Black Gay Men and HIV | Community HIV/AIDS Mobilization Project

Black Gay Men and HIV:

Next Steps in Research, Advocacy and Activism

Tuesday, February 13, 2007
6:30 - 8:30 pm
LGBT Community Center
New York City

In 2005, a Centers for Disease Control (CDC) study concluded that approximately 46% of Black men who have sex with men (MSM) in the United States are HIV positive. Why are the numbers so high among Black MSM and what is the federal government doing about it? In a climate of continued racial oppression and pervasive homophobia and stigma, how can we effectively respond to this epidemic?

This community forum addressed these questions and more. Speakers presented the latest research about Black MSM and HIV as well as explore what organizations and individuals can be doing to fight for prevention justice for Black gay and bisexual men.

Speakers:
Robert K. Burns, Mazzoni Center; Philadelphia Black Gay Men’s Leadership Council
Dr. Mindy Fullilove, Columbia University
Mark McLaurin, New York State Black Gay Network
Greg Millett, Centers for Disease Control and Prevention (CDC)
PowerPoint Presentation
Moderated by: Anthony Morgan, New York State Black Gay Network

Co-sponsors:

Community HIV/AIDS Mobilization Project (CHAMP)
Gay Men’s Health Crisis (GMHC)
LGBT Community Center
New York State Black Gay Network
People of Color in Crisis

Summary:

Welcome: Anthony Morgan, New York State Black Gay Network

I have worked in HIV prevention for 6 years, in the areas of youth and young adult development, treatment and education. I've been struck by how AIDS turned 25 this year, which is also my age and that of my friends. Thanks to CHAMP and the following co-sponsors for hosting this event: New York State Black Gay Network, People of Color in Crisis, LGBT Community Center and the GMHC.

I work at the New York State Black Gay Network, and we’re working towards building the capacity of the organization to better address black gay men's issues related to HIV. Black gay men carry a heavy burden of HIV infection. In 2005, a CDC study concluded that over 45% of black men who have sex with men (MSM) were HIV-positive. So, regarding HIV and African American men, the house is not only on fire but it is burning to an ember - and we need to get a new fire hose or otherwise salvage the house.

This is one of many dialogues that are occurring across the country about black gay men. The intention for tonight's conversation is that it be an action-oriented dialogue. With your questions and comments, we hope to chip away at this issue and get closer to understanding why rates of HIV infection are so high among black gay men. Some of the questions we hope to answer are:

Why is the epidemic growing in context of pervasive homophobia?

Where do African Americans figure into discourses of what is a gay community? Neighborhoods? What does displacement mean and what is the impact of it on the black community? How does the uprooting of black neighborhoods have an impact and/or drive AIDS in the black community?

What are the policy issues regarding how black gay men are impacted by HIV?

And, we will explore what organizations and community groups are doing to address the crisis.

Greg Millet, Centers for Disease Control and Prevention (CDC)
PowerPoint Presentation

Tonight I will present only a brief overview of the epidemiological research that others and I have done. My goal is to introduce some of the types of research that has been conducted regarding black MSM (men who have sex with men).

African American MSM are at exceptionally high risk for HIV. Black MSM comprise the highest proportion of new HIV diagnoses in 33 states from data collected from 2001-2004. Black MSM represents 49% of HIV incidence (new diagnoses of HIV) during this time period.

The proportions for other categories are:
-- High-risk heterosexuals: 25%
-- Intravenous drug users (IDU): 19%
-- MSM & IDU (combined risk factors): 5%
-- Other: 1%

African American MSM are infected with HIV at younger ages, have a much higher prevalence and incidence than Latino and white MSM, and are more likely to have undiagnosed HIV infection.

Black MSM have a faster progression from HIV to AIDS diagnosis than white MSM. Black MSM also are more likely to die of AIDS than Latino and white MSM.

A number of issues regarding study design and participation in HIV research of MSM hinder an understanding of the relationship between HIV infection and risk behavior in black MSM. As a result, there is little if any research that offers good, intricate statistical analysis to compute correlations between black MSM HIV infection and specific behaviors that put black MSM at risk of acquiring HIV. Generally, studies on MSM and HIV do not adequately explain why rates of HIV infection are higher for black MSM.

Some of the reasons why research on MSM does not address the specificity of HIV among black MSM are:

(1) Studies enroll few black MSM.

(2) Studies group all MSM together in analyses. This is a problem because there are different predictors for different groups, such as income groups.

