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Interventions for immigrant Latino men who have sex with men along the HIV prevention and treatment cascade

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Question

  • What is the latest evidence regarding interventions for immigrant Latino men who have sex with men along the HIV prevention and treatment cascade?

 Key take-home messages

  • Among reported HIV cases with a known race/ethnicity in Canada in 2017, 6.3% were among individuals from Latin America (1). In 2018, Latinx persons in the U.S. were disproportionately affected by HIV, accounting for 27% of HIV diagnoses, despite total Latinx persons representing only 18% of the U.S. population (2). Also, 2018 data suggests that approximately 67% of the Latinx population diagnosed with HIV in the U.S. were born outside the continental U.S., primarily in Mexico and South America (3).
  • Various factors can lead to increased HIV risk among Latino immigrants including social and geographic isolation, loneliness, disrupted family relationships, and missing family-based or community-based social norms (4). Barriers to adhering to HIV treatment may include unpleasant side effects, poor communication with providers due to language barriers, financial burden, and limited medication availability during migration periods (5).
  • There are interventions focused on increasing testing and preventive behaviours by providing: culturally appropriate services (6); biomedical strategies (e.g., awareness of self-testing kits) (6); strategies addressing issues of disclosure of sexual orientation, family rejection, homophobia, poverty, and racism (7); and peer-to-peer approaches (e.g., “promotores” or “navegantes” programs) (5).
  • Literature on increasing linkage and adherence to care includes the use of a transnational framework which incorporates recognizing, acknowledging, and building upon the connections that Latinx use to maintain ties to their place of origin while living abroad (8, 9).
  • A cognitive behaviour therapy group intervention to address coping with discrimination among HIV-positive Latino immigrant sexual minority men found that discrimination is related to medication non-adherence, medication side effects, and HIV/AIDS symptoms (10).

The issue and why it’s important

Evidence shows that a sizeable proportion of HIV cases in Canada occur among individuals from Latin America, particularly among Latino men who have sex with men (1). In 2017, information on race/ethnicity was available for 49.3% (n=1,184) of reported HIV cases in Canada; among reported HIV cases with a known race/ethnicity, 6.3% were from Latin America (1). Of the reported total of male and female cases, 8.0% and 1.3% identified as Latin American (1). Data available on both race/ethnicity and source of exposure demonstrated that the highest proportion of cases among those from Latin America occurred in the gay, bisexual, and other men who have sex with men exposure category (12.0%) (1).

A 2020 study reported that the U.S. has a large and rapidly growing Latinx population; over the past decade, the Latinx population grew by 43.0%, becoming the largest racial/ethnic minority (11). Furthermore, the Latinx population is disproportionately affected by HIV and has the second highest rate of AIDS diagnoses of all racial/ethnic groups (11). While Latinx persons accounted for about 18.0% of the U.S. population in 2018, 27.0% of the total number of HIV diagnoses were attributed to this group (2). Also, 2018 data suggests that approximately 67.0% of the Latinx population diagnosed with HIV in the U.S. were born outside the continental U.S., primarily in Mexico and South America (3). Based on these epidemiological trends, greater efforts are needed to promote HIV prevention strategies among this highly impacted population.

The literature states that various social–structural and circumstantial factors can influence the likelihood of engaging in actions that can increase HIV risk among Latino immigrants (4). These factors include social and geographic isolation, loneliness, disrupted family relationships, and missing family-based or community-based social norms that may influence risk behaviours in their new destination (4). A 2017 systematic review on risk behaviours among immigrant men who have sex with men in Europe and North America found that high rates of unprotected anal intercourse among Latino men who have sex with men suggests the influence of both cultural factors (e.g., machismo ideals emphasizing penetrative sex, fulfilling sexual urges, and having multiple partners) and structural factors such as racism, poverty, and consequent self-devaluation (12).

