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Lorece V. Edwards, Ian Lindong, Lawrence Brown, Anita S. Hawkins, Sabriya Dennis, Olaoluwa Fajobi, Randolph Rowel, Ronald Braithwaite, Kim D.

None of Us Will Get Out of Here Alive: The Intersection of Perceived Risk for HIV, Risk Behaviors and Survival Expectations among African American Emerging Adults Lorece V. Edwards, Ian Lindong, Lawrence
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None of Us Will Get Out of Here Alive: The Intersection of Perceived Risk for HIV, Risk Behaviors and Survival Expectations among African American Emerging Adults Lorece V. Edwards, Ian Lindong, Lawrence Brown, Anita S. Hawkins, Sabriya Dennis, Olaoluwa Fajobi, Randolph Rowel, Ronald Braithwaite, Kim D. Sydnor Journal of Health Care for the Poor and Underserved, Volume 28, Number 2 Supplement, May 2017, pp (Article) Published by Johns Hopkins University Press DOI: For additional information about this article Access provided by JHU Libraries (12 Sep :11 GMT) ORIGINAL PAPER None of Us Will Get Out of Here Alive: The Intersection of Perceived Risk for HIV, Risk Behaviors and Survival Expectations among African American Emerging Adults Lorece V. Edwards, DrPH Ian Lindong, MD Lawrence Brown, PhD Anita S. Hawkins, PhD Sabriya Dennis, DrPH Olaoluwa Fajobi, MPH, MS Randolph Rowel, PhD Ronald Braithwaite, PhD Kim D. Sydnor, PhD Abstract: The Human Immunodeficiency Virus (HIV) significantly affects minority emerging adults, among whom the rate of new diagnoses is high and health disparities are more pronounced. Importantly, emerging adults today have limited knowledge of the earlier toll of the virus when it was identified as a killer. Among this population, perceptions of risk for HIV are low and sexual risk taking behaviors are high. The Get SMART Project is a behavioral intervention aimed to provide re- purposed HIV, alcohol, and substance abuse prevention education and HIV testing to African American emerging adults ages The project was guided by the Health Belief Model, Community Promise, and Training for Institutional Procedures. Findings revealed that HIV testing is low. Marijuana and alcohol are drugs of choice. Emerging adults do not see themselves at risk for HIV, although they engaged in high- risk behaviors. Additionally, survival expectations influence behavior risk. DR. EDWARDS is Associate Professor and Director of the Center for Sexual Health Advancement and Prevention Education at Morgan State University School of Community Health and Policy. DR. LINDONG is Assistant Professor at Morgan State University School of Community Health and Policy. DR. BROWN is Assistant Professor at Morgan State University School of Community Health and Policy. DR. HAWKINS is the Assistant Dean at Morgan State University School of Community Health and Policy. DR. DENNIS is a Post- Doc Fellow at Morgan State University School of Community Health and Policy. OLAOLUWA FAJOBI is a Doctoral Candidate at Morgan State University School of Community Health and Policy. DR. RANDOLPH ROWEL is the Department Chair for Behavior Health Sciences at Morgan State University School of Community Health and Policy. DR. RONALD BRAITHWAITE is a Professor, Departments of Community Health and Preventive Medicine, Family Medicine and Psychiatry Morehouse School of Medicine and the External Evaluator for Grants at Morgan State University School of Community Health and Policy. DR. SYDNOR is the Dean for the School of Community Health and Policy at Morgan State University. Please address correspondence to Lorece V. Edwards, DrPH, Morgan State University, 1700 E. Cold Spring Lane, 201 Portage Campus, Baltimore, MS, Meharry Medical College Journal of Health Care for the Poor and Underserved 28 (2017): Edwards, Lindong, Brown, Hawkins, Dennis, Fajobi, et al. 49 Key words: African American emerging adults, HIV prevention, perceived risk, survival expectations. The human immunodeficiency virus (HIV) is having a significant impact on minority emerging adults, who face pronounced health disparities relative to their nonminority peers; among minority emerging adults the rate of new diagnoses is high. 1 Importantly, emerging adults today have limited knowledge of the earlier toll of the virus when it was identified as a killer that cut through every socioeconomic group, eventually wreaking severe havoc on the African American community. Fast forward to today: African Americans continue to be disproportionately affected by HIV, and HIV is greatest among sexual and racial minority populations. 1 Emerging adults in the United States today have never known a world without HIV. 1 They have no memory of the challenging times when HIV was almost always fatal. 1 The high prevalence of HIV in the African American community among social and sexual networks alone increases the risk for contracting HIV, as African American emerging adults are more likely to engage in risky sexual behavior, participate in urban sexual suicide (unprotected sex with multiple partners with an unknown HIV status),* use condoms inconsistently, and engage in sex while under the influence of alcohol and/or drugs (e.g., marijuana, which is sometimes called the sex drug). 