(3) Studies utilize non-random samples: researchers recruit friends, use convenience samples rather than probability-based samples. Since studies do not use random samples, it is not possible to generalize study results to specific communities of black MSM.

(4) Most significantly, research on black MSM places emphasis on particular domains of study, such as demographic, psychological and behavioral approaches. Though this work can be valuable, few studies include study of socio-cultural issues that drive HIV transmission among black MSM. Examples of these socio-cultural issues are the role of the church and stigma, or structural issues like the relationship between incarceration and HIV in the black community and/or racial disparities in healthcare access.

An illustration of the nature of the cumulative HIV/AIDS research with black MSM depicts the overwhelming focus on demographic, psychological and behavioral questions. This body of knowledge is not balanced by enough attention to the sociocultural and structural causes and influences on HIV transmission among black MSM.

I was the lead author of a review of research published in the American Journal of Public Health in 2006 entitled “Greater Risk for HIV Infection of Black Men Who Have Sex With Men: A Critical Literature Review.” Since 1987 when data was being collected, we’ve known that the risk behaviors reported by black MSM are comparable if not fewer than white MSM. Nevertheless, there are still considerably higher HIV rates of HIV infection among black MSM than white MSM. We developed hypotheses based on what was mentioned in the literature and what CBO partners said. Hypothesis were arranged into three categories: 1) not supported, 2) supported, and 3) inconclusive or contradictory evidence.

We found several noncontributors to high HIV prevalence among black MSM -- that is, the following hypotheses do not describe why black MSM acquire HIV at higher rates than other MSM racial/ethnic categories.

(1) Sexual Risk Behavior: One hypothesis is that black MSM are more likely than other MSM to engage in high-risk sexual behavior. This, however, is not supported by the research literature. In all of the articles reviewed that address this issue, it was conclusive that black MSM actually engage in less unprotected anal sex, have fewer partners, and are less likely to engage in commercial sex work than other MSM.

(2) Non-gay identity: Another hypothesis posits that black MSM are less likely than other MSM to identify as gay or to disclose their sexual identity, which may lead to increased HIV risk behavior. This is especially important given the controversy around the rhetoric of the "down low.” While black men are less likely to be gay-identified or to disclose their sexual identity, the literature does not say that this is related to greater HIV risk behavior – it is not predictive of HIV risk behavior. Nondisclosure of sexual identity is actually correlated with lower risk behaviors and fewer male sex partners, and low likeliness of being HIV positive.

(3) Substance use: A third hypothesis claims that black MSM are more likely than other MSM to abuse substances, especially injection drugs, that increase their risk for HIV infection. The literature does document that black men are as likely or less likely as other MSM to report alcohol or drug use. However, data gets more convoluted when researchers look at drug use during sex (which is a real risk). The studies contradicted themselves and were inconclusive. The only data that conclusively shows higher rates of drug use among black MSM is crack use; however, for other drugs, the research shows that there is usually a lower prevalence of drug use among black MSM than other MSM.

The literature review did reveal that there are several unique contributors to high HIV prevalence among black MSM. That is, the following explanations help to explain why black MSM may have higher rates of HIV-infection than other populations of MSM.

(1) Higher prevalence of sexually transmitted diseases (STDs): Black MSM are more likely than other MSM to contract sexually transmitted diseases that facilitate the acquisition and transmission of HIV. There are some higher STI rates among black MSM than other MSM groups.

(2) As a group, less frequent HIV testing -- black MSM are just as likely to report ever getting testing as other MSM, but less likely to be tested frequently, and are also more likely to be unaware of their HIV infection compared with other communities. Since black MSM get tested less frequently, they are less likely to know their HIV status. As such, they may unknowingly expose their sexual partners to HIV by engaging in more risky behaviors for HIV transmission than by men who know that they are HIV-positive. Furthermore, less frequent HIV testing for black MSM also helps to explain why unrecognized HIV infection rates are so high.

(3) Black MSM report different patterns of utilizing healthcare than other groups: Less than optimal use of preventative healthcare services has been associated with higher viral loads for HIV -positive persons. Higher viral loads, in turn, are associated with a greater likelihood that an HIV positive person would transmit HIV to sex partners.

(4) Characteristics of black MSM sexual networks: Black MSM are more likely to have sex with other black MSM. Since HIV prevalence is so high already in this community, then the likelihood of having sex with another HIV positive person is quite high. On the other hand, even though Asian/Pacific Islander (API) MSM report more risk factors associated with HIV infection, the current prevalence of HIV among this population is so low that there continues to be a low rate of HIV infection among API MSM.