A 2019 study among Latino men who have sex with men in the U.S. South found that HIV-related social support and HIV-related knowledge were associated with greater odds of testing; additionally, speaking only Spanish was associated with reduced odds of testing (13). A 2014 literature review of HIV care among Latinos in the U.S. South identified barriers to testing which included a lack of knowledge of testing services and being undocumented (5). Barriers to linkage to care included fear of deportation, lacking documentation, challenging interactions with the health-care system, and stigma (5). Barriers to adhering to treatment included unpleasant side effects, poor communication with providers due to language barriers, financial burden, and limited medication availability during migration (5). Another study examined the unique barriers Latino men who have sex with men faced in maintaining HIV care (14). This 2019 qualitative study conducted in-depth interviews with U.S. and foreign-born gay Latino men living in North Carolina (n=14) to assess their experiences with HIV testing, care, and treatment (14). Many participants had experienced interruptions in their care due to intersecting stigmatized identities (e.g. being gay, Latino, undocumented) and intersecting structures (e.g. healthcare, immigration policy, institutionalized homophobia) (14). Undocumented participants directly connected their immigration status to their ability to secure employment, which in turn impacted their retention in HIV care and treatment adherence (14). Similarly, a 2020 qualitative study among Latinx individuals in the U.S. stated that limited English proficiency, cultural differences, inadequate interpreter services, HIV-related and intersectional stigma, and isolation are barriers that may contribute to disparities in outcomes for Latinx people living with HIV (15). These unique barriers and needs faced by immigrated Latino men who have sex with men can pose a challenge in being linked and adhering to HIV care.

What we found

Few strategies have been found to reduce the disproportionate burden of HIV among Latinx populations in the U.S. (4, 11). Outreach efforts may be particularly challenging when reaching immigrants who are mobile and, in some cases, without documentation and potentially wary of engaging with formal healthcare services (4). Successful HIV prevention and care requires evidence-based approaches that combine biomedical strategies with behavioural interventions that are socially and culturally appropriate for the population or community being prioritized (6). Initiatives are also required to overcome the negative effects of social-structural factors on Latinx populations’ access to and participation in HIV-related services (4). A study published in 2019 examined perceptions of HIV pre-exposure prophylaxis (PrEP) users among Latino men who have sex with men (16). The study found that monolingual Spanish speaking participants were skeptical about the effectiveness of PrEP (16). Other assumptions among Latino participants included that PrEP users are more promiscuous and are more likely to engage in condomless intercourse without regard for consequences (16). These findings suggest that efforts are needed to address the stigmatizing and negative perceptions of PrEP that still persist in the gay community that may deter its adoption among Latino men who have sex with men (16). Identified interventions along the HIV prevention and treatment cascade for Latino men who have sex with men from the U.S. are explored in more detail below.

HIV prevention, testing, and diagnosis

A study published in 2020 examined the effectiveness of a Spanish-language peer navigation intervention called HOLA: Hombres Ofreciendo Liderazgo y Ayuda (Men Offering Leadership and Help) (11). This intervention was designed to increase HIV testing and condom use among social networks of immigrant Spanish-speaking Latinx gay, bisexual, and other men who have sex with men and transgender women in North Carolina (11, 17). The study randomized 86 adults to the HOLA intervention and 80 adults to a waitlist control to test whether the HOLA intervention group increased HIV testing (11). The HOLA intervention trained Latinx gay and bisexual men who have sex with men and transgender women to serve as peer leaders, known as Navegantes (Navigators) (11). Navegantes promoted sexual health, particularly HIV and sexually transmitted disease (STI) testing and condom use among those in the intervention group by using the skills and materials they gained through training (11). Also, rather than only educating members of their social networks about HIV testing, Navegantes worked to identify barriers to testing and problem solve ways to overcome these barriers (11). At the 12 month follow-up, HOLA participants’ past HIV testing increased from 58.1% at baseline to 90.2% (P<0.0001); while testing among the waitlist control participants did not significantly change (55.0% versus 60.0%) (11). The authors concluded that the intervention could also be adapted for HIV-positive Latinx men who have sex with men and transgender women to promote engagement in HIV care and prevent HIV transmission to sexual partners (11).

