David Malebranche's, University of Pennsylvania, presentation at the Sex in the City II: Men, Sex, Love and HIV conference, held in Chicago on September 25, 2014. Sponsored by AIDS Foundation of Chicago and other partners.

1. BEYOND PREP: INTERSECTIONALITY, RESILIENCE & THE HEALTH OF BLACK MSM
David Malebranche, MD, MPH
Primary Care Physician
University of Pennsylvania Student Health Services
Sex in the City Two: Men, Sex, Love and HIV
September 25, 2014

2. Agenda
Charles’ story
Approaches to health among Black MSM
Redefining Intersectionality
Resilience and health
A word about PrEP
Conclusion

3. Disclaimer
“MSM”
Not a sexual identity

4. Why focus on Black MSM?
Only subgroup with increasing HIV incidence
General health issues often ignored
Emphasis on deficits and pathology
Intersectionality often not addressed
Rosenberg et al., 2014; Prejean et al., 2011

5. Healthcare and Black MSM
Less likely to have insurance/PCP than other MSM
Overutilization of ER over outpatient services
Same sex disclosure less than other MSM
Endorse conspiracy theories and distrust
Experiences with racism AND sexual prejudice
Magnus et al., 2011; Bernstein et al., 2008; Wilson & Yoshikawa, 2009; Hutchinson et al., 2007; Montgomery et al., 2002; Wheeler, 2005; Malebranche et al., 2004

6. Charles
23 yo black SGL MSM
Works as study coordinator at HIV research unit
Started PrEP 2 weeks ago
Now with abdominal pain since starting PrEP
Hits you up on FB for advice and counseling on what to do next

7. What do you tell him?
A. Stop whining – it’s worth it to stay negative
B. Stop that shit! It’s poison!
C. Google “PrEP side effects” to investigate
D. Go to the ER – this could be lactic acidosis

8. Charles
Tells his doc about his symptoms
Doc’s response: “This usually doesn’t happen with PrEP.”
Next appointment is in 1 week
Tells you he has never had sex without a condom – but is scared shitless of HIV
Doc suggested PrEP because he “has sex with other men”

9. What do you tell him now?
A. F*** that doctor – stop the meds now
B. Get a second opinion
C. Demand to move up appointment to be seen
D. Stay on the meds and wait it out til next week

10. Charles conclusion…
Went to see different medical provider
Detailed sexual history
Recommended to stop PrEP, keep with safer sex and return if he feels he may need meds later
Stomach returned to normal
Got lots of flack on social media

11. “Take homes” from Charles’ story?
He’s young but seeing a medical provider
PrEP may not be for everyone
Sexual history taking leaves a lot to be desired
The medical system is horrible
RESILIENCE
Sought me out for advice
Took it upon himself to get a second opinion
Spoke up when something was wrong

12. Approaches to health for Black MSM
HIV-focused
LGBT health
Black men’s health
Individual level
Emphasis on risk behaviors

13. Intersectionality
Various biological , social and cultural categories such gender, race, class, ability, sexual orientation, and other axes of identity interact on multiple and often simultaneous levels, contributing to systematic social inequality
Kimberlé Crenshaw, 1989

14. Intersecting disparities
BLACK
Poverty
Education
Employment
Access to care
Chronic diseases
Racism/Profiling
Lack of Insurance
Homicide
HIV/STI
CSA
Mental health
Homelessness
Incarceration
Alcohol/Substance abuse
MSM/Gay men
Sexual prejudice
Obesity
HIV/STI
Suicide
Alcohol/Substance abuse
Homelessness
Mental health
Access to care
CSA

15. Addressing “LGBT health” or “Black men’s health” is not enough!
This is not a “post-racial” society
Gay civil rights ≠ Black civil rights
There are parallels in prejudice and oppression, but…
Not interchangeable identities/experiences
Invisibility due to religion and masculinity norms is real

16. Meaning of the word “gay”
“White dudes embracing in a public place.” (31)
“Gay to me is a lifestyle. I guess gay is being free, you know careless – meaning not caring how you act or the way you present yourself.”(29)
“Flamboyancy. They’re walking around with tight jeans on, switchin, head movin’ all around, nails painted, toes all done up. Actually, he’s white.” (23)
“Gay is not a positive word to me. It just doesn’t ring positive when I hear ‘I’m gay.’ It just doesn’t.” (27)
Malebranche et al., 2009

18. Intersectionality – mostly reactive?
Premise is based on socially oppressive forces
Often considered, but not implemented in practice
Not always used in resilience perspective
What’s good about intersecting identities?
About being Black
About claiming your sexual identity
About being “healthy”

19. Fluidity and balance of social identities
1.The gay white male in New York who may experience homophobia but also has white privilege
2.The black heterosexual male in Alabama who benefits from patriarchy and male privilege but is racially discriminated against
3.The Latina woman in San Diego who experiences sexism but may benefit from cultural linguistic privilege

