Secondary Logo

Barriers and Facilitators to Engaging African American Men Who Have Sex With Men in the HIV Care Continuum

A Theory-Based Qualitative Study

Jemmott, John B. III, PhD; Zhang, Jingwen, PhD*; Croom, Mikia, MSEd; Icard, Larry D., PhD; Rutledge, Scott E., PhD; O'Leary, Ann, PhD

Journal of the Association of Nurses in AIDS Care: May-June 2019 - Volume 30 - Issue 3 - p 352–361
doi: 10.1097/JNC.0000000000000087
Feature Article

African American men who have sex with men (MSM) have high rates of HIV, but interventions are needed to address their low rates of engagement in the HIV care continuum. To identify modifiable factors potentially affecting such engagement, we conducted qualitative interviews guided by the Theory of Planned Behavior with 27 African American MSM who had participated in an HIV risk-reduction intervention trial. Qualitative analyses resulted in four overarching themes: stigma, concerns with health care providers (HCPs), social support, and logistical issues. Facilitators of care continuum engagement included reassurance about health, feeling and looking better, receiving treatment, avoiding infecting others, good relations with HCP, and social support. Barriers included HIV stigma, concerns about confidentiality, negative perceptions of HCP, convenience and availability of testing/treatment facilities, cost, and lack of social support. Efforts to improve African American MSM HIV care continuum engagement should focus on individual and health care system changes.

John B. Jemmott, III, PhD, is a Professor, Perelman School of Medicine and Annenberg School for Communication, University of Pennsylvania, Philadelphia, Pennsylvania, USA. Jingwen Zhang, PhD, is an Assistant Professor, Department of Communication, University of California, Davis, Davis, California, USA. Mikia Croom, MSEd, is a Senior Research Coordinator, Center for Health Behavior & Communication Research, University of Pennsylvania, Philadelphia, Pennsylvania, USA. Larry D. Icard, PhD, is a Professor, College of Public Health, Temple University, Philadelphia, Pennsylvania, USA. Scott E. Rutledge, PhD, is an Associate Professor, College of Public Health, Temple University, Philadelphia, Pennsylvania, USA. Ann O'Leary, PhD, is a Senior Behavioral Scientist, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.

Corresponding author: Jingwen Zhang, e-mail:

Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.

There is growing recognition of the urgent need to address the important problem of inadequate progress along the HIV care continuum in African American men who have sex with men (MSM). The “test-and-treat” recommendation requires that people living with HIV (PLWH) be identified, enrolled in HIV care, and provided with antiretroviral therapy (ART) to suppress the virus, which will preserve their health and greatly reduce the likelihood of transmitting HIV to others (Cohen et al., 2011; Granich, Gilks, Dye, De Cock, & Williams, 2009). Unfortunately, in practice, the implementation of test and treat is fraught with challenges; each PLWH must pass through several stages to achieve viral suppression and many people's progress stalls short of that achievement. These important stages, known as the HIV treatment cascade or the HIV care continuum, consist of gaining awareness of one's HIV-positive serostatus, being linked to HIV clinical care, remaining in regular HIV care, receiving ART, and adhering to ART (Gardner, McLees, Steiner, Del Rio, & Burman, 2011).

According to the Centers for Disease Control and Prevention (2017a), of the 1.1 million PLWH in the United States in 2014, 85% had been diagnosed, 62% were receiving HIV care, 48% were retained in care, and 49% had achieved viral suppression, primarily a consequence of adherence to ART. African Americans are less likely than Whites to achieve each stage of the HIV care continuum, a racial disparity evident in African American MSM (Centers for Disease Control and Prevention, 2014). For instance, the odds of being unaware of an HIV-positive serostatus are 6.38 times greater among African American MSM compared with other MSM. Moreover, African American MSM living with HIV have lower odds of attending HIV care visits, being on ART, adhering to ART, or achieving viral suppression than do other MSM (Millett et al., 2012), a racial disparity that is especially disturbing considering the alarming rate of HIV diagnoses in African American MSM. In 2015, the estimated rate of HIV diagnosis was 84.8 per 100,000 in African American men compared with 10.8 per 100,000 in White men (Centers for Disease Control and Prevention, 2017b), and the estimated number of new HIV diagnoses in the male-to-male-contact transmission category was larger in African American men (10,315) than in White men (7,570; Centers for Disease Control and Prevention, 2017c). Furthermore, the 3-year survival rate after an AIDS diagnosis is lower in African American MSM than in White MSM (Centers for Disease Control and Prevention, 2013).

