection of Interventions
CTCA INTERVENTIONS:
„ one session weekly of individual psychotherapy within the
first 45 days of participation (choice of male or female
counselor), and/or weekly group sessions led by a trained
mental health professional. For the latter 45 days every
other week is an option
„ weekly peer group level discussion that focused on:
1) the history of accomplishment, cooperation and
success among Africans and African Americans of
diverse gender, sexualities and philosophies;
2) media and environmental literacy (deconstructing the
influence of media and mainstream institutions on Black
self-concept, manhood, culture and sexual prejudice);
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CTCA: Selection of Interventions
3) the benefits of critical thinking and self-respect; and
4) HIV 101 - Synthesizing Knowledge, Behavior and Practice
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The CTCA Model for HIV Prevention
Appropriate for the target population
(diverse, young adult, Black MSM):
Objectives:
1.
Promote critical thinking and develop informed perspectives on
inherited beliefs, and unlearn self-defeating or limiting myths
2.
Promote belief that reality is not “static” and that one can make
affirming and [HIV] risk-reducing and care life changes
3.
Provide practical engagement of realities relevant to race,
sexuality, masculinity, belief and gender roles as socially
reinforced, and then provide tools to effectively evaluate this
"reality"
4.
Increase commitment to changing risky behavior in tandem with
valuing [Black] self, community and potential partners
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CTCA
GOALS:
1.
Improve self-concept among participants
as Black men and/or men with
homosexual/bisexual desire or experience
2.
Encourage critical thinking
3.
Utilize self management skills for safer sex
negotiations, and treatment adherence
4.
Increase safer sex practices
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Implementation of CTCA
{
Session 1 – (Exercise) Black/African Literacy
“Name contributors to human history not born in the USA?”
Session 2 – (Discourse) Black Health Literacy – Why the
Disparity?
{
{
Session 3 – Black Images / Media Literacy
(Video/Film)
Girls Like Me
“Gangstalicious” – BoonDocks
Deep Impact
Antoine Fisher (example of CTCA)
Rosewood, Hannibal
Take Nigga From My Name
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Implementation of CTCA
{
Session 4 – Will the Real Black Man Please Stand up?
- What is a man?
- What qualities best describe a real [Black] man?
- Specifically, what qualities or actions make a [Black]
man less of a man?
- Who taught you these ideas?
- Why do they have credibility?
- Have these ideas benefited you personally? If so, how?
- Name three Black men you know personally that you
have great respect for?
- Do any of these ideas affect how you see yourself,
and/or your sexuality? If so, how?
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Implementation of CTCA
Session 5 – “NAS Syndrome” – Anti-Black Mantras and
Mythology - Deconstructing “Reality”
{
{
Session 6 – Check-In Reflection
Session 7 – What Living with HIV means - Synthesizing
Knowledge, Behavior and Practice
{
Session 8 – The Benefits of Critical Thinking & Cultural
Affirmation
{
Session 9 – Why We Resist Change (From Slave, Nigger,
Negro, Etc. Back to Nigger/Nigga)
{
Session 10 – Revisiting Commitment to Personal and
Community Health
{
Session 11 – Starting Another Epidemic – Leadership
Development and Graduation
{
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Evaluation Tools
Questionnaires with open and structured items were administered to subjects
to systematically gather key information about participant characteristics,
behavior, and experience. Trained facilitators read questions aloud, provided
clarification on the meaning of items, and allowed participants time to fill in
their response to each item in the instrument. The need of respondents for
privacy and confidentiality were accounted for in the design of group
processes.
•
Pre and Post Self Concept Assessments
•
Pre and Post Self HIV Risk Assessments
•
Psychotherapist Case Notes
•
Pre and Post Focus Group Interviews
•
Pre and Post Individual Interviews
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CTCA PILOT EVALUATION
EVALUATION:
1.
Pre-test (self concept/self-risk assessment questionnaires)
70% reported willingness to put self and sexual partners
(the community) at HIV sexual risk
b.
75% reported being a Black male as “traumatic”
(disorienting) (via 3 identified levels of oppression [racism/sexual prejudice)
c.
90% reported seeing no personal value to homosexuality
Post-test (self concept/self-risk assessment questionnaires)
a.
2.
a.
b.
c.
d.
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80% reported consistent use of safer sex practices
80% reported being no longer willing to put self and
intimate partner(s) at sexual risk
80% demonstrated increased levels of positive selfconcept as Black males
20%, most who were substance users in recovery, did
not fully benefit from 6 month study/intervention*
100% were tested for HIV and received results
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6 and 12 month follow-up
75% of participants reported consistent
retention of CTCA based messages and safer
sex behavioral practices
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CTCA PILOT
CONCLUSIONS:
1.
Improvement in self-concept, sexual
health and cultural pride/protection
2.
Promotion of critical thinking and proactive self-management
3.
Community building among diverse BMSR
reduced stigma
4.
Decrease in reported unsafe sex
5.
