Are bisexuals well served by HIV interventions that assume gay identity?

Studies published in STI journal have examined the impact of bisexual concurrency on HIV epidemiology in South Africa (Behrer & Baral) (B&B) and China (Yun & Shang) (Y&S), where it is reckoned at 53.7% and 31.2% of the MSM population, respectively.  However, a recent randomized control study of an educational intervention in Los Angeles (Harawa & Cunningham) claims to be among the first studies addressing bisexual concurrency among black MSM in the US.

US black MSM who have sex with women (MSMW) are less likely than white MSM to identify gay, and more concerned to fulfil traditional gender expectations.  Consequently, say the authors, they may be less well served by interventions based on contemporary conceptualizations of sexual behaviour in terms of fixed sexual identities.  This raises a number of interesting questions, among them, how far the situation of US black MSM resembles that of MSM in traditional societies (e.g. South Africa or China), and how far influential contemporary conceptualizations about sexual identity, based on the cultural experience of white MSM, constitute an appropriate model for interventions outside that specific social context.   The authors see potential benefits for MSMW of interventions based on more fluid and context-dependent models of sexual behaviour.

The intervention that is the object of this study – Men of African American Legacy Empowering Self (MAALES) – is an HIV education and risk-reduction course addressed specifically to the needs of this group (Williams & Harawa).  It consists in six two-hour sessions delivered over a three week period (with booster sessions at six and 18 weeks), and aims, above all, to be “culturally congruent”.  It is conducted by black MSM facilitators, and its content is theoretically grounded in a teaching model developed in African American communities (the critical thinking model), as well as in reasoned action theory and empowerment theory.

The study itself compares sexual behaviours, at base-line and three and six months after the intervention, of 437 black MSMW randomly assigned to either the MAALES intervention or a twenty-minute HIV education and risk-reduction session based on a standard HIV test counselling approach. Adjusted results indicate the achievement of significantly less unprotected sex acts with male or female over prior ninety days at six months in the intervention arm as against the control arm (RR 0.61), significantly less unprotected sex acts with females (RR 0.5), and a near-significant reduction in sex acts with males (RR 0.63).  Given the time and resources dedicated to the MAALES as compared to the control intervention, one wonders how much of this behavioural modification is owed to the greater investment in the patients in the intervention arm of the study, and how much to the superiority of its culturally congruent methodology over the conventional alternative.

In their conclusions Harawa and Cunningham tend to corroborate the emphasis of Behrer and Baral, Yun and Shang and others on the influence of societal and cultural factors.  There have even been attempts to quantify the impact of psychosocial constructs on MSM sexual behaviour (Konda & Kegeles).  Yet, Harawa and Cunningham differ somewhat from these other studies in the greater stress they place on the role of participants as responsible agents.  They also recommend on the basis of the more frequent reporting of unprotected sex with females in their study, and the relatively low levels of sex with males, that interventions aiming to “responsibilise” MSMW should prioritize the reduction of risky behaviour which involves females, rather than males.

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