Many other interventions have been conducted to encourage HIV testing among Spanish-speaking Latinx individuals and men who have sex with men. These include:

  • A 2020 study examined a six-month social marketing campaign titled Sólo Se Vive Una Vez (You Only Live Once) in Baltimore among Spanish-speaking Latinxs which promoted free HIV testing by addressing HIV stigma (18). The campaign included a website, community outreach events, and advertisements via radio, billboards, local partners, and buses (18). The campaign included LGBTQ+ community stakeholders in the development of campaign materials, including men who have sex with men and transgender individuals in videos and advertisements, and advertising on dating applications used by Latinx men who have sex with men in Baltimore (Grindr and Scruff) (18). The authors found that the high number of visitors to the campaign’s website via Grindr (2,097 users, 21.4% of website users) suggested that they were able to reach this population (18).
  • A 2017 randomized controlled trial (RCT) evaluated the HOLA en Grupos intervention, a Spanish-language behavioural HIV prevention intervention designed to increase condom use and HIV testing among Latino gay, bisexual, and other men who have sex with men (19). There were 304 Latino men who have sex with men, aged 18 to 55 years in North Carolina who were randomized to the four session HOLA en Grupos intervention or a general health education comparison intervention (19). The intervention was grounded on social cognitive theory, empowerment education, and traditional Hispanic/Latino cultural values; it included four interactive modules (19). Results indicated that relative to comparison participants, HOLA en Grupos participants reported increased consistent condom use during the past three months (Adjusted Odds Ratio [AOR]= 4.1; P <0.001) and HIV testing during the past 6 months (AOR= 13.8; P <0.001) (19). HOLA en Grupos participants also reported increased knowledge of HIV and STIs, condom use skills, and self-efficacy (19).
  • A 2017 study in New York City explored the process of developing an intervention called Latinos en Pareja (Latinos in a Relationship) among predominantly Spanish-speaking Latino gay couples (20). The process of developing the intervention included engaging community stakeholders, capturing the lived experiences of Latino gay couples, and identifying key priority issues among participants (such as mental health, problematic drug and alcohol consumption, and legal problems) (20). The intervention focused on increasing risk reduction norms, sexual communication skills, and social support, and provided guidance on how to utilize culturally and linguistically appropriate services (20).
  • A 2016 study describes the Tu Amigo Pepe campaign — a 16-week pilot that included Spanish-language radio announcements, a website, social media outreach, text message reminders, and a toll-free hotline directed at young Latino immigrant men who have sex with men (21). The goal of the campaign was to reframe negative attitudes, beliefs, and norms towards HIV testing and to promote self-efficacy towards HIV testing (21). At the end of the intervention 90.2% of respondents stated that they had ever tested for HIV, an 8.2% increase from baseline (21).
  • A 2015 study described a couple-based intervention in New York City called Conectando Latinos en Pareja which integrated social, cultural, behavioural and biomedical strategies to address HIV among Latino men who have sex with men (6). In a focus group of 20 couples (40 individuals), 37 (93%) had no prior knowledge of PrEP, post-exposure prophylaxis (PEP), or HIV self-testing kits (6). The intervention emphasized providing an overview of these prevention tools while also addressing behavioural, social and structural issues such as language barriers (6). A proposed RCT will determine the preliminary efficacy of the intervention to increase the proportion of sex acts among Latino men who have sex with men that are HIV protected (i.e., anal sex acts in which condoms, PrEP, treatment as prevention, or a combination thereof, are used to reduce risk of HIV transmission) (22).
  • A 2015 publication examined Chicos Net, an HIV prevention behavioural intervention conducted in Toronto, Ontario that aimed to empower Latino participants by allowing them to share their experiences regarding homophobia, racism, dating, body image, and sexual desires (23).
  • A 2014 literature review assessing HIV care among Latinos in the U.S. South found that having tailored strategies (e.g., community outreach), and organizational-level interventions (e.g., increasing provider endorsement of HIV tests) can improve access to HIV care for Latinos (5). Culturally tailored, community-based participatory methodologies, including peer-to-peer approaches (e.g., “promotores” or “navegantes” programs), have been successful in increasing testing intentions and testing behaviours (5, 24, 25).
  • A 2013 intervention conducted in San Francisco called La Familia was a 12-session program offered over a 6-week period that specifically addressed issues of disclosure of sexual orientation, family rejection, and issues relating to oppression for immigrant Latino men who have sex with men in the U.S. (7). A total of 35 Latino immigrants participated in the discussion-focused intervention, with 66.0% (n=23) participating in four or more sessions (7). Survey results indicated that the program helped the participants to: increase their safer sex behaviours, feel more comfortable in disclosing their sexual orientation, and experience greater support from friends who understood their problems (7).
  • A 2011 study described an HIV prevention program for Spanish-speaking gay, bisexual, and other men who have sex with men who were within three years of arrival in Canada (26). The Mano en Mano program consisted of an initial day-long session followed by four two-hour evening sessions addressing HIV prevention, social isolation, social service, and migration issues. Results showed a significant shift toward safer sex practices and decreased sense of social isolation expressed in exit interviews (26).