The literature revealed that there are a number of inconclusive hypotheses for the greater HIV prevalence among black MSM. For the following issues, we simply don't know what is going on conclusively. There is insufficient or conflicting scientific evidence for the following possible explanations for greater HIV prevalence among black MSM.

(1) Biological or genetic explanations: inconclusive evidence that this might be a factor.

(2) Circumcision: Though some research demonstrates that circumcision reduces the likelihood of acquiring HIV, there is no data specific to black MSM living in the US to evaluate the role of circumcision in association with HIV status. Though white MSM have higher rates of circumcision than aggregated non-white MSM, there are contradictions in the data. For instance, black MSM have higher rates of circumcision than Latino MSM; yet, Latino MSM have lower rates of HIV infection than black MSM.

(3) Known HIV partners: it is not known from existing research whether or not Black MSM have sex with partners known to be HIV positive and what role this phenomenon would have on rates of HIV infection given the possibility that they might.

(4) Adherence to anti-retroviral therapy: Lower rates of adherence to HIV medications by HIV positive individuals are associated with a greater risk of transmitting HIV to others; however, there are mixed conclusions in research as to whether black MSM are less likely to adhere to anti-retroviral therapy than other MSM.

(5) Role of incarceration: Though black MSM are more likely to report a history of incarceration than other MSM, there has only been one study to test the association of incarceration and HIV infection with black MSM. This study found no association. There simply are not studies that allow us to understand the role that incarceration plays or does not play in driving HIV infection among black MSM.

There are major limitations with behavioral intervention research for black MSM. Of 129 scientifically evaluated effective behavioral interventions targeting Black participants, only two exclusively target black MSM. That is less than 2% of the intervention evaluations. This really is criminal given the high rates of HIV in the black MSM community.

The CDC is looking at exploratory research on structural and socio-cultural topics.

-- Brothers y Hermanos program
-- Racial identity and masculinity
-- Internet sex seeking
-- Association with high risk of HIV

Currently there are a number of new and ongoing research studies, including exploratory research addressing structural and sociocultural issues.

-- Internet interventions
-- Community-level -- can we influence community norms around HIV risk behavior?
-- Unrecognized HIV infection -- social networks, alternative testing and PCRS (partner, counseling and referral services).
-- Popular opinion leader intervention -- can we adapt strategies in the white gay male community to black MSM communities?
-- Tenofovir trial in Black MSM communities.

We need to realize that the CDC has a commitment to do research among black MSM. Two months ago the CDC made it quite clear that this is where the CDC focus is right now.

Dr. Mindy Fullilove, Community Research Group, Columbia University

I am a research psychiatrist and a professor of Public Health at Columbia University, and I have worked in AIDS since 1986.

Now I want to address the fact that the title of this forum is Black Gay Men and HIV -- but I am not a black gay man (laughter). But what I have common with black gay men is that we both draw our identities from two different communities. Black gay men draw their identities from the both the black and gay communities. I also have two identities as a "mulatto." I want to start by talking about my identity, because it is quite a complex thing to draw identity from two spaces. In my case, my mother was white and my father was black, and they married and had children in the 1950s when miscegenation laws were still on the books in many states [that is, laws that forbade white and black people from having children, who would be of "mixed race"]. Fortunately, I grew up in New Jersey where it was legal for my mother and father to wed, but such unions still were not culturally accepted. I was not accepted by others in childhood, and I was tormented.

Many years later, I made a movie about HIV and AIDS that spoke to issues of multiculturalism. I was chatting with a person, a young black man, I was interviewing, who is someone who happens to be from my childhood neighborhood back home. After reminiscing about their old neighborhood, this man acknowledged that other kids in the neighborhood tortured me. Then he told me that he had something to give me, and he told her the names of all of the boys in the neighborhood that he had had sex with -- and it was a lot of boys! He disclosed this information to me in the spirit of solidarity, so that I would have some power, since I would have information that they did not know that I had. This man understood what it is like to draw an identity from two different places and to be rejected by both.

Not only do black gay men draw identity from two places, but both of those places are unstable. The gay world is extremely unstable -- it is formed in defiance of larger society. And so if you draw your identity from two unstable places, how do you remain stable? And how do you control infections if you are unstable? There is no way to control infections in the presence of dual instabilities.

