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The ‘Down Low’: More Questions than Answers. Greg Millett, MPH Epidemiology Branch Division of HIV/AIDS Prevention National Center of HIV/STD/TB Prevention. Overview. Introduction to the ‘Down Low’ Epidemiology of HIV/AIDS Black MSM Black Women Relevant Studies Gaps and Recommendations.

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The down low more questions than answers l.jpg

The ‘Down Low’: More Questions than Answers

Greg Millett, MPH

Epidemiology Branch

Division of HIV/AIDS Prevention

National Center of HIV/STD/TB Prevention


Overview l.jpg
Overview

  • Introduction to the ‘Down Low’

  • Epidemiology of HIV/AIDS

    • Black MSM

    • Black Women

  • Relevant Studies

  • Gaps and Recommendations



  • What is the down low l.jpg
    What is the ‘Down Low’?

    • Black men

    • Heterosexually identified

    • Have sex with men

    • Don’t tell female partners


    Assumptions about men on the dl l.jpg

    Identities

    Black

    Male

    Heterosexual (gay’ or ‘bisexual’ do not apply)

    Masculine

    Shun mainstream gay subculture

    Transitional rather than permanent status

    Partners/ Practices

    Casual male partners

    Steady female partner

    Nondisclosure of MSM activities

    Unprotected sex with both female and male partners

    Assumptions about Men on the DL


    Assumptions about men on the dl6 l.jpg

    Identities

    Black

    Male

    Heterosexual (gay’ or ‘bisexual’ do not apply)

    Masculine

    Shun mainstream gay subculture

    Transitional rather than permanent status

    Partners/ Practices

    Casual male partners

    Steady female partner

    Nondisclosure of MSM activities

    Unprotected sex with both female and male partners

    Assumptions about Men on the DL


    Assumptions about men on the dl7 l.jpg

    Identities

    Black

    Male

    Heterosexual (gay’ or ‘bisexual’ do not apply)

    Masculine

    Shun mainstream gay subculture

    Transitional rather than permanent status

    Partners/ Practices

    Casual male partners

    Steady female partner

    Nondisclosure of MSM activities

    Unprotected sex with both female and male partners

    HIV Status

    Unaware of HIV status

    Nondisclosure of HIV+ status to sexual partners. 

    Assumptions about Men on the DL


    Assumptions about men on the dl contd l.jpg
    Assumptions about Men on the DL, contd

    • Culturally- and race-specific term

      • Assumed Black men are on the down low

      • Other racial/ethnic groups engage in identical behaviors

    • Reasons it is a culture-specific phenomenon

      • Term arose from Black MSM community

      • General Black community identifies the DL as a problem

      • Press about the DL has focused entirely on Black men

      • Black men on the DL identify with term


    Assumptions about men on the dl contd9 l.jpg
    Assumptions about Men on the DL, contd

    • "I sleep with men, but I am not bisexual, and I am certainly not gay. I am not going to your clinics, I am not going to read your brochures, I am not going to get tested. I assure you that none of the brothers on the down low like me are paying the least bit of attention to anything you have to say." -JL King


    Evolution of a concept l.jpg
    Evolution of a Concept

    1991

    1994

    1995

    1996

    1997

    1998

    1999

    2000

    2001

    2002

    2003

    2004


    Evolution of a concept contd l.jpg
    Evolution of a Concept, contd

    “…So I creep yeahJust keep it on the down lowSaid nobody is supposed to knowSo I creep yeah'Cause he doesn't knowWhat I do and no attentionGoes to show…”

    “…And keep it on the down lowNobody has to knowWe can keep it on the down lowNobody has to know

    1991

    1994

    1995

    1996

    1997

    1998

    1999

    2000

    2001

    2002

    2003

    2004


    Evolution of a concept contd12 l.jpg
    Evolution of a Concept, contd

    1991

    1994

    1995

    1996

    1997

    1998

    1999

    2000

    2001

    2002

    2003

    2004


    Evolution of a concept contd13 l.jpg
    Evolution of a Concept, contd

    1991

    1994

    1995

    1996

    1997

    1998

    1999

    2000

    2001

    2002

    2003

    2004


    What is the uproar about l.jpg
    What is the uproar about?