Linkage to and retention in medical care

A five-year multi-site study selected ten demonstration sites across the U.S. that would identify and re-engage a total of 1,000 Latinx individuals who were newly diagnosed, or who were HIV-positive and had fallen out of care during the study period (2013–2018) (8). This study was guided by the transnational framework that “recognizes, acknowledges, and builds upon the connections that Latinx use to maintain ties to their place of origin while living in the U.S.” (8, 9). Common transnational practices that immigrants engage in to remain connected to their place of origin included communication, travel, social and economic remittances, or civic engagement (8). Each site integrated transnationalism and cultural elements in a way that was most congruent with their organization’s capacity and target population. For example, demonstration sites hosted informational events at embassies, churches with Spanish services, and bars that hosted Latin nights (8). Outreach materials drew on cultural references of national pride, such as the Taíno sun from Puerto Rico, or the Mexican or Puerto Rican flag (8). Individual level initiatives were also conducted (8). For example, if a participant frequently video chatted with their family in Mexico City, the intervention site would explore issues of HIV disclosure and the presence of social support. If a participant travelled to and from the U.S. and Mexico or Puerto Rico, the intervention site addressed implications for treatment adherence and emergency care resources while abroad (8).

This framework was further explored in a 2019 study which aimed to explore how nine intervention sites applied a transnational framework and incorporated Latino cultural constructs into programs designed to promote linkage and retention in HIV care among Mexican and Puerto Rican Latinos in the U.S. (27). A main theme identified across the sites included developing trusting and supportive relationships between navigators and clients to assure clients that no estás solo (you are not alone) (27). Many clients were able to connect with navigators over the shared experience of being Latino, an immigrant, or in some cases having the shared experience of living with HIV (27). A second theme included empowering clients to connect and stay in primary care by educating clients about HIV and by facilitating engagement or referrals to care (27). Across interventions, HIV education discussions offered hope and served to assure clients that HIV no longer meant death, a belief that a number of participants recounted holding at the time of their diagnosis (27). All of the interventions provided some type of appointment escort, where navigators offered to accompany clients to their medical visits to provide emotional support, linguistic interpretation or translation, modeling of self-advocacy skills by asking health providers questions, and practical support for care engagement (27).

A 2019 qualitative study aimed to improve understanding of the HIV testing, care, and treatment adherence experiences of Latino men who have sex with men in North Carolina (14). Study participants (n=14) noted that the mental health burden of living with HIV was a central part of the HIV experience that created challenges for retention in HIV care and adherence to treatment (14).

Ineffective coping with the stress of discrimination (e.g., rumination, substance use) may lead to worse long-term mental and physical health (10). Among HIV-positive Latino sexual minority men, discrimination is related to medication non-adherence, medication side effects, and disease symptoms (10). A 2020 study examined the effects of a pilot intervention that consisted of a nine-session, community-based, cognitive behavioural therapy group intervention to address coping with discrimination among HIV-positive Latino immigrant sexual minority men in Los Angeles (10). Specifically, facilitators taught participants coping skills, such as mindfulness, cognitive restructuring, and relaxation, and helped participants to understand responses to discrimination in terms of the events that led to the behaviour, and the behaviour’s consequences (10). The intervention was pilot-tested using a pre-post design among 30 HIV-positive Latino immigrants (10). Preliminary results found decreased negative emotional coping responses to discrimination among participants (i.e., feeling less anger, sadness, powerlessness, helplessness, and shame) (10). Study authors concluded that the intervention holds promise for reducing disparities by empowering Latino sexual minority men to leverage innate resilience resources to improve their health (10).

  Factors that may impact local applicability

Many of these studies have examined interventions in the U.S. context where the prevalence of HIV among Latino immigrants is high and results may not be entirely applicable to the local context of Latino immigrants in Canada. Also, risk behaviours among immigrant Latino men who have sex with men can vary from one location to another. For example, one study noted that substance use varied, with high rates of club drug use in Miami among Latino men who have sex with men, but no reported club drug use in rural North Carolina (12). Also, many the studies tend to report on the broad category of Latino men who have sex with men without assessing variation between more specific ethnic or national origin groups (12). Therefore, it is important to consider the local context when adapting interventions.