2 As HIV rates continue to escalate among this population (approximately 1,000 per month, CDC Vital Signs, 2013 ) academic institutions are essential partners in the many efforts to reduce HIV risk among youth, and they can serve multiple functions in supporting sexual health and wellness among this population. African American emerging adults are particularly affected. Of the nearly 21,000 infections estimated to occur each year among African Americans, one- third (34%) are among people aged 13 to 24 years. 2 In 2014, an estimated 9,731 youth aged 13 to 24 were diagnosed with HIV in the United States; 81% (7,868) of diagnoses among youth occurred in people aged Among those aged diagnosed with HIV, African American males have the higher rates of infection among all race/ ethnicity groups as well as gender. 3 African Americans, who make up 12% of the U.S. population, account for 44% of new infections overall 4 and 57% among youth. 5 Young same gender- loving (SGL) African American men are at highest risk of acquiring HIV (as much as 11 times more than young White males). 6 HIV in this subgroup is multifactorial; higher rates of sexually transmitted diseases (STD), stigma, alcohol and substance abuse, socioeconomic status, internalized homophobia, and lack of awareness of HIV status, are likely to escalate HIV acquisition rates. Over 70% of HIV infected SGL young African American men are unaware of their HIV status. The problem is magnified by the low rates of care and treatment (21%) and controlled viral load (18%) of those youth diagnosed with HIV. 2 The university environment offers a great opportunity for addressing HIV highrisk behaviors, including unsafe sex and multiple sex partners. In prevention studies *I coined the term urban sexual suicide as part of my research. Its definition is included in the text of this paper in parentheses. 50 Perceived risk and survival expectation conducted in HBCU settings, African American youth generally perceive themselves as having low risk of contracting HIV and STDs despite having higher rates of unprotected sex, multiple sex partners, particularly low rates of HIV testing and awareness of HIV status, 7 8 while engaging multiple high- risk behaviors. However, HBCUs are in a unique position to tackle HIV on campus and in the community through comprehensive sexual health awareness education courses, traditional/ non- traditional HIV testing, innovative HIV activities, and equipping students with prevention education, strategies for increased condom use, and tools to facilitate behavioral risk reduction. However, predefined boundaries (attitudes) towards HIV and sex education and/or HIV- associated stigma and social conservatism by school authorities may have contributed to the lack of HIV awareness/ education among youth and emerging adults, 9 and thereby increased the rates of acquisition among this population. HIV risk perceptions. Understanding adolescent and young adult perceptions of HIV risk is important for targeted HIV prevention studies. El Bcheraoui et al. 10 investigated patterns of condom use among students of HBCUs and noted that 46% did not use a condom during their last sexual intercourse, and those who perceived themselves as being at average/ high risk of acquiring STIs were less likely to use a condom during their last sexual intercourse (Adjusted OR: 0.6; 95% CI: ). Reasons for not using condoms included unwillingness to spoil the moment, having unplanned sex, and not believing themselves to be at risk for HIV. Condom use during last sexual intercourse was significantly less likely among students who worked fewer than 20 hours a week compared with both unemployed students and students working more than 20 hours a week. To identify risk factors for HIV acquisition, Camacho- Gonzalez et al. 9 administered surveys to HIV- infected and non- infected emerging adults ages The inclusion was limited in that participants only needed to fit the age criteria and reside in the Atlanta metropolitan statistical area. This investigation employed self- administered surveys and 17 focus groups to facilitate exploration. Quantitative ACASI surveys revealed several noteworthy findings. Transactional sex was a frequent practice. Eighty- eight percent of the participants indicated that it is common to exchange sex for material things and daily living expenses. Furthermore, it was noted that the main reason for lack of condom use was fear of rejection (58%) and personal preference (65%). Focus group data discussion with HIV- infected participants included comments such as, Nobody is using protection. Although, HIV- infected emerging adults share their HIV status upon request for sexual engagement, sexual partners are not concerned about their HIV status and will engage in unprotected sex anyway. Some participants expressed the view that there is no need to discuss HIV with a prospective sexual partner if one is not in a relationship or considering a relationship with the person in question. Rather, in the words of the old, callous expression, common attitudes towards sex are, Wham, bam, see ya later. Youth and emerging adults carry the highest incidence of HIV infection in the United States. 