Thus, interventions to engage African American MSM in the HIV care continuum are of vital importance to not only prevent the transmission of HIV but also to increase the longevity of those living with HIV. Such interventions are most likely to be effective if they are informed by behavior change theory and address the population-relevant modifiable factors that can potentially affect progress along the HIV care continuum. However, the literature contains few intervention trials targeting engagement in the HIV care continuum among African American MSM specifically (Bouris et al., 2017; Cao et al., 2017; Henny, Wilkes, McDonald, Denson, & Neumann, 2018; Risher et al., 2017). As a step toward developing an intervention to engage African American MSM in the HIV care continuum, we conducted a theory-based qualitative study to identify modifiable factors relevant to testing, treatment, retention, and medication adherence with respect to HIV among African American MSM. The study was guided by the Theory of Planned Behavior, which holds that beliefs underlie attitudes, norms, and self-efficacy or perceived behavior control, which affect behavioral intentions, which in turn affect behavior (Ajzen, 1991; Albarracin, Johnson, Fishbein, & Muellerleile, 2001). We selected the Theory of Planned Behavior because of the ease of integrating it with qualitative data from specific populations (Jemmott, 2012; Jemmott et al., 2013; Montano, Kasprzyk, Hamilton, Tshimanga, & Gorn, 2014) and because it has been the theoretical basis of numerous effective HIV-related interventions (Blank et al., 2011; Coleman, Jemmott, Jemmott, Strumpf, & Ratcliffe, 2009; Jemmott, Jemmott, Fong, & Morales, 2010; Jemmott, Jemmott, O'Leary, et al., 2010; Kamb et al., 1998; Villarruel, Jemmott, & Jemmott, 2006; Zhang, Cederbaum, Jemmott, & Jemmott, 2018).

Back to Top | Article Outline


The institutional review boards of the University of Pennsylvania and Temple University approved the study. The participants were African American MSM in Philadelphia, Pennsylvania, who had participated in “Project Being Responsible for Ourselves (BRO),” a randomized controlled trial evaluating HIV risk-reduction and health-promotion interventions (Jemmott et al., 2014; Zhang et al., 2016). A research coordinator contacted men from the original BRO study database after they had completed the BRO trial to invite them to participate in a one-on-one confidential interview. Potential participants were informed that the purpose was to gain greater understanding of men's feelings, beliefs, and behaviors related to HIV testing, treatment, and adherence to medication. An interviewer collected written informed consents from participants. Participants were given $25 compensation and two public transportation tokens.

All interviews and data collection sessions were held in seminar rooms at the University of Pennsylvania. Recruiters were able to reach 27 men from the contact list who had current contact information and were willing to participate in the study (March 11, 2014 to April 25, 2014).

Interviews were conducted using an interview guide. The interviewers took detailed notes of participant responses. Interviews lasted between 30 and 45 minutes. Participants who reported being HIV positive were asked additional questions about their experiences in the continuum of care. Before the interviews, participants completed a brief demographic survey. The interviewers consisted of three women (two African American and one White); each had at least a Bachelor's degree. Each interviewer attended a 4-hour training on face-to-face interviewing and data collection and all had been certified in human subjects training. The interviews followed the interview guide strictly to make sure individual characters did not influence the quality of the interviews.

The interviews were theory based, designed to elicit information relevant to the Theory of Planned Behavior (Ajzen, 1991; Fishbein & Ajzen, 2010), which has been employed to identify modifiable variables pertinent in diverse cultural and social contexts and has been successfully applied to a broad range of behaviors (Albarracin et al., 2001; Armitage & Conner, 2001). The theory holds that behavioral, normative, and control beliefs underlie attitude, subjective norm, and self-efficacy or perceived behavioral control, and that these variables determine intention for a behavior, which predicts engaging in the behavior. The interviewers asked questions relevant to behavioral, normative, and control beliefs about three stages in the HIV care continuum, including HIV testing, seeking care, and medication adherence. To elicit behavioral beliefs, which are similar to the Social Cognitive Theory variable outcome expectancy (Bandura, 1986), we asked the men to list the good things and bad things that would happen if they engaged in the behavior of interest (e.g., What is good [bad] about getting tested for HIV?). To elicit normative beliefs, we asked participants to list the referents who would approve or disapprove of their behaviors (e.g., Who would approve [disapprove] of you going to a doctor for HIV care?). To elicit control beliefs, which are similar to the Social Cognitive Theory variable, self-efficacy (Bandura, 1986), we asked participants to list factors that would facilitate or inhibit the ability to perform the behavior (e.g., What makes it easy [hard] to take your medication as prescribed?).

Two coders analyzed the interviewers' written field notes by content analysis through the systematic classification process of coding themes identified in the notes (Hsieh & Shannon, 2005). The two coders were trained social scientists who had extensive experience conducting research in HIV-related interventions for African Americans. The lead coder created categories or themes of responses for each question. Several iterations of the classification process were taken until no new themes could be generated. The final themes were used by each coder independently to categorize all responses for each question. The coders then met to review the coding and resolve any differences. Disagreements were resolved by reviewing each item, both coders providing rationalization for coding and determining the best themes.

