A Report for the HIV Prevention Section of the San Francisco Department of Public Health Prepared by Jorge Sánchez and Rafael Díaz Cause Data Collective October 2009 Table of Contents Latino Action Plan Executive Summary.....................................................................1-17 Findings and Recommendations ................................................. 3 Report Components and Project Process.................................. 11 Epidemiological Context ............................................................ 14 Chapter 1/ Double Edges of Freedom.......................................18-32 Chapter 2/ Qualitative Analysis of Focus Group Data ...............33-73 Spanish Speaking Group – ages 23-35 ..................................... 34 Spanish Speaking Group – ages 36 .......................................... 45 English Speaking Group– ages 18-35 ....................................... 52 English Speaking Group – ages 36+ ......................................... 63 Similarities & Contrasts.............................................................. 71 Chapter 3/ Demographic Profile ................................................74-82 Chapter 4/ Nuestras Voces Quantitative Findings.....................83-93 Chapter 5/ Lessons From Providers........................................94-112 Chapter 6/ Literature Review: Latino Gay Men & HIV ...........113-132 Literature Review References.................................................. 130 Postscript...............................................................................133-135 Executive Summary Latino Action Plan Introduction In 2007, the HIV Prevention Section of the San Francisco Department of Public Health (SFDPH), AIDS Office prioritized the creation of a community-based plan to adequately address the HIV prevention needs of Latino Men who have Sex with Men (MSM). This effort eventually came to be known as the Latino Action Plan (LAP). By the spring of 2008, Mr. Oscar Macías and Mr. Erik Dubón of the SFDPH convened a working group of local Latino MSM and allies to discuss the creation of this plan for the City and County of San Francisco. Team This group enlisted Dr. Rafael Díaz and Mr. Jorge Sánchez of Cause Data Collective as consultants for the development of LAP. All research protocols including qualitative and quantitative instruments were designed by Mr. Sánchez and Dr. Díaz. Mr. Sánchez also coordinated recruitment and general project logistics. The recruitment and field interview team for LAP was comprised of Mr. Jose Vazquez, Mr. Jose Antonio Aguilar, Mr. Anthony Herrera, Mr. Oscar Macías, and Mr. Andrew Abundiz. Mr. Sánchez and or Dr. Díaz moderated all focus groups. Qualitative analysis was conducted by Mr. Sanchez, Mr. Juan Carlos Guerrero, and Mr. Jaime Cortez. Quantitative analysis was conducted by Dr. Díaz, with the assistance of Ms. Diane Burkholder and Mr. Kurt Schroeder. Meetings and presentations with providers were conducted and documented by Mr. Sánchez and Mr. Abundiz. The project’s literature review titled, Latino Gay Men and HIV was written by Dr. Díaz and Mr. Sánchez. LAP’s protocols were reviewed by Independent Review Consultants Inc. and received IRB approval in October of 2008. Mr. Macías worked with Mr. Sánchez to secure this IRB approval. Additional research assistance was given to the project by Mr. Phillip Lowenthal and Ms. Elizabeth Truesdale. Mr. Miguel Casuso designed all project presentations, tables and graphs. Mr. Macias coordinated activities, and ongoing meetings for LAP’s Working Group, whose members included: Mr. Jorge Zepeda, Mr. Jose Luis Guzman, Mr. Pedro Arista, Dr. Sonya Arreola, Mr. Steven Gibson, Ms. Maritza Penagos, Mr. Jorge Vieto, and Dr. Eduardo Morales. Latino Action Plan 1 Cause Data Collective Our deep gratitude goes to the 157 men who generously shared their lived experiences and personal knowledge so as to give life and voice to this endeavor. This report is dedicated to them. LAP also gratefully acknowledges the members of San Francisco’s HIV Prevention and Planning Council (HPPC), and Dr. Grant Colfax of the SFDH for giving the project support, enthusiasm and guidance. Latino Action Plan 2 Cause Data Collective Findings & Recommendations Latino Action Plan Below is a summary of LAP’s ten major findings and respective recommendations based on analysis of data collected by the team. Although policy and implementation is beyond the parameters of the task assigned to the authors of this report, included below are some thoughts on implementation for each of the findings and recommendations with points of comparison to three different sources: the National Latino AIDS Action Network (NLAAN) Federal Recommendations, The State of California Latino Advisory Board’s Recommendations (“Entre Familia”) and the SFDPH African American MSM Action Plan that also presented its recommendations to the HPPC in 2009. These research findings have been ranked in order of importance according to the opinions of the project’s research team: Summary Finding 1 The City of San Francisco is a magnet for migration of young Latino gay men looking for sexual freedom and gender self-expression. Oftentimes, men expressed “here you can be as you like.” The city’s gay culture, particularly sexual and social gay venues, welcomes these young men in sexually objectifying ways that puts them at risk for substance abuse and HIV risk. Many men we interviewed reported initially feeling welcomed by fellow gay men, but in the end many men also reported not feeling truly embraced by the city’s mainstream gay community. Meanwhile, it should also be noted that the entry into local contexts of risk is oftentimes facilitated by internet-mediated contacts and hook-ups. Sometimes, the initial Internet contact happens before the young men arrive to San Francisco. Recommendation 1 A guiding structure (perhaps a website) that orients new waves of young Latino gay men who are newcomers to San Francisco. Such a website would ensure that migrants’ “landing pads” would be healthy and supportive contexts rather than situations of risk where Latino gay men are sexually objectified. Newcomers would be helped, for example, to face new contexts of risk (e.g., PnP) they are likely to encounter in the San Francisco gay community, as well as connect to existing groups and sources of support for Latino gay men in the City. Program content should address race-based sexual objectification and isolation including issues related to being in a new city with a charged sexual climate. Latino Action Plan 3 Cause Data Collective Implementation Any DPH/pass through funds provided to agencies to create web-based HIV prevention messages and interventions must be required to have culturally and tailored messages to & linkages for the Latino MSM community (in both English & Spanish). If there are agencies creating web-based messages without DPH funding, the DPH should collaborate (and possibly offer to provide technical assistance) with them to make sure these messages are tailored to the prevention needs of Latino MSM. Furthermore, HIV Prevention programs tailored to gay men in general should address the ways that men of color—both Latino and African American—are objectified/sexualized. Cultural competency reports for these agencies should include objectives on the work they are doing with the community it serves (and not just within the agency) to address racism and sexual objectification of minorities. Summary Finding 2 The overwhelming sense from most of LAP’s qualitative participants is that, in San Francisco, it is very easy to find sex, but extremely difficult to find meaningful relationships. Many men feel socially pressured to give up expectations of partnerships where they can integrate emotional and sexual satisfaction. This sexual cultural climate forces many men to give up their desire for gay partnership and family – or even to belittle this deep desire as “Latino drama,” which was the case in one focus group. This, in turn, leads to the prioritizing of “hot sex” as the most valued commodity and a sense of giving up – not caring, throwing in the towel – with respect to HIV prevention. Men in groups casually talked about the ease with which partners for sex can be found, “You enter a chat room like it was some sort of catalog. You go in you pick. They even put ‘top’ or ‘bottom’ it is very easy!” Oftentimes participation in these sexual contexts is fueled and made possible by the use and abuse of drugs, particularly stimulants. Recommendation 2 Programs that provide relevant and tailored education on the interconnection of sexuality, relationships, substances and HIV – many men do not feel well informed and need places where they can talk freely about their desire for connection and meaningful relationships. Community building needs to be fostered through these programs so that men can meet in contexts that emphasize a sense of “familia” for men by addressing issues of interconnection. Implementation HIV prevention programs tailored to Latinos should be inclusive to include different members of the community, MSM of different ages and varying degrees Latino Action Plan 4 Cause Data Collective of acculturation, women and straight-identified men—these groups build social networks and re-create family type settings that increase the cultural resiliency of Latino MSM. (For example, the Shanti LIFE program has been replicated in Spanish for HIV+ individuals and participants feedback was how much they enjoyed having both men and women, gay and straight