Increase HIV treatment literacy and
involvement
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CTCA PILOT
LIMITATIONS:
1.
Small sample size
2.
Selection bias
3.
No control group
*Scientifically
the data collected from the initial 150 males engaged, or 32 involved in the study can not be
determined as completely generalizeable. It is the experience of the Chief Strategist and Investigator
of the CTCA study that the co-factors described by participants are relevant to many Black males
putting themselves, each other and women at HIV/AIDS risk across the nation.
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Diverse Black male leadership development
to reduce HIV stigma
CTCA in Los Angeles 1994
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Same gender loving (SGL), Bisexual,
Heterosexual, HIV+ and HIV- men Building
community to prevent HIV
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CTCA in New York – Harlem – HIV Positive Leadership Among BMSR
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Diverse Black leadership to prevent
secondary and primary HIV prevention
Straight talk with Straight Sistas
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Starting a new kind of epidemic among Black
males
A Typical "Closing Affirmation" with Brotherly Hugs After Session
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Diverse Black Male Leadership Development
and Community Building
CTCA in Los Angeles
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How to reduce stigma and increase services
access to diverse HIV positive BMSR
• Thoroughly
train project staff, preferably consisting of
diverse members of BMSR sub-population & women
(HIV+/HIV-)
• Build community with, between and among BMSR
(HIV+/HIV-)
• Train staff on the history of stigma, specifically within
Black communities, e.g. “Stigmaphobia”
• Train staff on HIV treatment, adherence and non
adherence
• Don’t assume “gay” services address all BMSR
populations
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How to reduce stigma and increase services
access to diverse HIV positive BMSR
• Guide
clients toward ‘Black Health Literacy’
• Include staff training on sexual abuse, the culture of
incarceration; cultural affirmation & critical thinking
• Implement outreach/recruitment activities with a “widenet” approach
• Make sexual risks/category determinants through
behavioral interview, not “self-identity”
• When possible, provide individual & group support options
for mental health (or referral)
• When possible provide a [trained] couples counseling
option to services (or referral)
• Develop, adapt, implement innovative prevention and care
strategies for BMSR
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The AmASSI Critical Thinking & Cultural
Affirmation (CTCA) Strategy
{ CTCA
post-test measures indicate substantial
reductions in reported risk taking behaviors, and in
participant willingness to put self and sexual partners
(the community) at risk for HIV. Findings strongly
argue for intervention approaches that build selfconcept, develop leadership and normalizes HIV+
positive engagement among diverse BMSR
subgroups, are culturally responsive, and delivered by
skilled practitioners drawn from the client group of
reference.
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CTCA Update
Resulting from the initial success of CTCA the model
has been selected by the Universitywide AIDS Research
Program (UARP) in San Francisco for further study, in
collaboration with AmASSI–L.A., Los Angeles County
Department of Health Services - Epidemiology
Program, Charles R. Drew University of Medicine and
Science, and UCLA Sexual Health Program UCLANeuropsychiatric Institute.
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References
Social Cognitive Therapy:
Pajares (2002). Overview of social cognitive theory
and self-efficacy. 4.21.06. From
http://www.emory.edu/EDUCATION/mfp/eff.html.
Bandura, A. (1977). Social learning theory. Orville,
Ohio: Prentice Hall
Bandura, A. (1986). Social foundations of thought and
action: A social cognitive. Englewood Cliffs, NJ:
Prentice Hall
Pajares, F. (1997). Current directions in self-efficacy
research. In M. Maehr & P. R. Pintrics (Eds.).
Advances in Motivation and Achievement (10) 1-49.
Greenwich, CT: JAI Press
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AmASSI prevention strategies (featuring CTCA)
identified as “best practices” in following sources:
“HIV Best Practices,” HIV Prevention and Outreach Strategies Best
Practices, a publication of the United States Conference of Mayors
Best Practices Center, June 2001.
“Next Steps for Public Health,’ editorial, American Journal of Public
Health, 93(6), 862-65, 2003.
‘For Us, By Us,” POZ Magazine, Special African American Edition,
Summer 2003.
“Models of Effective Program,” What Works in HIV Prevention for
Women of Color, a project of AIDS Action, 2001.
“Grantees Address Racial and Geographic Health Disparities,” The
California Wellness Foundation Portfolio, Summer 2001.
“Effective Interventions for Young MSM,” presented at the National
HIV Prevention Conference, July 29, 2003. – Presenter, Dr. Darrell
P. Wheeler
Oppression, Black Men Who Have Sex with Men and HIV,” presented
at ‘Fighting Oppression: Preventing HIV Among MSM and MSM/W of
Color Symposium,’ 2003. – Presenter, Dr. David Malebranche
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CTCA participant and non-participant HIV Status
(HIV status of subjects unknown until after study)
CTCA study participants:
(N = 32)
9 HIV+
23 HIVRecruits not in study: 78 of 118 tested for HIV
CTCA study participants:
(N = 78)
11 HIV+
67 HIV10/15/2007
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