What we did

We searched Medline (including Epub Ahead of Print, In-Process & Other Non-Indexed Citations) using text terms HIV and (Latin* or Hispanic* or Spanish speak*) and (gay* or men who have sex or bisexual* or MSM or GBMSM or homosexual* or queer*). Searches were conducted on August 4, 2020 and results limited to English articles published from 2010 to present. Reference lists of identified articles were also searched. The searches yielded 714 references from which 27 were included.

Reference list

  1. Haddad N, Li J, Totten S, McGuire M. Adult immunization: HIV in Canada—Surveillance report, 2017. Canada Communicable Disease Report. 2018;44(12):324.
  2. Centers for Disease Control and Prevention. HIV in the United States and dependant areas. 2018. Available from: www.cdc.gov/hiv/statistics/overview/ataglance.html Accessed September 8, 2020.
  3. Centers for Disease Control and Prevention. HIV surveillance report: Diagnoses of HIV Infection in the United States and Dependent Areas, 2018. 2019. Available from: www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-surveillance-report-2018-updated-vol-31.pdf Accessed September 9, 2020.
  4. Painter M. Health threats that can affect Hispanic/Latino migrants and immigrants. In: Martínez AD, Rhodes SD. New and emerging issues in Latinx health. Cham, Switzerland: Springer Nature Switzerland AG. 2020.
  5. Morales-Aleman MM, Sutton MY. Hispanics/Latinos and the HIV continuum of care in the Southern USA: A qualitative review of the literature, 2002–2013. AIDS Care. 2014;26(12):1592–604.
  6. Martinez O, Wu E, Levine EC, Muñoz-Laboy M, Fernandez MI, Bass SB, et al. Integration of social, cultural, and biomedical strategies into an existing couple-based behavioral HIV/STI prevention intervention: Voices of Latino male couples. PLoS One. 2016;11(3):e0152361.
  7. Melendez RM, Zepeda J, Samaniego R, Chakravarty D, Alaniz G. “La Familia” HIV prevention program: A focus on disclosure and family acceptance for Latino immigrant MSM to the USA. Salud Publica de Mexico. 2013;55 Suppl 4:S491–7.
  8. Sauceda JA, Brooks RA, Xavier J, Maiorana A, Gomez LG, Zamudio-Haas S, et al. From theory to application: A description of transnationalism in culturally-appropriate HIV interventions of outreach, access, and retention among Latino/a populations. Journal of Immigrant and Minority Health. 2019;21(2):332–45.
  9. Carrillo H. Sexual culture, structure, and change: A transnational framework for studies of Latino/a migration and HIV. In: Organista, K. HIV prevention with Latinos: Theory, research, and practice. New York: Oxford University Press. 2012.
  10. Bogart LM, Galvan FH, Leija J, MacCarthy S, Klein DJ, Pantalonec DW. A pilot cognitive behavior therapy group intervention to address coping with discrimination among HIV-positive Latino immigrant sexual minority men. Annals of LGBTQ Public and Population Health. 2020;1(1).
  11. Rhodes SD, Alonzo J, Mann-Jackson L, Song EY, Tanner AE, Garcia M, et al. A peer navigation intervention to prevent HIV among mixed immigrant status Latinx GBMSM and transgender women in the United States: Outcomes, perspectives and implications for PrEP uptake. Health Education Research. 2020;35(3):165–78.
  12. Lewis NM, Wilson K. HIV risk behaviours among immigrant and ethnic minority gay and bisexual men in North America and Europe: A systematic review. Social Science & Medicine. 2017;179:115–28.
  13. Painter TM, Song EY, Mullins MM, Mann-Jackson L, Alonzo J, Reboussin BA, et al. Social support and other factors associated with HIV testing by Hispanic/Latino gay, bisexual, and other men who have sex with men in the U.S. South. AIDS & Behavior. 2019;23(Suppl 3):251–65.
  14. Barrington C, Davis DA, Villa-Torres L, Carcano J, Hightow-Weidman L. Intersectionalities and the HIV continuum of care among gay Latino men living with HIV in North Carolina. Ethnicity & Health. 2019:1–16.