I will start to talk about the black community and its instabilities. There is a complete lack of research of the social and cultural causes of the HIV epidemic. This is the domain that my husband [Dr. Robert Fullilove] and I are engaged in research. We are not adequately funded to do this work; it is not even considered to be a part of AIDS research. Once I was invited to a CDC meeting to talk about structural issues, which included issues like racism and homophobia. But the specific instructions were that we would not talk about those things because they felt that there was nothing they could do to change them. I declined the meeting.

But these things frame our lives; they are a part of our lives. If our neighborhoods are attacked, we can't stay healthy.

This box is the world -- the way in which these buildings and neighborhoods are what you might call an exoskeleton on the outside. We also have communities. The Pittsburgh Hill District is one of thousands of black communities that developed after the first great black migration around the First World War, when manufacturing jobs were available in the North and Midwest. People could make not a good living, but a decent living. Black people lived in segregated neighborhoods and made a community life.

It would be hard for the US government to fund studies to excavate the oppression that the US government inflicted upon people. We don't know how we will ever get the work done that we need to have done, and I put this issue of funding out there. The US government is not going to pay for this. After all, racial segregation and "redlining" was a government policy -- these things did not happen by accident, but as a consequence of deliberate policy.

"Redlining" is a system that says if you are not white and you live in an old building, then your neighborhood was is not a good site of investment. Investment only was for areas with new buildings and white people. And even one non-white person was enough to bring down the investment rate of neighborhoods. So if you ever wondered why people get so frantic when black people move into neighborhoods, it is because it only takes one to destroy the economic rating of the neighborhood.

So now we have two government policies. We talked about segregation -- people were forced to live in ghetto areas. On top of that, the US government declared that the ghetto areas were not good sites of investment. And on top of that, they came up behind that 12 years later and declared that these neighborhoods are blighted and that they need to bulldoze them. So that's what they did. Urban renewal came next.

For example, where Lincoln Center is today was once a black neighborhood.

Where did these people go? They were dispersed. What happens when you get dispersed? Networks were broken. What happens when your networks get broken? A whole series of catastrophes happen when networks are broken. It is our social networks and their integrity -- dense, mutual networks of mutual aid keep people healthy. You can be quite poor and be very healthy, you don't have to be rich to be happy. When you displace people, you damage their networks, and you send them into a new state. Part of this new state is that the networks are much smaller and they have trouble communicating.

The processes of segregation, redlining and urban renewal left smaller networks in their wake. These remaining, smaller networks have trouble communicating -- it's like trying to communicate over a noisy channel. Messages can't get through, so people had to devise new ways of communication in these environments experiencing extreme disruption.

So, people had to resort to other communication strategies on a continuum of fist / stick / knife / gun -- that's a transition of communication in a noisy channel. When the noise is too loud, people go to each one in progression. If I can't get through to you by just talking, I use my fist. But when that stops working and the disorder of the community goes up, I use a stick. And if that stops working I take a knife and if that stops working I go to the ultimate equalizer, which is the gun.

In the midst of the collapse of the black community, in the period after urban renewal in the seventies, the gay community came out in mass at same time that urban renewal campaigns were underway, and gay people settled into ghettos. These are displaced people. Homophobia causes gay people to come to these places out of their communities of origin. Being gay back home will cause them to experience violence against their person. They established communities. But today, gentrification and more subtle market forces displace them. Where do they go? They get dispersed and go to the four winds and their networks are shattered. In this context, black gay men find themselves on two icebergs that are melting. And trying to stay healthy.

I also want to address the issue of "down low," which is an idea that attempts to explain why HIV is spreading within the black community. This is a rumor with no substance. In essence, a rumor plus injustice leads to a riot. This rumor led to a quiet riot in which lots of rage needs a target. And since black gay men are out, they are thus a visible and vulnerable target.

Black gay men, like me, are mulattos -- those who draw from two cultures never live in a culture of our own, because they live between two worlds. The issue is to get these small fragments of reality to recoalesce into some larger holes that are less involved with rejection and stigmatizing. Getting the black world and gay world and the whole world to come together and understand that they don't have to hate us just because we are not like them -- that we are something new, that we invented ourselves -- that is the job before us. We cannot imagine ourselves in isolation -- we must constantly imagine ourselves as drawing from the worlds from which we come. But creating it!

Mark McLaurin, New York State Black Gay Network

Tonight I will talk about the history of the HIV prevention movement among gay black men. Much of this anecdotal. In my experience, the HIV prevention advocacy movement among Black Gay Men is characterized by two things.