Back to Top | Article Outline


The participants were 27 African American MSM, who ranged in age from 22 to 63 years, with a mean age of 48.6 years (SD = 10.2). All had been tested for HIV at least once. Eighteen participants (67%) said they were living with HIV, and these men had known they were positive ranging from less than 1 year to 27 years (median = 16.5 years, mean = 15.5 years). All 18 participants said they had received HIV care, and 17 of the 18 participants (94%) said they had been prescribed ART. Eleven of the 17 participants had been prescribed ART within 1 month of diagnosis; of the others, 2 were prescribed ART within 8 months of diagnosis, 2 within 5 years, and 2 within 22 years. One person said he had declined ART because he was feeling fine, and one man said he was no longer taking ART. Of the 16 participants currently on ART, 12 (75%) said they were taking their ART as prescribed and 4 (25%) said they were not. Of the 16 men on ART, 11 (69%) said their viral loads were undetectable. Of the nine participants who said they were negative, five had been tested in the previous 6 months, one in the past year, and three in the past 2 years.

Back to Top | Article Outline

Becoming Aware: HIV Testing

The responses on HIV testing from negative participants did not differ much qualitatively from those of the positive participants. Although a few diagnoses happened a long time ago, the fundamental personal psychological experiences remained relatively the same. Table 1 summarizes participant beliefs about HIV care–related behaviors. Behavioral beliefs about the positive consequences of HIV testing focused on stress relief and receiving early treatment. In addition, some participants emphasized the benefit of learning one's serostatus so they could avoid infecting other people. Negative consequences of HIV testing included participants' fear of possible breach of confidentiality and the daunting prospect of hearing that the test result was positive.

Table 1-a

Table 1-a

Table 1-b

Table 1-b

For normative beliefs about getting tested for HIV, participants cited a variety of referent groups that would approve their getting tested, such as health care providers (HCPs), friends, and family. Most said no important referents would disapprove of their getting tested, although some said that some of their friends or partners might disapprove because they would be afraid of a possible positive test result.

Participants discussed many positive control beliefs, that is, beliefs about things that would facilitate the ability to be tested for HIV. Many of the men mentioned having a support system such as a friend to go with you to be tested. These men felt that the notion of getting tested was daunting and that having a friend accompany them would help ease their nerves and make them feel supported. Several mentioned destigmatization of HIV in the media and disassociation of HIV from race, gender, and class would be a facilitating factor and further added that requiring that testing be part of regular HCP visits or required if a person reported having unprotected sex would be a good destigmatization strategy. It is important that, many men reported that having a good relationship with HCP and having trust in their HCP would be key in increasing the likelihood of being tested. Lastly, some discussed facilitators such as easy access to mobile testing and treatment, ensuring the test's confidentiality, and having financial incentives for testing (e.g., gift cards). Negative control beliefs or beliefs about factors perceived to inhibit the ability to be tested focused on their fear of a positive test result and subsequent discriminations from other people, housing, or employment. Participants mentioned actual barriers in terms of lack of psychosocial support, lack of easy access to testing, and lack of insurance.

When asked about their experiences being tested, a few reported that they felt afraid and that “waiting for the results is scary.” Waiting triggered a lot of emotions including “anxiety, worry, and embarrassment.” Some men reported unsafe sexual practices as the reason to be tested; others reported regular testing as a part of their routine care regimen. A few men reported having illnesses, wanting to prevent getting sick, and having friends who were getting sick as the reason for getting tested. One man, however, reported being tested without his consent while in prison in 1995.

Back to Top | Article Outline

Seeking Care

Men who said they were living with HIV were asked additional questions about their experiences seeking health care after initial diagnosis. Because experiences seeking care many years ago were less relevant to today's health care environment, we focused on reporting responses from 11 participants who had been diagnosed within the past 10 years. Some participants said that they had been tested at community-based organizations and subsequently referred by case managers to a provider. These men reported being informed about resources, including organizations that could help with coping and managing care.

The positive behavioral beliefs about receiving HIV care focused on the benefits of care for managing the illness and keeping one healthy. Participants valued being educated about the disease and keeping track of their CD4+ T-cell counts and viral loads. Especially, some mentioned by actively seeking care, they could secure advice and support from both HCP and their support networks, including family and friends. Most of the negative behavioral beliefs about receiving HIV care revolved around the men's perceptions of HCP. Most concerns were about having a HCP whom they did not trust or felt uncomfortable to communicate with. Other negative consequences of engaging in HIV care included long waits for an appointment, being stuck with needles, and encountering familiar people in the care setting who did not know their serostatus.

The referents who would approve of the men seeking HIV care included their support networks such as friends, particularly friends who were PLWH, family members, and HCP. All said no important referents would disapprove of their getting care.

Positive control beliefs about the things that would facilitate the ability to seek care focused on having a supportive nonjudgmental HCP whom they could trust and communicate with. The negative control beliefs about things that would inhibit the ability to see a HCP for HIV care included fear of the unknown, lack of transportation, and lack of nearby HIV care facilities.

We also asked participants about their experiences in HIV care, beginning with the initial visit. Some men focused on their internal feelings and emotions about the visit. One reported negative feelings, such as being uncomfortable with the many personal questions about his sex life. A few other men reported feeling scared with one man saying that he “had a nervous breakdown and was still in a tender state” during his first visit. He explained his feelings in terms of his recent diagnosis and the effect that his diagnosis and subsequent initial health care visit had had on his emotional state. Other men with earlier diagnoses focused on outside factors such as misinformation received from the health care team and the health care community's lack of knowledge about treatment options. The men's responses were not all negative, however. One man reported that, although he was scared at first, his HCP consoled him, assuring him that he could get better, and another man reported that he felt at ease once rapport was established with his HCP. Another participant indicated that his first visit was great: that he felt reassured, that the visit was empowering and positive, and that it took away his stress.

