Uncovering HIV

By Drew Winter

Robin Lin Miller is an ecological-community psychology professor at MSU who is helping to conduct a study on HIV prevention and sexual activities of black men in the state.

What are you working on right now and why?

I am working on several projects now. I am currently conducting a project with my MSU colleague, Miles McNall, called “The Young Men’s Health Study.” The study examines the HIV prevention needs of Michigan’s young black men who have sex with men. The project was commissioned by the state Department of Community Health at the urging of its statewide HIV prevention and care planning council (MHAC). The purpose of the study is to help the state better understand how best to reduce new HIV infections among young black men. In Michigan, the rate of new HIV infections among young people has increased over the prior seven years. Consistent with national trends, in Michigan blacks and men who have sex with men comprise the majority of new cases of HIV infection. There have been very few studies in the U.S. of young black men who have sex with men, despite the disproportionate impact of HIV on these men since very early on in the epidemic. This study is very important to people in the state who are working on HIV prevention because we have so little data to guide us on how we can do a better job of preventing HIV among young black men.

Our project focuses on young men between the ages 13 to 24 throughout the state and in particular, men in counties with the highest rates of infection among young black males and men who have sex with men: Wayne and its surrounding counties, Berrien, Kent, Ingham and Washtenaw. We are including men in any part of the state in the study, but these areas provided our initial focus because so much of the burden of the HIV epidemic in Michigan affects men living in these areas. One of the exciting things for me about the study is that Dr. McNall, my graduate students and I are conducting it collaboratively with five young black men who have sex with men and who live in these counties. These young men have helped us to define the focus of the study, to develop the interview guide, and to select and train the interviewers we now have working throughout the state. Once the data are all in, they will help us to analyze it and interpret and disseminate the results. So, in many ways, it is their study. It takes their point of view on what it is like to be a young black man who has sex with men and lives in Michigan into account.

We started the project in August of 2008. The first thing that we did was to interview county and state government officials and people working at community based-organizations throughout the state on what they thought they needed to know in order to improve their decisions and programming. We put that together with what was already known, and presented that to the young men we are collaborating with. They used both sets of information to set the priorities for what we would ask. The entire interview is focused on those things that the young men we are working with and key decision makers around the state think would be helpful to improve their work and which existing data from Michigan and elsewhere do not address it well. We are winding up recruitment over the next few weeks, though we are still eager to have more men participate before we close enrollment, especially men from outside of Detroit and in the western region of the state. We will present results to the state at the end of the summer, though I expect that we will be exploring these data for some time.

I have several other related projects. The other Michigan-based projects include a collaborative project with Dr. Tina Timm and the Ruth Ellis Center in Detroit on reducing sexually transmitted infection risks among adolescent and young adult lesbian and bisexual women and an evaluation project with MPowerment Detroit. I have several out-of-state multi-site research projects too. These are part of a national research network called the Adolescent Trials Network, which does research focused on reducing HIV transmission and improving HIV-related care for adolescents at risk.

What is your background, and how did you get involved in this project?

I am trained as a community psychologist, which is an area of psychology with which most people are probably unfamiliar. Community psychologists use research as a vehicle to promote health and well-being in communities, prevent problems such as negative health and mental health outcomes, and create a more socially just society. Because of our concern with social justice, we tend to focus on people who are not enfranchised in society, such as GBLTQ communities, people of color, the poor and immigrant/refugees. We also focus on social problems such as violence against women, racism and other forms of oppression, homelessness, and inequality in educational, economic, and workplace settings.

Community psychologists conduct research in ways that take into account the social, cultural, economic, geographic and historical contexts in which people live and also conduct research that is focused on taking action and testing solutions to social problems. We typically work collaboratively with communities to do research and identify how to make improvements to promote well being. I joined the faculty at MSU because it has one of the oldest and best training programs in community psychology in the country.

I started doing research on HIV prevention among gay men in 1987 when I worked at the Gay Men’s Health Crisis in New York City. I started off working just on HIV prevention exclusively and did work there with the house ball community and male sex workers, among other groups of gay and bisexual men. I ultimately ended up directing all of the agency research and evaluation efforts until I left in 1995 to do HIV prevention research among young black men in Chicago. I came to MSU in 2005 and, as a way to get to learn what was happening in the state, applied to become part of Michigan’s statewide HIV prevention and care advisory planning body. My involvement in the Young Men’s Health Study is a natural extension of the action research work that I have done over the prior decades on HIV issues for young men and of my involvement in MHAC.

What do people need to know about this topic?

First and foremost, that the Centers for Disease Control indicated at the last International AIDS Conference that it had underestimated how many new annual infections there are in the United States and have since called for increased efforts to prevent HIV in the United States. AIDS is still a major public health issue in this country. The majority of new infections in the U.S. are among men who have sex with men and black men are disproportionately represented among these new cases, relative to their numbers in the general population. According to the CDC and related to our study, black men who have sex with men comprised the majority on new cases of HIV infection among those aged 13 to 29 during the last year for which complete data are available. The CDC also estimates that about 46 percent of black men who have sex with men residing in urban areas in the U.S. are HIV infected.