9 Understanding emerging adult perspectives on HIV transmission risk is important for targeted HIV prevention research. Numerous studies demonstrate that African American college students are well informed about the severity of HIV/ AIDS, know how the infection is transmitted, and are aware of prevention strategies, yet they Edwards, Lindong, Brown, Hawkins, Dennis, Fajobi, et al. 51 continue to engage in unsafe sexual behaviors It appears that these students have knowledge but their attitudes and behaviors are impediments. Several factors play a role in youth and emerging adult s risk factors for HIV acquisition: transactional sex (exchanging sex for money, food, drugs, clothing, and shelter), alcohol and substance use, high levels of risk- taking sexual behaviors, congruent sex partners, and survival expectations. Perceptions of HIV risk among emerging adult populations are low. Furthermore, HIV risk behaviors have been found to be associated with marijuana use and as noted above marijuana is viewed as the sex drug. 13 Perceived risk priorities. The importance of assessing the local culture and social environment for factors relevant to risk and/or protective behaviors in health and development among young adults has become fundamental to intervention planning. 14 Moreover, the concept of risk is critical in examining health behavior. Risky behaviors among emerging adults are relatively frequent, and the determinants of perceived risk must be given full consideration when planning interventions and prevention studies. Risk portfolios are useful for work with emerging adults. For the purposes of this research, a risk portfolio is the ranking and prioritizing of risk based on a set of values, beliefs, and knowledge. Among youth and emerging adults, risk is prioritized to determine what has the greatest harm or danger. Police engagement was noted as a risk priority because it was uncertain if one would live long enough to talk about their encounter. When youth and emerging adults perceive a sense of hopelessness, they have little reason to delay immediate gratification (e.g., unprotected sex, multiple sex partners, violence, alcohol and substance, drunk driving). According to Geller et al., 15 police contact may threaten the health of individuals stopped in several ways. The physically invasive, often rough manner in which officers approach individuals raises the risk of injury. Despite the heated contemporary debate on police practices, emerging adults who are stopped have expressed feelings of hopelessness and being dehumanized Other researchers such as Shedd 21 suggest high rates of distress and perceptions of injustice among African American emerging adults. Emerging adult African American men stopped by the police fear physical violence/ aggression, social injustices, and never being seen as anything other than symbolic assailants. 19 Racially biased policing is a critical concern among inner- city youth and emerging adults, especially males. Increasing numbers of emerging adults in urban neighborhoods are exposed to high levels of community violence. Community violence may take many forms, but it generally includes factors such as homicide, rape, other types of sexual assaults, and robbery In many low- income, ethnic minority communities, violence has become a constant stressor that is unpredictable, and can affect innocent bystanders as well as those directly involved High levels of community violence often result in chronic fear and perceptions of danger among emerging adults that affects their day- to-day functioning. 28 The psychological impact of living under conditions of chronic fear and threat can often lead to hopelessness. Many youth and emerging adults who have been victims of community violence (e.g., assault, gunshot wounds) report a sense of futurelessness characterized by a strong belief that they will not reach adulthood The sense of futurelessness exacerbates perceived risk. Perceived risk priorities for African Americans are furthered intensified by the 52 Perceived risk and survival expectation neighborhoods in which they live. According Massey and Tannen, 31 26% of all African Americans in the United States live in hypersegregated metropolitan areas. Among African Americans living in metropolitan areas, 53.1% of African Americans live in metropolitan areas characterized as highly segregated or hypersegregated. Racially segregated Black neighborhoods create high- risk landscapes that increase the threat to Black lives, whether in the form of disproportionate exposure to lead poison and toxic waste, educational inequality, redlining, subpriming, or transit inequity. 