When asked how regularly they had been going to the HCP for HIV care, 15 men (83%) said every 3 months, 2 (11%) said every month, and 1 (6%) said every week. The men mentioned several things that could help them keep up with their HIV care appointments, including a planner book, understanding the importance of staying on medication, making the next appointment while at the clinic, reading about treatment for HIV, receiving reminder phone calls, having transportation such as a pick-up service, posting reminders in a calendar, reminder cards, and living near the provider. The things that made it hard to keep HIV care appointments included feeling sick and unmotivated, distance, lack of transportation, conflict with work or school hours, and expensive co-payments.

Back to Top | Article Outline

Adherence and Viral Suppression

Positive behavioral beliefs about the consequences of taking ART as prescribed focused on the positive health effects, such as keeping the viral load undetectable, feeling and looking better, and protecting other people. Negative behavioral beliefs revolved around side effects such as fatigue and weight gain and interferences with their alcohol consumption and their social life.

The referents approving of their taking ART as prescribed included their HCP and supportive network members such as family and friends. Those who would disapprove included family members who could not accept the fact that they were taking HIV medications and “people who do not care about me.”

Positive control beliefs about things that would facilitate the ability to take ART as prescribed included specific things that could make medication adherence easier. Most mentioned setting reminders and having pills and water available. Some also mentioned having a support group of people who were also taking ART. Negative control beliefs about things that would inhibit taking ART as prescribed included visiting or socializing with people to whom they had not disclosed their HIV status, spending nights out partying or traveling, forgetting to take the dose, and forgetting to refill the prescription.

When asked whether they sometimes forgot to take their medication, 5 men (31%) said yes. The reasons included a variety of scenarios, such as simply being too busy, leaving the medication at home while spending the night out, and having to take the medication with food but not eating at the same time every day.

Back to Top | Article Outline

Influence of Age

Finally, to extract insight from different age group experiences to inform more targeted interventions, we took an exploratory analysis to compare the responses from participants aged 50 years and older and those younger than 50 years. We found both groups mentioned all types of behavioral beliefs listed in Table 1, but there are two subtle differences. First, participants aged 50 years and older were more likely to mention stigma in the Black community about HIV as a barrier for testing and seeking care. Second, older participants were less likely to discuss the bad things about adhering to medication, as one participant mentioned he got used to the side effects. However, they also mentioned simply forgetting to take the medication was a barrier for adherence, whereas younger participants did not mention this problem. The difference between those who had known their HIV status for many years and those who were diagnosed within the past 10 years was that a few participants with diagnoses from long ago mentioned the lack of knowledge from HCP and the health care team.

Back to Top | Article Outline


The analysis of the data from our study resulted in several overarching themes regarding HIV care–related behaviors among African American MSM: (a) stigma, (b) concerns about HCP, (c) social support, and (d) logistical issues. The themes were evident in participant responses about seeking HIV testing, seeking care, and adhering to ART regimens, often regarding both behavioral beliefs and control beliefs. The issue of stigma was perhaps the most formidable barrier to progress on the HIV care continuum. When asked about HIV testing, participants said that destigmatizating HIV would help them seek testing. Because HIV is a stigmatized disease, the participants were afraid about possible breaches of confidentiality, afraid that others might find out. This was seen as a possible negative consequence of seeking testing. It was also a potential negative consequence of seeking care and of taking ART. People they knew and to whom they had not disclosed might observe them in the health care setting or taking medications and surmise that they were living with HIV, potentially leading to ostracism and discrimination. HIV stigma is particularly destructive because it prevents people from disclosing their status, which in turn undercuts their ability to enlist support to engage in HIV care–related behaviors. Additionally, our data suggest that participants who were 50 years or older considered stigma to a greater extent than younger participants in thinking about HIV care–related behaviors.

Another overarching theme concerned HCP. Having a good relationship with HCP was seen as motivating participants to seek HIV testing, but concerns about HCP were most evident in seeking care. Participants expressed negative outcome expectancies regarding seeking care, including encountering providers who were poor communicators, untrustworthy, judgmental, and ill-informed about HIV.

A third theme involved social support as a facilitator of engagement in the HIV care continuum. Being accompanied by a friend was seen as facilitating HIV testing. Friends, including those who were PLWH and sexual partners, were seen as sources of normative support, approving participant participation in all three HIV care–related behaviors. In addition, support groups were also mentioned as sources of normative support for seeking care and adhering to ART regimens, where a support group of people who were also taking ART was seen as helping participants adhere.

