Exiting the subway in the north Bronx yesterday, I was confronted by the diversity of culture that makes peripheral New York City neighborhoods so unique. The fruit market displaying mountains of yucca, papaya, aloe, and manioc, and the rapid-fire Spanglish being spoke around me, reflected the neighborhood's Caribbean-Latino population; the shiny new center for Latter-day Saints showed Mormons really are everywhere; and the liquor store selling Manischewitz wine suggests that there must still be some Jewish people (or connoisseurs of the concord grape) within shopping distance.
But this vibrant mix hides the signs of real poverty that continue to tarnish this and other poor neighborhoods in the city. Condemned houses next to homes surrounded by barbed wire and patrolled by pit bulls in spiky collars hint at a lurking unease; this is mirrored by the people nodding off next to buildings and under signs for drug treatment programs. The study I am currently involved with concerns the sexual transmission of HIV, and it is in these high-drug-use neighborhoods that HIV is also transmitted among those who inject drugs and the people they sleep with.
A study I collaborated on during this past summer involved interviewing injection drug users about their injection practices. We primarily looked at injection behavior as it relates to hepatitis C virus transmission. Most of the older injection drug users we spoke with were both HIV and HCV positive and had been injecting since they were in their teens. While, at this point in their lives, these users were well aware of the primary ways to prevent transmission (not sharing needles, works, or water used to mix drugs) and lived in the sort of stable conditions that allowed them to practice preventive behavior, the younger injection drug users, who also knew how to prevent HIV and HCV transmission, lived in conditions of such constant daily volatility—they're homeless, say, or turning tricks for drugs—that they did not have the wherewithal to protect themselves (or others) from disease transmission. As such, the cycle continues.
Asking people to change their behavior with the aim of disease prevention is a tricky business. As my interviews and focus groups have clearly shown, injection drug use and sexual behavior are areas in which rationality does not often trump desire—though public health experts don't expect this to be true. The idea that if people know how to protect themselves they will protect themselves underlies many social marketing campaigns and health interventions related to drug use and sexual behavior, both domestically and internationally. While this paradigm works for most of the people most of the time, it also works for some people none of the time.
The goal of the study that took me to the Bronx yesterday is to figure out the moments when that paradigm doesn't work in order to develop alternative programming and campaigns that might. I tried to be creative in study design. For example, the person we hired to assist with recruitment is a former-investment-banker-turned-gay-porn-star-turned-events-planner. He has been liaising with several community groups to find participants who represent the ethnic/racial makeup of MSM (men who have sex with men) living in New York City and has been recruiting through his extensive network of event attendees. His contacts are impressive!
Today, I've been reviewing the data that we've collected so far (while stopping to have lunch with my Brazilian friend Ilka) to see if I have any preliminary answers. I really don't have any answers yet, but there are some things that stand out. It seems that in some ways discussions of HIV and AIDS have gone back "in the closet." Whereas in the early days of the AIDS epidemic, there was a social and political imperative to talk about AIDS and promote condom use, at some point that imperative shifted. Not only are some men not talking about HIV very much before sex (as one participant said, "It really spoils the mood"), many men now feel free to exercise their option to use condoms only some of the time, and often not at all.
Many men have told me: "I check out a guy before we get together, and if he looks clean, I won't use a condom." Others don't use condoms with their steady partners but use condoms with all other partners. Some men who are in steady relationships are also in steady threesomes. Many men who sleep with men also sleep with women. I mention all of this to say that the models of sexuality that have been used to develop HIV and sexually transmitted disease prevention programming need to be expanded accordingly, to include the myriad ways that sexuality is expressed. If we can get a handle on this—and we are starting to—then we will be better able to create programs that resonate with a wider range of people.
All this talk of sex! Too bad my husband is in Hong Kong. Now I'm off to a friend's birthday dinner.