  15. Sherbuk J, Petros de Guex K, Añazco Villarreal DF, Knight S, McManus KA, Flickinger TE, et al. Beyond Interpretation: The unmet need for linguistically and culturally competent care for Latinx people living with HIV in a southern region with a low density of Spanish speakers. AIDS Research and Human Retroviruses. 2020. [Epub ahead of print].
  16. Brooks RA, Nieto O, Landrian A, Donohoe TJ. Persistent stigmatizing and negative perceptions of pre-exposure prophylaxis (PrEP) users: Implications for PrEP adoption among Latino men who have sex with men. AIDS Care. 2019;31(4):427–35.
  17. Rhodes SD, Daniel J, Alonzo J, Duck S, Garcia M, Downs M, et al. A systematic community-based participatory approach to refining an evidence-based community-level intervention: The HOLA intervention for Latino men who have sex with men. Health Promotion Practice. 2013;14(4):607–16.
  18. Shah HS, Dolwick Grieb SM, Flores-Miller A, Greenbaum A, Castellanos-Aguirre J, Page KR. Sólo se vive una vez: The implementation and reach of an HIV screening campaign for Latinx immigrants. AIDS Education and Prevention. 2020;32(3):229–42.
  19. Rhodes SD, Alonzo J, Mann L, Song EY, Tanner AE, Arellano JE, et al. Small-group randomized controlled trial to increase condom use and HIV testing among Hispanic/Latino gay, bisexual, and other men who have sex with men. American Journal of Public Health. 2017;107(6):969–76.
  20. Martinez O, Wu E, Frasca T, Shultz AZ, Fernandez MI, Lopez Rios J, et al. Adaptation of a couple-based HIV/STI prevention intervention for Latino men who have sex with men in New York City. American Journal of Mens Health. 2017;11(2):181–95.
  21. Solorio R, Norton-Shelpuk P, Forehand M, Montano D, Stern J, Aguirre J, et al. Tu Amigo Pepe: Evaluation of a multi-media marketing campaign that targets young Latino immigrant MSM with HIV testing messages. AIDS & Behavior. 2016;20(9):1973–88.
  22. Martinez O, Fernandez MI, Wu E, Carballo-Diéguez A, Prado G, Davey A, et al. A couple-based HIV prevention intervention for Latino men who have sex with men: Study protocol for a randomized controlled trial. Trials. 2018;19(1):1–12.
  23. Betancourt G. A theoretical model for intervening in complex sexual behaviours: Sexual desires, pleasures and passion—La Pasión—of Spanish-speaking gay men in Canada. Lesbian, Gay, Bisexual and Trans Health Inequalities. 2015:159–72.
  24. Rios-Ellis B, Espinoza L, Bird M, Garcia M, D’Anna LH, Bellamy L, et al. Increasing HIV-related knowledge, communication, and testing intentions among Latinos: Protege tu familia: Hazte la prueba. Journal of Health Care for the Poor and Underserved. 2010;21(3):148–68.
  25. Rhodes SD, Hergenrather KC, Bloom FR, Leichliter JS, Montaño J. Outcomes from a community-based, participatory lay health adviser HIV/STD prevention intervention for recently arrived immigrant Latino men in rural North Carolina. AIDS Education & Prevention. 2009;21(Supplement B):103–8.
  26. Adam BD, Betancourt G, Serrano Sanchez AA. Development of an HIV prevention and life skills program for Spanish speaking gay and bisexual newcomers. Canadian Journal of Human Sexuality. 2011;20(1):11–17.
  27. Zamudio-Haas S, Maiorana A, Gomez LG, Myers J. “No estas solo”: Navigation programs support engagement in HIV care for Mexicans and Puerto Ricans living in the continental US. Journal of Health Care for the Poor and Underserved. 2019;30(2):866–87.

Suggested citation

Rapid Response Service. Interventions for immigrant Latino men who have sex with men along the HIV prevention and treatment cascade. Toronto, ON: The Ontario HIV Treatment Network; September 2020.

Prepared by

Nicole Andruszkiewicz & David Gogolishvili

Photo credit

Youssef Naddam

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