The final major theme concerned logistical issues or practical barriers to HIV care, including concerns about accessible facilities for HIV testing, transportation, costs, and insurance coverage for HIV care. Logistical issues such as not having medications available when they should be taken, not having water with which to take them, and forgetting to take them were seen as reducing participant likelihood of taking ART as prescribed. Especially for older participants, forgetting to take their medications was more frequently mentioned than by their younger counterparts.

Our confidence in these four themes was increased by the similarities in findings across questions designed to elicit different types of behavioral, normative, and control beliefs regarding HIV testing, care seeking, and ART adherence. Moreover, many of our themes dovetailed with those of other studies about the HIV care continuum, particularly fear of learning one has HIV (Adam, de Wit, Bourne, Know, & Purchas, 2014; Lauby, Bond, Eroglu, & Batson, 2006; Nel, Yi, Sandfort, & Rich, 2013); stigma (Adam et al., 2014; Kalichman et al., 2009; Lauby et al., 2006); needles (Lauby et al., 2006); concern about breaches of privacy (Marks, Gardner, Craw, & Crepaz, 2010); the importance of good relationships with HCP and trust in health care (Bogart, Wagner, Galvan, & Banks, 2010); social support (Jemmott, Jemmott, O'Leary, Icard, & Rutledge, n.d.; Lauby et al., 2012); and competing life issues, such as socializing, partying, and consuming alcohol, presenting challenges to medication adherence (Kalichman et al., 2013).

Back to Top | Article Outline

Trustworthiness and Limitations

Hallmarks of trustworthiness in qualitative research findings include assessments of credibility, transferability, and confirmability. We used several strategies to maximize credibility and widen our own understanding of the phenomena, including (a) searching our data for rival conclusions and negative cases, (b) using multiple coders and discussing themes within a larger group of researchers/co-authors from the parent study, and (c) comparing emergent themes to existing theory (e.g., Theory of Planned Behavior, Social Cognitive Theory) and perspectives (e.g., stigma, social support). Regarding transferability, our description of themes for these African American MSM study participants was similar to those presented in studies of HIV stigma and health services seeking in other MSM populations (Christopoulos et al., 2013; Logie et al., 2017; Wei et al., 2014).

Although we did not audio record participants and could not use direct quotes from them, our interviewers took detailed notes to enhance confirmability of findings being centered in the experiences of the participants. We strove to establish rapport with the participants and stressed the value of honest and frank responses to the development of future HIV care interventions. Interview notes were coded independently, discussed by two experienced coders for agreement, and then presented to the researchers/co-authors to increase neutrality and decrease unintended personal bias of the coders.

The sample consisted of African American men residing in an urban area in the northeastern United States who had previously participated in an intervention trial. The original trial had 595 participants. For our qualitative study, the recruiter did not systematically track the contact records with these participants. One limitation was that we did not have statistics to compare our participants to the original pool of participants or other African American MSM. Another limitation was that we did not have repeated contact with the participants to assess credibility within the population. Additional contacts may have increased depth and afforded a review of our themes through member checking, as may have follow-up focus groups. However, the rich experience of the research team and familiarity with the population from other studies and comparisons with other published studies reduces this concern. Lastly, all our interviewers were female. One possibility is that if we had trained African American MSM as interviewers, the interviewees might have identified more with the interviewers and revealed more information.

Back to Top | Article Outline


Notwithstanding these limitations, our findings have implications for developing interventions centered on the HIV care continuum. Our findings support the use of multilevel interventions targeting different factors, including personal contacts, HCP, and community members. Interventions should primarily focus on addressing the stigma of HIV and homophobia to reduce barriers to HIV testing and care. It is important that, interventions for African American MSM aged 50 years and older devote more resources to address and reduce perceived HIV-related stigma within their social groups.

Interventions targeting individuals could employ activities specifically designed to buttress beliefs about the positive consequences of HIV testing, seeking HIV care, and adhering to ART regimens, while weakening beliefs about the negative consequences of these behaviors. Such interventions could also build self-efficacy to surmount barriers to HIV testing, care seeking, and ART adherence by using strategies such as skills building (Bandura, 1986; El-Bassel et al., 2010; Garofalo et al., 2016; Hersch et al., 2013; Kalichman et al., 2016), including role-playing and vicarious reward from testimonials of African American MSM living with HIV who have experienced positive consequences from testing and engaging in HIV care behaviors. For older African American MSM, interventions could consider providing additional tools such as automatic reminders to increase medication adherence.

Interventions with HCP aimed at increasing HIV testing and care could also focus on creating an environment that African American MSM would perceive as welcoming and building more positive provider–patient relationships. Existing social groups or specially created groups of PLWH could be employed in interventions aimed at encouraging engagement in HIV care and ART adherence. Similarly, dyadic interventions involving the participant and his partner could be employed to provide support for engaging in HIV care behaviors (Bouris et al., 2017; El-Bassel et al., 2011; 2010).