    • "We will continue to lose sisters because men will not come out.” -JL King

      Down-Low' Activity Threatens Black Women’ by R Dotinga for Gay.com/PlanetOut.com Network 4/30/02


    What is the uproar about contd l.jpg
    What is the uproar about?, contd

    • “Too often the DL brother is constructed as the vessel of contagion… behind this …[is a ] heterosexist assumption that AIDS is born and bred in gay communities then venomously spread to pure, sterile black communities… [the fact is] that many …straight black people are HIV-positive and spreading the disease among themselves without any help from ‘evil’ black gay men.” Posted by Blackbrit 8/1/03 NY Times Magazine Web Forum



    Black men aids cases by exposure l.jpg
    Black Men: AIDS Cases By Exposure

    • 2002 AIDS cases among Black men:

      32% Men who have sex with men

      19% Injection drug use

      14% Men who have sex with women

      4% Sex with men/ Injection drug use

    N= 14,334


    Black msm hiv data l.jpg

    Initial dx of HIV among MSM ages 13-24

    Black 16% ; Latino 13%; White 9%(MMWR, 1/14/00)

    Among MSM ages 23-29

    HIV Prevalence: Black 32% , Latino 13%, White 7% (MMWR, 6/1/01)

    HIV Incidence: Black 14.7%, Latino 3.5%, White 2.5%. (MMWR, 6/1/01)

    Black MSM: HIV Data


    Black women heterosexual contact aids cases l.jpg
    Black Women: Heterosexual Contact AIDS Cases

    • In 2002

      • Black women 65% of heterosexual transmission AIDS cases among all women

      • 42% of AIDS cases among Black women was transmitted sexually

    • It is unknown what proportion of these heterosexually transmitted HIV cases are attributable to DL men in comparison to non-DL men


    Black msm prevalence of sex with women l.jpg
    Black MSM: Prevalence of Sex with Women

    * Different timeframes (‘ever’, 6 months, year, past 5 years)

    + Sex with ‘men and women’. No estimate of sex with ‘women only’ provided.



    Sexual identity and behavior l.jpg

    “… I think a lot of these young men only have wives or girlfriends to cover up their homosexuality. In the meantime, they are denying who they are...”

    Posted by Brandip 8/3/03 NY Times Magazine Web Forum

    Sexual orientation: to whom you are attracted (men, women, both)

    Sexual identity: how you describe yourself (to yourself and others)

    Sexual behavior: with whom you have sex

    (Purcell et al., 1996)

    Sexual Identity and Behavior


    Sexual behavior and identity l.jpg
    Sexual Behavior girlfriends to cover up their homosexuality. In the meantime, they are denying who they are...” and Identity

    • Black MSM studies mostly gay- ID men rather than bisexual men

    MSM Behavior Studies

    Gay ID

    Sample


    Sexual behavior and identity24 l.jpg
    Sexual Behavior girlfriends to cover up their homosexuality. In the meantime, they are denying who they are...” and Identity

    • Black MSM studies mostly gay- ID men rather than bisexual men

    • Studies of bisexually active men primarily bisexual-ID, not heterosexual

    MSM Behavior Studies

    Bisexually

    ID

    Sample

    Gay ID

    Sample


    Sexual behavior and identity25 l.jpg
    Sexual Behavior girlfriends to cover up their homosexuality. In the meantime, they are denying who they are...” and Identity

    • Black MSM studies mostly gay- ID men rather than bisexual men

    • Studies of bisexually active men primarily bisexual-ID, not heterosexual

    • Studies of heterosexual-ID men primarily men who only have sex with women

    MSM Behavior Studies

    Bisexually -ID

    Sample

    Gay-ID

    Sample

    DL men

    Heterosexually-ID Sample


    Heterosexually identified black msm sexual risk taking l.jpg
    Heterosexually-Identified Black MSM: Sexual Risk-Taking girlfriends to cover up their homosexuality. In the meantime, they are denying who they are...”

    (Wohl et al., 2002)


    Popular theories of hiv risk among dl men l.jpg
    Popular Theories of HIV Risk among DL Men girlfriends to cover up their homosexuality. In the meantime, they are denying who they are...”

    • Homophobia in Black community

    • Dual minority status (fragmented identities)

    • Nondisclosure of sexuality

    • Incarceration

    • Drug use


    Popular theories of hiv risk among dl men28 l.jpg
    Popular Theories of HIV Risk among DL Men girlfriends to cover up their homosexuality. In the meantime, they are denying who they are...”

    • Homophobia in Black community

    • Dual minority status (fragmented identities)

    • Nondisclosure of sexuality

    • Incarceration

    • Drug use


    Popular theories of hiv risk among dl men29 l.jpg
    Popular Theories of HIV Risk among DL Men girlfriends to cover up their homosexuality. In the meantime, they are denying who they are...”

    • Homophobia in Black community

    • Dual minority status (fragmented identities)

    • Nondisclosure of sexuality

    • Incarceration

    • Drug use


    Popular theories of hiv risk among dl men30 l.jpg
    Popular Theories of HIV Risk among DL Men girlfriends to cover up their homosexuality. In the meantime, they are denying who they are...”

    • Homophobia in Black community

    • Dual minority status (fragmented identities)

    • Nondisclosure of sexuality

    • Incarceration

    • Drug use


    Popular theories of hiv risk among dl men31 l.jpg
    Popular Theories of HIV Risk among DL Men girlfriends to cover up their homosexuality. In the meantime, they are denying who they are...”