One of these things, whether you talk about Atlanta or LA or NYC, the discussion about providing HIV prevention services for black gay men speaks to an environment that is crisis-driven. Probably similar to other communities, but not exactly the same. Most of time when hear about some sort of black gay agency or initiative, it often started in someone's living room. A few people get together, acknowledge that the funerals have not stopped, all of us are still sick, so what are we going to do? These sort of indigenous community responses began to evolve in the black community, and they were crisis-driven. That has implications for how we do work now.

Another word that would characterize the early work of black gay male HIV prevention advocacy was that it was balkanized. There were all of these factions do work and different factions did not always talk to each other well. That was one of the initial tensions of getting people together to do this work. People working in different cities did not communicate with one another very well, so when you try to call a national meeting together with the CDC (who did try to call us together on a couple of occasions), it was hard. But the CDC was also part of the problem of why we weren't talking to one another anyway. So you had this weird issue of the CDC calling us together to talk about the problem that they are largely responsible for creating.

Also, this is a movement that is both under and over resourced. How is this possible? In many respects, there is not enough money devoted to address HIV infection among black gay men. That is a no-brainer. But the part of the problem in a movement that is both crisis-driven and balkanized is that organizations could actually be over-resourced. In the very beginning, the person who started an agency in a living room and cobbled together the articles of incorporation and their board consisted of their family and friends. Then the CDC awarded them with grants. But without the internal infrastructure to handle the money these organizations started to fail. There were, for example, no internal controls for cash flow planning or boards that were involved in organizational planning, as many of these early groups were ad hoc in nature.

But, above all, this was a movement and is a movement that is heroic in nature. These are people who came together against all odds and continue to in the face of unspeakable tragedy, of remarkable intransigence on the part of federal, state and local governments, private and community foundations and quite frankly on the part of the communities in which they existed, to do the work that we needed to do. Many of the folks that started are gone now but we carry on in their footsteps and memory. This a heroic movement with many names known and unknown.

Moving forward -- one of things that sparked most recent advocacy was the fact that the latest surveillance from the CDC in 2005 suggest that 46% of random sample of black gay men in 6 major cities may be HIV-positive. This is a problem of monstrous proportions.

But people forget that the CDC came out with numbers in 2000 that something like 36% of black gay men are HIV-positive, and in 1995 that number was 31%. It has always been disproportionate among black gay men, but for some reason the figure of 46% struck a nerve with someone. But this is a long standing problem, and not something that just recently occurred. Now there is a new sense of urgency to fashion a response in terms of black gay men.

A couple of things are new, however, since the CDC reported the 46% prevalence rate.

One of the things is a new recognition of the impact among young black MSM; there may not have been that recognition a few years ago. When I got involved a few years ago, there were not any young people around those prevention tables. Now there are more and there is an increasing recognition of problem being concentrated among young black gay men. So we see more attention to the house and ballroom scene. Some advocates recently had the opportunity to have an audience with Secretary John Agbenobe, who is second in command under the Secretary of Health and Human Services to talk to him about issues like the house and ballroom community, which illustrates how far we have come to talk about more specific groups of marginalized black and Latino gay men.

In policy and programs arena, another battle has been to fund HIV prevention campaigns for black gay men -- particularly that simply inserting a black person in the same campaign targeting white gay men without addressing the cultural specificity will just not work. Initially, when there was a rush of monies and efforts to address HIV prevention for black gay men, agencies took these hot, safe sex condom posters and simply replaced the white model with a black one. Then these groups would claim they were devoting efforts to black gay men without at all addressing the cultural specificity and particularities around that particular community. Something that more and more has become an article of faith around those do HIV prevention, and more importantly around those who fund HIV prevention, is that there are some specificities in these communities that you have to address if you are going to address HIV prevention in an effective manner

Lastly, one of the things we have seen in the last five years is that there really has been an increase in community activism and mobilization in different communities. For instance, there is a fledgling network of black prides in places like St. Paul, Minnesota. They are springing up all across the county, which is a manifestation that community mobilization is beginning to occur. One of the most salient examples of that is here in the city is with People of Color in Crisis’s black pride event. This is not only a black gay pride, but it is also an HIV prevention intervention and community mobilization. I think they have 20,000 people who come and access services during the weekend. [For more info see www.prideinthecity.com].

Looking forward, new things happening are that the National Black Gay Men's Advocacy Coalition (NBGMAC) was formed a year and a half ago. This group formed because black gay men need a voice on policy issues that impact them in Washington DC. The group now has a staff member and has set up meetings with officials.

We also see less infighting now among those of us doing work on a national basis. An example of the greater cooperation is that NBGMAC probably could not have been established 10 years ago.