Back to Top | Article Outline


African American MSM have high rates of HIV and low rates of engagement in the HIV care continuum, but few existing interventions target engagement in the HIV care continuum specifically for African American MSM. We provide information that can be used to address this important gap in the literature. Analysis of our data resulted in four cross-cutting themes (stigma, concerns about HCP, social support, and logistical issues) that interventions to encourage engagement in the HIV care continuum by African American MSM might address. Consistent with our theoretical framework, the Theory of Planned Behavior, research using quantitative methods should explore the predictive power of these themes in larger, more diverse samples of African American MSM. Research along these lines would support the development of theory-based, culturally appropriate interventions to help reduce disparities in HIV care affecting African American MSM.

Back to Top | Article Outline


The authors report no real or perceived vested interests related to this article that could be construed as a conflict of interest.

Back to Top | Article Outline

Key Considerations

  • Multilevel interventions should primarily focus on addressing HIV-related stigma and homophobia to reduce barriers to HIV testing and care.
  • Interventions with HCPs should focus on creating an environment that African American MSM perceive as welcoming and building more positive provider–patient relationships.
  • Interventions for older African American MSM should devote resources to reduce perceived HIV-related stigma and provide reminder tools to increase medication adherence.
Back to Top | Article Outline


This study was supported by the National Institute of Mental Health (R01 MH079736: PI: John B. Jemmott, III). The findings and conclusions in this report are those of the authors and do not represent official views of the Centers for Disease Control and Prevention.

