Black MSM tend to experience earlier sexual debut than their heterosexual counterparts, often with older, more experienced partners.32 It is not uncommon for young African-American MSM to have relationships with older Black MSM in order to have access to housing, food, and other resources to survive. These relationships, while often caring, have helped perpetuate HIV across multiple generations of Black MSM. Like African-American women, young Black MSM feel they cannot ask their older partners to use condoms, for risk of being cut off or threatened with violence. Many of these older Black men were infected through similar relationships in their youth, and in turn transmit HIV to their younger partners.33
Stigma, Racism, and the 4H Club
Stigma is perhaps the greatest driving force behind HIV infection among African-Americans. Both African-American men and women in many Black communities continue to express a deep reticence to embrace community members living with HIV/AIDS, despite the prevalence of the disease. It is not uncommon for families, fearing reprisals from others, to say that a loved one died of cancer rather than HIV. Michael K. Evanson, senior policy analyst in the Division of Science and Policy at the Health Resources and Services Administration (HRSA), HIV/AIDS Bureau (HAB), echoes this sentiment:
Unfortunately we are still dealing with stigma particularly in the South where the epidemic is still growing at a more alarming pace than in other areas of the country. You hear stories that people are still very much ashamed to have HIV due to religious beliefs and cultural stigma. People view the disease with a lot of disdain and blame those who are living with it. There are certainly huge barriers that still exist [to testing and care.].
Many recount stories of family and friends fearing they might contact HIV through casual contact. Black PLWHA often are forced to eat with disposable cutlery, plates, and cups during social gatherings, and often find their hosts cleaning whatever they touched with disinfectant.
Distrust of the medical system as well as HIV stigma in the African-American community contribute to testing and engagement in care barriers.
“Admitting that you have HIV is a hard thing. It is hard to even admit it to yourself,” says one gay man from Washington, D.C. “It was difficult for my family to accept my diagnosis and me for a long time. They couldn’t see that I was the same person.”
Stigma is not only a barrier to screening and diagnosis, it is one of the leading reasons why many African-Americans do not seek out or stay in care. Some Black patients point to bad experiences in the past with providers who did not understand how to address the needs of African-Americans living with HIV. “Before doctors and nurses really got trained, we were turned away. People didn’t want to touch us, or treat us. It is a memory that is hard to forget,” says a Black gay man who has been living with AIDS for the past 25 years. “Who would want to subject themselves to that? And unfortunately many people still anticipate that kind of treatment and stigma when they seek out care in 2012.”