There are a couple of foreboding issues for the future. One problem is the new tendency to subsume the black gay community under other community's banners (like within African American community or within the gay male community). But we need a distinct and separate seat at the table when we talk about HIV. We are willing to carry that water for both of those communities when it is appropriate, but this community needs to have its specific characteristics recognized by having its own seat at the table.

Another thing going forward that we really need is research. Like Greg said, we have little research on what really works with HIV prevention in the black community. The CDC may give us $100,000 to do HIV prevention in the black gay community, but we don't necessarily have research to show us what really works. We have ideas, but we need to figure out what really works with new research.

I recommend that we all involved get in touch with community and/or national groups around black gay men because this is an exciting and challenging time to have a chance to change the face of AIDS in the black gay men community.

Robert K. Burns, Mazzoni Center, Philadelphia Black Gay Men's Leadership Council

Everyone in here has a voice. It is very important to recognize that you have voice regardless of what community you are working in. Not using your voice could put you in a compromising position. It is important to be involved on a community level.

I've been doing this work since I was 21. Now I am 31 and I must admit that I am tired. I started doing this work when I was involved with a partner who was miseducated.

I started doing outreach work with the AIDS Task Force in Cleveland. Though the project I worked on was housed within a white gay organization, we were able to successfully run a program for black gay men that we could not do in traditional black organizations because we felt that such organizations could not provide the right level of services for black gay men.

Later I went to Philadelphia. At Lincoln University, I took a role as the director of a CDC-funded project focusing on Black, Latino and Asian men. I also got involved in the ballroom community. For those of you who don't have an understanding of the ballroom community, think of Paris is Burning, but that represents only a portion of what is going on in that community. If you have a negative impression based on the stereotypes that illegal activity goes on (such as back-alley operations), some of that is true, some isn’t -- but there are processes that got me involved in it.

It gave me a chance to do a lot of on-the-ground work in order to get community to hear something different than they had heard before.

I got involved in the Philadelphia Black Gay Men's Leadership Council. We organized as black gay men based upon a community advisory board we were on, and we responded to that statistic released in 2005 that said that 46% of black gay men were HIV positive. We were dismayed by that information, and we decided that we need to figure out how to do something else to respond to this situation. We wanted to do something different to affect this issue because the numbers in Philadelphia were astonishing. Many of the black gay men testing positive were doing so during their first testing opportunity -- these men were finding out they were HIV positive when they had never even had an HIV test before. So we had to do something.

So we started getting organized, and shortly thereafter we were hit by a media campaign. Now, in Philadelphia, we are dealing with significant issue around violence. There are hundreds of murders in the city. Meanwhile, the City of Philadelphia developed a media campaign to encourage black gay men to get HIV testing. But this marketing campaign depicted black men in the scope of a gun. This was astonishing to us, given the epidemic of violence in which black men have the highest murder rate in the city. We approached the city to talk to them about our problems with the marketing campaign. But it was to no avail, and the campaign launched anyway. Therefore, we mobilized to get it removed. [For more information, see the report from CHAMP’s forum “Selling Us to Ourselves?” here: http://www.champnetwork.org/index.php?name=nysale]

We sent the message that this is not acceptable for our community. And we won; the campaign was discontinued. Our organizing allowed us to develop partnerships with Department of Health in Philadelphia. In partnership with City of Philadelphia, we developed a very successful HIV prevention campaign around a Kwanza event, and we also did a campaign around a LGBTI conference by hosting several plenaries and workshops. Many of us are also involved in advocacy trainings.

You have a voice!

Don't let the fact that these monstrous agencies get funding to do these campaigns to serve your community make you feel that you have to do the things they ask you do to do. I ask you to question why is my community not part of the survey. Why is my community still forgotten? Ask the critical questions and use your voice to be the voice of change. I have been doing this work for many years now, and I can't continue to do this work without new people to come into the fold to support me to do the work. If new voices are not heard, we will continue to see the same things happen in our community – like groups of black gay men folding in several places.

We have to have a voice and move forward because these organizations cannot work alone.

Questions and Discussions, moderated by Anthony Morgan

Question: I hear about these two icebergs that are melting simultaneously, then hear a message from the CDC about what is happening in our community, the black gay community. Then I hear about what is happening within policy and advocacy to target the black gay community. How does this all happen? What is going on Dr. Fullilove? What are your ideas for a prevention approach for AIDS in black America given the fact that we live on two different axes?