Back to Top | Article Outline


Adam P. C. G., de Wit J. B. F., Bourne C. P., Know D., Purchas J. (2014). Promoting regular testing: An examination of HIV and STI testing routines and associated socio-demographic, behavioral and social-cognitive factors among men who have sex with men in New South Wales, Australia. AIDS and Behavior, 18(5), 921–932. doi:10.1007/s10461-014-0733-z
Ajzen I. (1991). The theory of planned behavior. Organizational Behavior and Human Decision Processes, 50(2), 179–211. doi:10.1016/0749-5978(91)90020-T
Albarracin D., Johnson B. T., Fishbein M., Muellerleile P. A. (2001). Theories of reasoned action and planned behavior as models of condom use: A meta-analysis. Psychological Bulletin, 127(1), 142–161. doi:10.1037//0033-2909.127.1.142
Armitage C. J., Conner M. (2001). Efficacy of the Theory of Planned Behaviour: A meta-analytic review. The British Journal of Social Psychology, 40(pt 4), 471–499. doi:10.1348/014466601164939
Bandura A.. (1986). Social foundations of thought and action: A social cognitive theory. Englewood Cliffs, NJ: Prentice-Hall.
Blank M. B., Hanrahan N. P., Fishbein M., Wu E. S., Tennille J. A., Ten Have T. R., Aiken L. H. (2011). A randomized trial of a nursing intervention for HIV disease management among persons with serious mental illness. Psychiatric Services, 62(11), 1318–1324. doi:10.1176/ps.62.11.pss6211_1318
Bogart L. M., Wagner G., Galvan F. H., Banks D. (2010). Conspiracy beliefs about HIV are related to antiretroviral treatment nonadherence among African American men with HIV. Journal of Acquired Immune Deficiency Syndromes, 53(5), 648–655. doi:10.1097/QAI.0b013e3181c57dbc
Bouris A., Jaffe K., Eavou R., Liao C. H., Kuhns L., Voisin D., Schneider J. A. (2017). Project nGage: Results of a randomized controlled trial of a dyadic network support intervention to retain young black men who have sex with men in HIV care. AIDS and Behavior, 21(12), 3618–3629. doi:10.1007/s10461-017-1954-8
Cao B. L., Gupta S., Wang J. T., Hightow-Weidman L. B., Muessig K. E., Tang W. M., Tucker J. D. (2017). Social media interventions to promote HIV testing, linkage, adherence, and retention: Systematic review and meta-analysis. Journal of Medical Internet Research, 19(11), e394. doi:10.2196/jmir.7997
Centers for Disease Control and Prevention. (2013). Rates of diagnoses of HIV infection among adults and adolescents, by area of residence, 2011--United States and 6 dependent areas. Retrieved from
Centers for Disease Control and Prevention. (2014). HIV in the United States: The stages of care. Retrieved from
Centers for Disease Control and Prevention. (2017a). Monitoring selected national HIV prevention and care objectives using HIV surveillance data: United States and 6 dependent areas, 2015. Retrieved from
Centers for Disease Control and Prevention. (2017b). CDC Fact Sheet: HIV among African Americans. Retrieved from
Centers for Disease Control and Prevention. (2017c). HIV among African American gay and bisexual men Retrieved from
Christopoulos K. A., Massey A. D., Lopez A. M., Geng E. H., Johnson M. O., Pilcher C. D., Dawson-Rose C. (2013). “Taking a half day at a time:” Patient perspectives and the HIV engagement in care continuum. AIDS Patient Care and STDs, 27(4), 223–230. doi: 10.1089/apc.2012.0418
Cohen M. S., Chen Y. Q., McCauley M., Gamble T., Hosseinipour M. C., Kumarasamy N., Fleming T. R. (2011). Prevention of HIV-1 infection with early antiretroviral therapy. The New England Journal of Medicine, 365(6), 493–505. doi:10.1056/NEJMoa1105243
Coleman C. L., Jemmott L., Jemmott J. B., Strumpf N., Ratcliffe S. (2009). Development of an HIV risk reduction intervention for older seropositive African American men. AIDS Patient Care and STDs, 23(8), 647–655. doi:10.1089/apc.2008.0276
El-Bassel N., Jemmott J. B., Landis J. R., Pequegnat W., Wingood G. M., Wyatt G. E., Bellamy S. L. (2010). National Institute of Mental Health Multisite Eban HIV/STD Prevention Intervention for African American HIV Serodiscordant Couples: A cluster randomized trial. Archives of Internal Medicine, 170(17), 1594–1601. doi:10.1001/archinternmed.2010.261
El-Bassel N., Jemmott J. B. III, Landis J. R., Pequegnat W., Wingood G. M., Wyatt G. E., Bellamy S. L. (2011). Intervention to influence behaviors linked to risk of chronic diseases: A multisite randomized controlled trial with African-American HIV-serodiscordant heterosexual couples. Archives of Internal Medicine, 171(8), 728–736. doi:10.1001/archinternmed.2011.136
Fishbein M., Ajzen I. (2010). Predicting and changing behavior: The reasoned action approach. New York, NY: Taylor and Francis Group.
Granich R. M., Gilks C. F., Dye C., De Cock K. M., Williams B. G. (2009). Universal voluntary HIV testing with immediate antiretroviral therapy as a strategy for elimination of HIV transmission: A mathematical model. Lancet, 373(9657), 48–57. doi:10.1016/S0140-6736(08)61697-9
Gardner E. M., McLees M. P., Steiner J. F., Del Rio C., Burman W. J. (2011). The spectrum of engagement in HIV care and its relevance to test-and-treat strategies for prevention of HIV infection. Clinical Infectious Diseases, 52(6), 793–800. doi:10.1093/cid/ciq243
Garofalo R., Kuhns L. M., Hotton A., Johnson A., Muldoon A., Rice D. (2016). A randomized controlled trial of personalized text message reminders to promote medication adherence among HIV-positive adolescents and young adults. AIDS and Behavior, 20(5), 1049–1059. doi:10.1007/s10461-015-1192-x
Hsieh H.-F., Shannon S. E. (2005). Three approaches to qualitative content analysis. Qualitative Health Research, 15(9), 1277–1288. doi:10.1177/1049732305276687
Hersch R. K., Cook R. F., Billings D. W., Kaplan S., Murray D., Safren S., Spencer J. (2013). Test of a web-based program to improve adherence to HIV medications. AIDS and Behavior, 17(9), 2963–2976. doi:10.1007/s10461-013-0535-8
Henny K. D., Wilkes A. L., McDonald C. M., Denson D. J., Neumann M. S. (2018). A rapid review of eHealth interventions addressing the continuum of HIV care (2007-2017). AIDS and Behavior, 22(1), 43–63. doi:10.1007/s10461-017-1923-2