32 Smith and Holmes 33 find that sustained excessive force complaints against police increase exponentially between the least segregated cities and the most segregated cities. Racial segregation escalates danger in all forms for residents who live in disinvested, redlined Black neighborhoods, creating what we call high- riskscapes where the threat of death and harm are perceived as immanent rather than far off. High- riskscapes alter risk portfolios and perceptions of residents risk and place concerns for STIs low on the list of concern because the threat of violence and the mandates of survival in environments of concentrated poverty and unresolved traumas rank as primary concerns. Hence, we cannot effectively address STI or HIV perceptions without mitigating the impact of high- riskscapes, which elevate immediate threats and diminish longer- term threats, especially when youth and emerging adults believe they will not live past the age of 35. The GET SMART Project funded by the Substance Abuse and Mental Health Services Administration (SAMHSA) is an intervention research project guided in part by the Health Belief Model (HBM) located in an urban HBCU in a Northeastern metropolitan area in the U.S. The project is designed to assess and then address unprotected sexual behavior among students in college campuses and in the community that lead to illicit drug use, excessive alcohol consumption, underage drinking, and precarious sexual behaviors that increase risk for acquiring HIV and sexually transmitted diseases (STDs). The main goal of the project is to provide re- purposed prevention education, access to HIV testing, linkage to care, alcohol and substance use prevention education, and connections to needed resources. The project is aimed primarily for African American emerging adults (ages 18 24) on campus and in the local community. The incorporation of Community- Based Theater and Fine Arts in the intervention makes the approach taken in the GET SMART Project unique. Framed in a universal language through artistic expressions within two dynamic evidence- based interventions (Community Promise and Training Interventions Procedures (TIPs) for the University), the project tailors itself to the culture, norms, beliefs, attitudes, and practices unique to African American emerging adults. In addition, a modified version of an American Cancer Society- designed program for smoking cessation is built in the intervention. The project takes a multidisciplinary approach to not only address the reduction of alcohol, substance abuse, and HIV/ AIDS transmission, but also the structural and social environmental determinants that drive risk- taking behaviors among young adults. Figure 1 is a depiction of the prevention framework of the project. Methods Research Design: Quan QUAL (explanatory sequential mixed- method approach). Built into the GET SMART Project is a continuous assessment of its participants Edwards, Lindong, Brown, Hawkins, Dennis, Fajobi, et al. 53 Figure 1. Perceived Risk Hierarchy Theory. (TM) attitudes, knowledge, beliefs, perceptions, and practices related to personal and environmental risk factors for alcohol and substance use, and HIV. The initial phase of the project was a quantitative approach using a survey methodology to assess alcohol and substance use and sexual risk behaviors that may lead to HIV. The survey design was deemed most appropriate, as it would be efficient in obtaining a valid and reliable quantification of the magnitude of risk behaviors in a university and community setting. The survey instrument used was the Minority AIDS Initiative (MAI) Adult Questionnaire provided by Program Evaluation for Prevention and Contract (PEP- C). This instrument is a modular survey with four sections that cover basic demographic information and knowledge, attitudes, beliefs, and practices relating to alcohol, smoking, illicit drugs, and sexual relations. The instrument reflects, in its series of questions, the multifactorial nature of alcohol and substance use and sexual behavior. The second phase of the study was a qualitative approach to understanding the results of the initial quantitative phase. By means of facilitated prevention education sessions with group interviews, numeric data were substantiated with qualitative contextual data to add depth and explanation to the responses gathered from the MAI questionnaire. There were approximately 10 prevention education group sessions on campus and three in the community conducted over a span of 12 months, each group including no fewer than five participants (5 7 participants per group, in practice). Additionally, each 60 to 90-minute prevention education session/ group interview has a designated facilitator and a scribe to document key discussion points. A 90-minute session sufficed to obtain data saturation from the participants over the 12-month time spam. Participant selection and procedures. Emerging adults aged 18 to 24 years were eligible to participate in the survey. The survey was advertised through the university website, student information , and health and wellness fairs. Participants were verified for eligibility using either a university- issued identification or confirmation using university student account. The MAI Adult Questionnaire was adminis
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