Dr. Fullilove: The crucial issue is we think too narrowly. We focus too much on getting people tested, certain things directly linked to HIV -- and these are things that need to be done. But we can't stabilize the setting in which the epidemic is being generated. When we first started studying AIDS in 1986, one of the first things that black people told us is that the black community is being torn apart by the crack epidemic -- and the first thing that was obvious when we studied the crack epidemic was that it was going to fuel the AIDS epidemic. Since then in our study of the crack epidemic, the violence related to it, the trauma caused by violence and other epidemics -- asthma, sedentary/obesity -- so we are creating new diseases, more configurations of diseases. It is never said that, but it is true -- medicine is in a complete state of gridlock because doctors have no idea how to treat somebody who have this whole panoply of diseases. We send them away with a bunch of medicines, but we really don't know what to do about them. So, this instability is causing diseases that we can't manage. And the instability is caused by profound things in our society, such as deindustrialization (there are no jobs), like the fact that black people have been systematically excluded from education, mass incarceration. This is not just happening to people who are gay-identified -- it is happening across the board to families, to ones neighbors. When this is happening to your network, you can't stay stable when this happens to you around you. We need to think more broadly in terms of issues that have to do with jobs, jail, neighborhood displacement and gentrification. I agree with Mark -- these are questions of how do we do this? I do not come with you with answers. I only know that after 20 years of studying the AIDS epidemic, we have not answered the big questions.

Question: I have a question regarding social movements and political courage. I work with a group called Healthcare-Now, which is fighting for universal healthcare. Mindy and Greg, can you comment on potential and lack of potential for a human rights movement for reparations for black people in the US and single-payer health insurance -- these are things we could do to restore stability.

Dr. Fullilove: Poor and working people in the US are getting pushed around, as are people across the world. We need to form a social movement because we are pushed against wall. Issues like global warming or the war bring about social movements because they are so obvious. I don't know if the spark will be reparations because it is so obscure. Movements form around obvious things and the issue of reparations may not be too obvious.

Health care and single payer is important. If we had the best single-payer system possibility we will not get to the source of health problems. The source of health problems is the fact that working poor people get pushed out of their neighborhoods. Health is driven by our relationship to where there is work, where we can live, what is available to eat -- like if there are no vitamins in our food, how will we be healthy? How do we grab on that? I don't know -- but confronting these issues is the soil on which social movements will grow deeper.

Question: Can you elaborate more about interventions for men who seek sex with men on the internet?

Greg: We are figuring out how to do interventions. There is an effective intervention available as a video that was sent out online. Perhaps we can do something like that in a different context. I know that the intervention will be far more involved, but I cannot speak to it quite yet because the protocol for it has not been written yet.

Question: The campaign in Philadelphia - what was it?

Robert: It was a social marketing intervention that involved cards, a website, public service announcements (PSAs) on black radio and TV stations that were intended to encourage black men to get tested. In terms of results, the city did not provide data to say that it had a substantial impact except for increased hotline calls (call volume spiked), but the city really could not pinpoint the cause because there are other campaigns going on. Really, the campaign probably failed because there was no structural support. A Latino group had problems adapting it for their population.

Question: Regarding the lack of research out there on these issues, what are the avenues to get money for that research and what are the opportunities to get that money in this political climate?

Mark: The CDC has traditionally been the focus as the end-all-and-be-all for prevention for black gay men, but we realized that the National Institutes of Health (NIH) is really the big dog for research. We do have access to the CDC because it has a history of working with community-based organizations, while the NIH is more connected with researchers. We are having a meeting with the director of the NIH and we are giving him the research agenda. We want programs that are more impactful in black gay male community, for instance, the effect of childhood sexual trauma. If you get researchers around the table they agree that there is childhood sexual trauma. So we are asking the Office of AIDS Research to explore this. A challenge in the recent past has been that the Republicans have had a hit list of NIH researchers, but this might be less of issue now that Democrats in power. Though they are not that courageous, at least the Republicans do not have the power to conduct oversight hearings any more.

The dollars follow research. With the article in JAMA, all of sudden research actions came after that and action in congress helped. Also the emergence of black gay researchers doing research with black MSM helps.

Question: As a youth, I can say that we are not educated. How can we help youth get educated? They don't know that they have HIV, and as they get a little older they are already dying.

Robert: Get involved, even if it is volunteer work at GMHC. Hang out with staff, keep coming back whether or not they shut you down, ask questions, get your voice heard, find a mentor, someone who is willing to teach you, apply for scholarships at conferences, present at conferences -- just get out there and motivate people to get involved.