Jemmott J. B. III, Jemmott L. S., Fong G. T., Morales K. H. (2010a). Effectiveness of an HIV/STD risk-reduction intervention for adolescents when implemented by community-based organizations: A cluster-randomized controlled trial. American Journal of Public Health, 100(4), 720–726. doi:10.2105/AJPH.2008.140657
Jemmott J. B. III, Jemmott L. S., O'Leary A., Ngwane Z., Icard L. D., Bellamy S. L., Makiwane M. B. (2010). School-based randomized controlled trial of an HIV/STD risk-reduction intervention for South African adolescents. Archives of Pediatrics & Adolescent Medicine, 164(10), 923–929. doi:10.1001/archpediatrics.2010.176
Jemmott J. B. III (2012). The reasoned action approach in HIV risk-reduction strategies for adolescents. Annals of the American Academy of Political and Social Science, 640, 150–172. doi:10.1177/0002716211426096
Jemmott L. S., Jemmott J. B. III, Ngwane Z., Icard L. D., O'Leary A., Gueits L., Brawner B. (2013). Let us protect our future! A culturally congruent evidenced-based HIV/STD risk-reduction intervention for young South African adolescents. Health Education Research, 1, 166–181. doi:10.1093/her/cyt072
Jemmott J. B. III, Jemmott L. S., O'Leary A., Icard L. D., Rutledge S. E., Stevens R., Hsu J. (2014). On the efficacy and mediation of a social cognitive one-on-one HIV risk-reduction intervention for African American men who have sex with men: A randomized controlled trial. AIDS and Behavior, 19(7), 1247–1262. doi:10.1007/s10461-014-0961-2
Jemmott J.B. III, Jemmott L.S., O'Leary A., Icard L.D., Rutledge S.E. (n.d.). Baseline data on correlates of HIV testing in Project BRO. Unpublished analyses. Annenberg School for Communication, University of Pennsylvania, Philadelphia, United States.
Kamb M. L., Fishbein M., Douglas J. M. Jr., Rhodes F., Rogers J., Bolan G., Peterman T. A. (1998). Efficacy of risk-reduction counseling to prevent human immunodeficiency virus and sexually transmitted diseases: A randomized controlled trial. Journal of the American Medical Association, 280(13), 1161–1167.
Kalichman S. C., Simbayi L. C., Cloete A., Mthembu P. P., Mkhonta R. N., Ginindza T. (2009). Measuring AIDS stigmas in people living with HIV/AIDS: The Internalized AIDS-Related Stigma Scale. AIDS Care, 21(1), 87–93. doi:10.1080/09540120802032627
Kalichman S. C., Grebler T., Amaral C. M., McNerey M., White D., Kalichman M. O., Eaton L. (2013). Intentional non-adherence to medications among HIV positive alcohol drinkers: Prospective study of interactive toxicity beliefs. Journal of General Internal Medicine, 28(3), 399–405. doi:10.1007/S11606-012-2231-1
Kalichman S. C., Kalichman M. O., Cherry C., Eaton L. A., Cruess D., Schinazi R. F. (2016). Randomized factorial trial of phone-delivered support counseling and daily text message reminders for HIV treatment adherence. Journal of Acquired Immune Deficiency Syndromes, 73(1), 47–54. doi:10.1097/QAI.0000000000001020
Lauby J. L., Bond L., Eroglu D., Batson H. (2006). Decisional balance, perceived risk and HIV testing practices. AIDS and Behavior, 10(1), 83–92. doi:10.1007/s10461-005-9029-7
Lauby J. L., Marks G., Bingham T., Liu K., Liau A., Stueve A., Millett G. A. (2012). Having supportive social relationships is associated with reduced risk of unrecognized HIV infection among Black and Latino men who have sex with men. AIDS and Behavior, 16(3), 508–515. doi:10.1007/s10461-011-0002-3
Logie C. H., Lacombe-Duncan A., Brien N., Jones N., Lee-Foon N., Levermore K., ..., Newman P. A. (2017). Barriers and facilitators to HIV testing among young men who have sex with men and transgender women in Kingston, Jamaica: A qualitative study. Journal of the International AIDS Society, 20(1), 21385. doi: 0.7448/IAS.20.1.21385
Marks G., Gardner L. I., Craw J., Crepaz N. (2010). Entry and retention in medical care among HIV-diagnosed persons: A meta-analysis. AIDS (London, England), 24(17), 2665–2678. doi:10.1097/QAD.0b013e32833f4b1b
Millett G. A., Peterson J. L., Flores S. A., Hart T. A., Jeffries W. L., Wilson P. A., Remis R. S. (2012). Comparisons of disparities and risks of HIV infection in Black and other men who have sex with men in Canada, UK, and USA: A meta-analysis. Lancet, 380(9839), 341–348. doi:10.1016/S0140-6736(12)60899-X
Montano D. E., Kasprzyk D., Hamilton D. T., Tshimanga M., Gorn G. (2014). Evidence-based identification of key beliefs explaining adult male circumcision motivation in Zimbabwe: Targets for behavior change messaging. AIDS and Behavior, 18(5), 885–904. doi:10.1007/s10461-013-0686-7
Nel J. A., Yi H. S., Sandfort T. G. M., Rich E. (2013). HIV-untested men who have sex with men in South Africa: The perception of not being at risk and fear of being tested. AIDS and Behavior, 17, S51–S59. doi:10.1007/S10461-012-0329-4
Risher K. A., Kapoor S., Daramola A. M., Paz-Bailey G., Skarbinski J., Doyle K., Shah M. (2017). Challenges in the evaluation of interventions to improve engagement along the HIV care continuum in the United States: A systematic review. AIDS and Behavior, 21(7), 2101–2123. doi:10.1007/s10461-017-1687-8
Villarruel A. M., Jemmott J. B. III, Jemmott L. S. (2006). A randomized controlled trial testing an HIV prevention intervention for Latino youth. Archives of Pediatrics & Adolescent Medicine, 160(8), 772–777. doi:10.1001/archpedi.160.8.772
Wei C., Yan H., Yang C., Raymond H. F., Li J., Yang H., Stall R. (2014). Accessing HIV testing and treatment among men who have sex with men in China: A qualitative study. AIDS Care, 26(3), 372–378. doi: 10.1080/09540121.2013.824538
Zhang J., Jemmott J. B. III, O'Leary A., Stevens R., Jemmott L. S., Icard L. D., Rutledge S. E. (2016). Efficacy and mediation of a theory-based physical activity intervention for African American men who have sex with men: A randomized controlled trial. Annals of Behavioral Medicine, 51, 106–116. doi:10.1007/s12160-016-9832-6
Zhang J., Cederbaum J., Jemmott J. B. III, Jemmott L. S. (2018). Theory-based behavioral intervention increases mother-son communication about sexual risk reduction among inner-city African Americans. Journal of Adolescent Health, 63(4), 497–502. doi:10.1016/j.jadohealth.2018.04.017

African American men; HIV care continuum; men who have sex with men; qualitative interviews; stigma; Theory of Planned Behavior

© 2019 Association of Nurses in AIDS Care