The research on black men who have sex with men is paradoxical because despite these high infection rates, the studies we do have consistently show that black men who have sex with men of all ages report comparable or less sexual risk behavior, fewer lifetime sexual partners, and lower rates of alcohol and drug use before or during sex than their counterparts in other racial/ethnic groups. One of the things we also know from research is that black men who have sex with men and young men in particular, are overrepresented among what are called “late testers” – people who get tested very close to the time when they will begin to manifest the symptoms that warrant and AIDS diagnosis, and those who do not know they are HIV positive. Encouraging early testing is one important part of any comprehensive strategy to change the tide of the epidemic among black men.

What is your research uncovering?

The data from the current project are still coming in, but several things are striking from what we have looked at so far. One is that about half of the young men we’ve interviewed made their sexual debut with either men or women at age 14 or younger. I think this underscores the importance of explicit education on how to be sexually safe at very young ages, before people make their sexual debut, as is done in other countries such as those in Scandinavia. A second striking finding is that over 80 percent of the young men are actively engaged in a church community. Though churches have long been cited as an important influence on Black life, our data actually show how significant it is that we work to get churches involved in effective HIV prevention efforts. That is, HIV prevention that is evidence-based and affirming of who these young men are sexually and spiritually. We ask about many more things, so I should have much more to say after we have completed our analyses.

What are the main hurdles to reducing HIV and how can we achieve that?

HIV prevention is woefully under-funded in the United States. As a nation, we spend very little of our HIV-related funding on prevention efforts. Most of the money goes to testing and care, as well as to research, some of which concerns prevention. We also lack the diversity of programming that might constitute a comprehensive and coordinated strategy. In the current economic climate, the squeeze on the health department to do more with less will worsen.

As a nation, I think we are ambivalent about programs that have been shown to help, such as programs and policies that increase access to clean syringes or are explicit about the diversity of human sexual experience. We have a very long way to go to reduce the stigmas associated with HIV and the behaviors that transmit it. For instance, I went to a presentation recently in which the data indicated that black men who have sex with men trust private physicians more than they do other sources of information such as gay and lesbian community-based organizations and the government. Yet, black men who have sex with other men who have a private physician are less likely to disclose to that physician that they have sex with men. Data are now beginning to show more clearly that experiencing rejection by your family and your community and having family who disapprove of your sexuality are associated with distress, mental health problems, and increased sexual risk taking among young men. Reducing stigmas should be a fundamental part of HIV prevention efforts.

In his book “On the Down Low: A Journey into the Lives of Straight Black Men Who Sleep with Men,” J.L. King did not want to be identified as gay. Why?

That is a controversial book on many levels. It is worth reading rebuttals to it, such as the one written by Keith Boykin. Keith points out that historically being on the down low meant keeping an action or a relationship secret, so it could refer to a woman cheating on her husband with another man or any other act of keeping something close to your chest. When someone tells you to keep something on the down low, they may simply mean that they want you to keep something quiet.

Having a social identity that does not align perfectly with one’s behavior or one’s attractions is not at all unusual. People select and reject social identities for many reasons and those that they adopt at one phase of life may change later in their lifetime. Research by people such as Lisa Diamond and Roger Worthington provide good examples of how typical it is that behavior, attraction, and identity are incongruent with one another and that identity can be fluid over time. Some of the research on Black men who have sex with men indicates that they have sex with women regardless of what their sexual orientation identity may be and more than other men who have sex with men. hey are also less likely than other men to adopt an identity as gay. In my research in Chicago, I studied 880 young black men who have sex with men as part of a larger study called the CITY Project. We collected data in four waves, one wave each summer from 1999-2002. About 24 percent to 57 percent of the young men in any given wave of data reported that they did not identify as gay. In the data we are collecting here, so far about a little over 25 percent of the young men are not gay identified.

Gregorio Millett, Darrell Wheeler, Lisa Bond and colleagues have conducted research on black men who identify as being on the down low. In a recent paper, published in the American Journal of Public Health, they demonstrate absolutely no relationship between having a down-low identity and having unprotected sex with male and female partners. These researchers suggest that focusing on having a down-low identity is not likely to be very productive from an HIV prevention standpoint and that people have made too much about the down low phenomenon. They state that we ought to focus on risk behaviors instead of this particular social identity. I agree. I also think that we must focus much more on the social-structural factors that underlie the disparity in HIV infection rates and other negative health outcomes that we see in Black communities. I think this is critical in Michigan, where we have striking disparities in things we know to be associated with good health, such as education, economics, and housing. These things are fundamental to having access to the resources one needs to live a productive, healthy, and satisfying life.