20. Resilience and Health

21. Abundance of deficit models
Focus predominantly on individual level behavior
“Blaming the victim” – individual level behaviors
Only examines “barriers” to health
May only examine dynamics short term
Herrick et al., 2014

22. HIV prevention as main focus
3MV – “Many men, Many Voices”
Four day, 7 session group level intervention – Black MSM
Mpowerment
Community-level, 3 day training gay/bi men
D-up: Defend yourself!
Community level intervention for Black MSM – social network based
Kelly et al., 1989; Wilton et al., 2009; Jones et al., 2008; Kegeles et al., 1996

23. Resilience definition
“an individual’s ability to properly adapt to stress and adversity.”
“the process of overcoming the negative effects of risk exposure, coping successfully with traumatic experiences, and avoiding the negative trajectories associated with risk.” (Fergus et al., 2005)
Models
Transactional model of resilience (Kumpfer, 1999)

24. “WITHOUT ADVERSITY TO OVERCOME THERE IS NO RESILIENCE”
Fergus et al., 2005

25. Resilience in the Literature
Identity reaffirmation within context of substance abuse and new HIV diagnosis
“Street life” resiliency for inner city Black men
LGBT and “Minority Stress”
Black lesbians
Response to homophobia and heterosexism
Denial of race/cultural context in LGBT persons
Institutional solutions for aging gay men
Coping with new HIV diagnosis
Bletzer, 2007; Payne 2011; Meyer 2003, 2011; Russell 2005; Bowleg 2003; Genke 2005

26. Impact of intersecting identities
INTERSECTION OF RACISM/SEXUAL PREJUDICE ON DISCLOSURE
“As being a young Black male, if I would come and say something’s wrong with me. They [medical providers] would say, ‘Oh, look at this, you know they probably just hip-hoppin’ and screwin’ down and you know, smokin’ the blunts, and then he gonna come here, talkin’ about he sick.’ So its like I’m stereotyped already. And now if you say you’re gay, everybody can get the picture of the feminine, gay brother. So I guess it can come to the sexuality because they feel, ‘Oh, you must have been loose in the booty already.’” (Darnell, Harlem, 19)
Malebranche et al., 2004

27. Resilience and Black MSM
Little if any mention in literature
Often lumped with other gay men or gay men “of color”
Mentioned in sole context of HIV and overcoming sexual “risk”
Promising work is going on…

28. Social media and resilience
Counter narrative project
http://thecounternarrative.org/
Charles Stephens
Collective memory and cultural restoration
Digital storytelling
Video journaling
Young Black Gay Leadership Initiative (YBGLI)
“25 under 25” #speakoutHIV

29. #speakoutHIV
25 under 25

30. Challenges to resilience approaches
Diversity in social identities
Overwhelming social attachment to deficit models
Funding steam for health?
Limitations of outcomes based research
Internalized racism, homophobia, etc.
People often don’t see this as “health”

31. A word on PrEP…
Adam Zeboski

32. Pre-exposure Prophylaxis (PrEP)
Daily HIV medication for HIV negative persons
Not a substitute for ABC’s
Major studies supporting PrEP
iPrEx study – 44% reduction in HIV acquisition
US MSM safety trial – no HIV seroconversions in medication arm
Adherence is primary determinant in effectiveness

33. CDC PrEP guidelines - 2014
Risk assessment – who may be eligible?
HIV+ partner
Multiple sexual partners
Inconsistent condom use
Commercial sex work
Recent bacterial STI
Truvada 1 pill daily
Obtain HIV testing before starting
Repeat HIV testing every 3 months
Renal function testing every 6 months
Check Gilead website if cost an issue

34. Three main PrEP Players

35. Medical Judgment
“I was talking to her [the doctor] about the symptoms I was having. And she’s like, she asked me when the last time I had anal sex? And I told her like whenever it was. And she’s like, ‘Well, you know…,’ and this really surprised me, ‘Well, you know, the anus really isn’t made for that.’ And I was like, ‘Yeah, I know, but it’s a little too late, you know?’” (Lloyd, Manhattan, 33)
Malebranche et al., 2004

36. Envisioning broader “health” for Black MSM
Holistic definition that begins with who we are
PreP or PEP may be entryway for some
HIV IS NOT THE ONLY ISSUE FACING BLACK MSM!!!
Promoting generational health resilience
Utilizing technology
Utilizing social media and marketing approaches
NOT waiting on the CDC or NIH to fund/approve

37. “INVITING IN” – Darnell Moore

38. Future directions
Avoiding “one size fits all” approaches
Generational and inter-generational approaches
Moving beyond traditional research models
Focusing on what works
Conceptualizing HIV as one part of health
Social work, Sociology, Anthropology, Urban Planning ALL NEED TO BE INVOLVED

39. What do you see?
https://www.youtube.com/watch?v=7zFHkBQBg-4.

40. Thank you!!