Anthony: Go to organizations, go to balls, go to clubs -- we need to hold these groups accountable.

Comment: There is a dearth of information on health in general. I work at a middle school, and health is considered a frill that is maybe taught by a gym teacher. I heard one lesson on HIV at school that did not even define HIV. It instead only asked for knowledge of safe sex. We need to teach kids at young age.

Question: I do theater work related to doing reading and discussion series around that issue. It is a challenge to think about HIV from a broader perspective. I hope to tackle a host of social justice issues. What are the challenges of trying to do work from a broader perspective? I'm thinking of the "I am Gay" campaign in Harlem.

Mark: In terms of addressing HIV prevention, we need to think outside of box. I don't think that the lack of condom distribution or education about how to use a condom is the driver of HIV in this community. Something deeper is at work. We should also launch campaigns relevant to black gay men's lives, like a campaign that confronts homophobia in the black community. This is an HIV prevention intervention because it is about giving them a safe and secure home and to give them security to be safe around a whole range of health issues. We have been screaming at the CDC for long time about its obsession with "condom counting." The major challenge to thinking outside of the box is figuring out what box to fall into. NY City/State is more progressive. The state has a LGBT portfolio in which governor is tripling funding for traditional HIV prevention needs. But we need to seed new organizations.

Greg: We need people on the inside to push the agenda. It was not until we got there that we pushed research and published papers. When the research is out there and in papers that scientists could read, then something could happen. Unfortunately, it is happening twenty years too late, and we need to push it up fast and get as much done as possible.

Question: My frustration is with the attitude that this epidemic did not only start yesterday. What do you say to the young man who asks what has been going on?

Mark: I spoke to some of the reasons: the ad hoc, crisis-driven nature and balkanization of the efforts. I can understand a 25 year old's frustration, but from my standpoint, when we know more we do better.

Mindy: We don't know the history of last 25 years even though many of us have lived it. We need a history written down -- not just about AIDS but also about crack and deindustrialization, etc. Every step forward is often 10 steps back, and we feel like we move backwards more rapidly than we are moving forward. This work is very tiring, and we need enthusiasm and energy and a lack of cynicism. We need to school ourselves on the history because this fight is desperate.

Robert: We can't look to service organizations as our savior if the community is not willing to do the work. I drive a 32-foot recreational vehicle around to conduct rapid testing and people in the community refuse it. Until we own it will not change. Doing work to give back to the community is hard if it seems like my community does not care.

Question: In my school a couple of months ago we handed out condoms due to rumor of an HIV epidemic in our school, but the principal says we can't do that because it is not in our curricula. Instead, they teach abstinence. What can we do?

Mark: Talk to CHAMP and their Find the Condoms In Your School Campaign about it or SIECUS, they know much more than we do. [For more information visit www.myspace.com/findthecondoms].

Comment: You have to be revolutionary about it. Try to hand out condoms a block away from school as students come and go. Think outside of the box. Also, there are a lot of resources available to you from AIDS Service Organizations in New York City.

Question: On a personal level, what are the reasons why black gay men engage in risky sex?

Mark: We loose sight of the fact that the natural state of sex is to do it without a condom, and to change that we have to create a different consciousness. It is natural and it feels good is often the reason, and sometimes there is nothing deeper. We should own the fact that some folks will make that decision, and we can send them through condom use programs as much as you want and they will keep making this decision.

Robert: Black men may be greater risk takers given the context of the risk of incarceration and violence.

Greg: Actually we (black gay men) engage in less unprotected sex than other groups. Issues of depression and mental health are not addressed in the black community very well -- black people do not want to talk about going to therapy or getting help for problems bothering us, and research shows that.

Comment: The incredible sense of isolation might be part of it.

Mindy: I propose the analogy of communication on a noisy channel earlier. How do you express your worth and dignity? It is in face of everyone who wants to deny his or her dignity. In this context black gay men invent sexuality forcefully and imaginatively. There is risk of HIV transmission in sex. Perhaps we need to present the gay male sexuality in another way to take the focus off of only what people do in bed -- for example, billboards of beautiful people who declare that they are gay.

Comment: If you ask people to wear condoms and engage in oral sex, you deny the fact that dick tastes good, and the condom becomes a barrier. Why are you asking me to wear something to protect me if I am not valued -- what do you tell young people what we are doing all this time -- when I was young there was no conversation around this.

Community HIV/AIDS Mobilization Project

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