    • Homophobia in Black community

    • Dual minority status (fragmented identities)

    • Nondisclosure of sexuality

    • Incarceration

    • Drug use


    Homophobia and aids phobia in black and white communities l.jpg
    Homophobia and AIDS-phobia in Black and White Communities girlfriends to cover up their homosexuality. In the meantime, they are denying who they are...”

    • “The ‘reporter’ or anthropological tour guide provided no basis for his assertion that blacks are generally more homophobic than whites…”

      Posted by Blublklove 8/4/03 NY Times Magazine Web Forum

    • Similar attitudes among Blacks and Whites re:

      • PWAs(Herek & Capitanio, 1993)

      • Homosexuals(Herek & Capitanio, 1995; Lewis, 2003)

    • Blacks and Whites have negative associations with gay sex and HIV(Herek & Capitanio, 1999)


    Sexual racial identity integration and hiv risk l.jpg
    Sexual/ Racial Identity Integration and HIV Risk girlfriends to cover up their homosexuality. In the meantime, they are denying who they are...”

    • Influence of racial and sexual identity on psychosocial functioning:

      • N= 174 Black MSM

      • Integrated identity associated with self-efficacy to engage in HIV preventive behaviors (Crawford, et al, 2002)

    Racial ID

    Hi

    Low

    Hi

    Sexual ID

    Low


    Disclosure and hiv risk l.jpg
    Disclosure and HIV Risk girlfriends to cover up their homosexuality. In the meantime, they are denying who they are...”

    • Compared to Black MSM who disclosed their sexuality, Black MSM nondisclosers:

      • Peceived HIV risk

        • Less likely to believe that they could become infected with HIV

      • HIV test and status

        • Less likely to report > 3 lifetime HIV tests

        • Less likely to be HIV-positive

      • Sexual partners and risk:

        • More likely to have> 3 lifetime female partners or report unprotected vaginal or anal sex with women

        • Less likely to > 5 lifetime male partners or report unprotected sex with men (MMWR, 2003)


    Prison and hiv risk l.jpg
    Prison and HIV Risk girlfriends to cover up their homosexuality. In the meantime, they are denying who they are...”

    • Few studies documenting homosexual activity among incarcerated Black men(Alarid, 2000; Lichtenstein et al., 2000)

    • Black MSM LA County (N=332)(Wohl et al., 2000)

      • No association between incarceration and HIV status

      • Higher rates of anal sex outside of prison

        • This finding was consistent across sexual orientation


    Drug use and hiv risk l.jpg
    Drug Use and HIV Risk girlfriends to cover up their homosexuality. In the meantime, they are denying who they are...”

    • Heterosexual-ID men (N=90 HIV+; N=272)

      • Cases more likely to use:

        • Heroin

        • Methamphetamine

        • Nitrites

      • No difference in trading sex for drugs between cases and controls

      • Cases less likely to report condom use when trading sex for drugs (Wohl et al., 2000)


    Summary l.jpg
    Summary girlfriends to cover up their homosexuality. In the meantime, they are denying who they are...”

    • Sexual orientation, identity, and behavior are not always congruent

    • Most previous research on Black MSM is not applicable to DL men.

    • Theories of HIV risk among DL men must be tested with DL populations


    Iv gaps and recommendations l.jpg

    IV. Gaps and Recommendations girlfriends to cover up their homosexuality. In the meantime, they are denying who they are...”


    Gaps and recommendations l.jpg
    Gaps and Recommendations girlfriends to cover up their homosexuality. In the meantime, they are denying who they are...”

    • Need additional qualitative and quantitative studies

    • Specify meaning of DL

    • Integrate probability-based methods into sampling procedures

    • Determine sexual risk of DL men in relation to other Black men


    Gaps and recommendations40 l.jpg
    Gaps and Recommendations girlfriends to cover up their homosexuality. In the meantime, they are denying who they are...”

    • Need additional qualitative and quantitative studies

    • Specify meaning of DL

    • Integrate probability-based methods into sampling procedures

    • Determine sexual risk of DL men in relation to other Black men


    Gaps and recommendations41 l.jpg
    Gaps and Recommendations girlfriends to cover up their homosexuality. In the meantime, they are denying who they are...”

    • Investigate contextual factors of HIV risk for DL men

    • Develop effective interventions for Black MSM


    Acknowledgements l.jpg

    CDC girlfriends to cover up their homosexuality. In the meantime, they are denying who they are...”

    Katherine Bina

    Lisa Fitzpatrick

    Alan Greenberg

    Charles Heilig

    Gary Marks

    Byron Mason

    Pilgrim Spikes

    Georgia State University

    John Peterson

    Acknowledgements


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