Subscribe >>



Living Classrooms

Culturally attuned messages delivered by peers may be the best way to stop HIV from surging among at-risk, "hidden" populations.

By Mat Edelson

HIV. They have it. And they pray that what they're learning in this room will help them to stop it from killing both themselves and those they love.

This second-story office overlooking Cathedral Street in downtown Baltimore once housed buttoned-down lawyers practicing jurisprudence. But on this early spring day, five African-American men in casual attire occupy the small space, their attention intensely focused on a PowerPoint presentation lighting up a side wall. Each, in his own way, is also seeking justice for himself and his friends. To their minds, the crime they've witnessed is nothing less than genocide, the perpetrator a potentially fatal disease that's vilely assaulted one out of every two men they know. It attacks body and soul, dividing families and friends, feeding on both poverty and desire.

Consider what's happening in this room a prototype. Or, better yet, a badly needed tweaking of existing HIV risk-reduction behavior models. The concept of fighting epidemics with peer educators—people infected with the disease and familiar to the at-risk community, who can be potent messengers of the educational message—isn't particularly new. What is groundbreaking is the realization that using a single educational model aimed at some amorphic group thought of as "gay" America simply doesn't work in all communities. It's a bit like assuming everyone enjoys the same kind of music. In the case of HIV prevention, many afflicted members of minority groups find the tune annoying at best and insulting at worst. They are ignoring the song.

Frangiscos Sifakis, PhD '02, MPH, discovered this truth while looking at epidemiological data from his 2004 study known as BESURE (Behavioral Surveillance Research Study). Part of a 25-city CDC study, Sifakis' team tested more than 1,000 mostly inner-city men who have sex with men (MSM, in public health parlance), and found a 52 percent infection rate among the African-American participants. These were infection levels far beyond those found in white and affluent communities. "My data indicate that there's an emergency situation here," warns Sifakis. When it comes to HIV prevention efforts in the inner-city MSM community, "the system failed," he says.

This failure in reaching culturally diverse pockets of the MSM community isn't unique to the U.S., he is quick to point out. A recent meta-analysis of countries including Brazil, Thailand, Peru and China—which he conducted in collaboration with Bloomberg School colleagues Chris Beyrer and lead author Stefan Baral—concluded that MSM in low- and middle-income countries had HIV infection rates up to nine times greater than the comparable heterosexual populations. "[MSM] ... are in urgent need of prevention and care," concluded the authors, whose study appeared in PLoS Medicine in December 2007.

In Moscow, where Sifakis has completed a behavioral assessment of over 200 MSM, the stigma associated with being HIV positive and an MSM makes prevention efforts tricky. Socially and politically, they are "a very marginalized group," engaged in what is considered to be almost an "illegal" activity, he says. "Not only do they have to register as an HIV case, but they have to register in terms of how it was transmitted to them, whether as an injection drug user or as a gay man. So you can imagine that people feel very, very uncomfortable getting tested."

In Thailand, Beyrer, MD, MPH '90, discovered how important cultural nuances are to the way HIV is measured and prevented. Beyrer, an Epidemiology professor who has extensively researched MSM HIV infection in Thailand, India, Russia and elsewhere, was surprised when so few Thai military conscripts reported having sex with other men. "I didn't believe the numbers," says Beyrer, director of the Bloomberg School's Center for Public Health and Human Rights. "Then one of the Thai interviewers told me the [way we had asked the] question was confusing." As it turns out, the conscripts didn't consider sex with Thai transgendered men—called "katoey"—to be sex with other men. Moreover, the Thai interviewer told Beyrer, "The way you ask it implies, in Thai, that they were playing the female role, and very few men are going to acknowledge that." When Beyrer rephrased the questions to include these cultural views, "the reporting of what we would consider same-sex behavior doubled."

Lessons like these have been crucial to Sifakis, as he is working to create culturally sensitive peer education models, both abroad in Russia (in partnership with Beyrer's Center for Public Health and Human Rights, with which he did the Moscow behavioral assessment), and at home in Baltimore with the second cycle of the BESURE study.

It is five men participating in this second cycle—all HIV positive—who are meeting in BESURE's offices above Cathedral Street, taking part in one of 12 sessions that will put their concepts of both themselves and HIV to the test. They are here to learn the importance of preventing their own re-infection (a different strain of the virus could complicate or compromise their existing drug treatment regimen). And they will be given training to become outreach counselors, to share the prevention message with those in their neighborhoods.

In their time here the men will role-play scenarios where they help people get over their fears of discussing their HIV status, confront the barriers they face in getting competent care, and analyze the health prevention message aimed at their community. All five men agree that their brethren aren't getting the message. But, says one, "I want to give people hope and help."

Sifakis notes that, historically, the public health community didn't address or even identify the cultural nuances in the African-American, inner-city MSM community. "We focus on the HIV part, but people have other worries. Getting infected with HIV is not their primary concern—survival is," he says, noting that finding food and shelter often trumps health concerns. "We can have educational programs that address the HIV problem, but if it's not addressed in the context of other social problems, it's not so applicable."

Complicating the picture is that the African-American MSM community consists of numerous subgroups that operate as unique social and cultural entities. African-American MSM meet at clubs, on the Internet, through sex workers, in IV-drug shooting dens ... In short, in numerous venues, each with their unwritten codes of conduct that often promote risk behavior. There's also a large group of closeted African-American MSM who operate on the "down-low" while maintaining a public heterosexual front, fearful of anti-gay discrimination. Add to that feelings of victimization and institutional racism, and you've got a difficult audience to quantify—and reach.

Fortunately, Sifakis can depend on a learned peer to make the potentially irrelevant very relevant for the BESURE participants. Lennie Green is Sifakis' prevention coordinator and peer education facilitator. Green, 52, is well-versed in the tragedy that is HIV, going back to when it was first called GRID: Gay-Related Immune Deficiency. "My social convoy was basically wiped out by this epidemic," says Green, who recalls at one point "going to two to three funerals a week. I got home from one funeral on a Sunday from New Jersey. I'm home three minutes. The phone rings. Somebody else had died."

Support JHSPH

The Johns Hopkins Bloomberg School of Public Health strives every day to keep millions of people around the world safe from injury or illness.

Make a Gift