“Proud I Am Negative”

In the United States, during the past decade, the annual incidence of new HIV cases has remained around 50,000 (Centers for Disease Control and Prevention 2015). While this suggests sustained HIV prevention gains, the rates among some subgroups have escalated. For instance, mother-to-child transmission rates have significantly declined as well as those among injection drug injectors (Centers for Disease Control and Prevention 2015). However, rates of new HIV infections have escalated among men who have sex with men (MSM), especially those who are black (Centers for Disease Control and Prevention 2015; Johnson et al. 2014).

HIV among Black MSM

In the United States, black men who have sex with men (BMSM) represented 51 percent of new annual infections among all black men (Centers for Disease Control and Prevention 2013b) with an estimated 10,600 new infections among BMSM in 2010 (Centers for Disease Control and Prevention 2013a). In 2011, BMSM accounted for over 12,000 cases (39 percent) of all new HIV cases among MSM (Centers for Disease Control and Prevention 2013a). By 2014, among all gay and bisexual men diagnosed with HIV, African Americans accounted for the highest number (estimated 11,201; 38 percent), followed by whites (estimated 9,008; 31 percent) and Hispanics/Latinos (estimated 7,552; 26 percent). Among all BMSM, those that are ages thirteen to twenty-four bear the greatest HIV burden (Centers for Disease Control and Prevention 2015). From 2005 to 2014, HIV diagnoses among African American gay and bisexual men aged thirteen to twenty-four increased 87 percent. But that trend has slightly declined, with diagnoses declining 2 percent between 2010 and 2014 among this age-group (Centers for Disease Control and Prevention 2015). Despite these modest epidemiological gains, BMSM in the United States have HIV infection rates that rival those among the general population in the developing world (Peterson and Jones, 2009).

Given these alarming HIV disparities among BMSM, a plethora of research has focused on potential risk factors associated with such disparities (Millett et al. 2007, 2012). However, within recent years, there has been a growing call for more research that examines resilience within MSM communities and a departure from studies that are deficit-based (Herrick et al. 2014). Consequently, the primary focus of this study was to focus on HIV-negative BMSM and explore factors, belief systems, and practices that are associated with HIV-seronegativity among this population.

Contributions of this Study

The National HIV Behavioral Surveillance (NHBS) is a national health survey that collects information on sexual risk, drug use, HIV testing behaviors, and HIV seroprevalence from populations at highest risk for HIV infection such as MSM. The 2006 NHBS data indicated HIV-seropositive prevalence was highest among BMSM, with 67 percent of them not being unaware of their status. Despite the high HIV burden that BMSM bear, there remains an urgent need for more research illuminating factors associated with how BMSM maintain seronegativity. For instance, in the NHBS study, little consideration was given to the 54 percent of black MSM found to be seronegative and much can be learned from how these men remain HIV, information that can support the important development of resilience-based programs and interventions for BMSM.

Resilience theory refers to positive adaptation in the face of risks (Fergus and Zimmerman 2005). Gay resilience theory refers to positive adaption in the face of many of the negative behavioral health risks trajectories that often confront and are associated with sexual minorities such as mental health problems, substance use, and risky sexual behaviors (Herrick et al. 2014). Gay resilience theory as it relates to HIV seronegativity refers to the process by which gay and bisexual men are resilient or display strengths as it relates to avoiding contracting HIV. Such resilience may be attributed to both internal personal processes (e.g., belief symptoms, cognitive practices, and behavioral practices) and/or network factors (e.g., social supports and social capital). A better understanding of HIV resilience can guide future research and prevention/intervention initiatives for BMSM.

Method

The study employed a phenomenological approach (Giorgi 2010) to explore the belief systems and practices related to BMSM maintaining seronegativity. This particular approach is well suited to this investigation, given that it can illuminate participants’ interpretation as to why and how they maintain HIV negativity. Focus groups were utilized as they offer several distinct advantages compared to survey approaches that were important for this study. Focus groups can generate new insights into social, complex phenomenon; amplify participants’ voices through group dialogue versus researcher-directed questions; contextualize how participants think about a topic rather than just what they think about it; and encourage participants to contribute through conversation with their peers in an economical and time-efficient method (Kitzinger 1994). Moreover, the focus group method is particularly useful when there are power differentials between the participants and decision makers or professionals and when the everyday use of language and culture of particular groups is of interest to a given topic (Kitzinger 1994; Morgan 1996).

The focus groups were guided by open-ended questions in three broad areas: (a) attitudes and beliefs related to being HIV negative, (b) how social supports may influence participants’ sexual risk behaviors, and (c) HIV harm reduction practices. Although data analyses were guided by these three broad questions, researchers were attuned to emergent codes that may have emerged outside of these categories. These categories were chosen based on prior quantitative findings documenting that black and Latino gay men who had strong supportive relationships were more likely to have had a test for HIV infection in the past 2 years and less likely to have recently engaged in high-risk sexual behaviour (Lauby et al. 2012). In addition, in-depth interviews conducted with young gay men of color indicated that community social support, confidential spaces, prevention knowledge, and validation from others were believed to be factors that would assist them with remaining HIV negative (Seal et al. 2000).

Sampling, Recruitment, and Enrollment

Recruitment occurred between June and August 2012. The sample of BMSM was recruited in New York City (NYC), primarily from Brooklyn as this borough has one of the highest HIV incidences in the city among BMSM (Centers for Disease Control and Prevention 2014). The convenience sample was recruited from professional networks of social services providers and organizations. Information about the study was distributed in person, by e-mail, messages, and flyers. Persons recruited from social service agencies were receiving HIV prevention, health and mental health, housing, adult education, and/or job assistance services. Prospective participants were recruited through active recruitment at community functions or partner organizations. Participants were eligible for study inclusion if they self-identified as black or African American, were residing in NYC, were twenty-one years or older, had tested HIV negative within the past three months, had a history of sex with men during the past three years and were sexually active with men within the last three months, were not in a monogamous long-term relationship with a man (i.e., a duration of six months or longer), had casual sex one or more times within the past six months, reported no injection drug use within the last year, and provided informed consent. Participants attended one of the three scheduled focus groups depending on their availability.

Prior to focus group participation, each participant completed a brief demographic questionnaire, which assessed age, race/ethnicity, sexual orientation, educational level, religion, place of birth, and residential location. Each of the three focus groups lasted approximately ninety minutes and participants each received US$50 and subway fare for their study participation. All focus groups were conducted in private settings that were readily accessible to study participants. Study procedures were reviewed and approved by the university’s Institutional Review Board.

Data Analysis

Qualitative data management software (NVIVO 10) was used for analysis and coding transcriptions. All identifying information was redacted and replaced with pseudonyms to protect participants’ privacy. Narrative data were transcribed verbatim and coded using a thematic approach (Corbin and Strauss 1990). Initial codes corresponded to the three domains of the interview guide from which a preliminary codebook was developed. First and second author discussed and reconciled codes, which resulted in a 95 percent agreement rate. Demographic data were analyzed using SPSS 19.0. Throughout this report, typical quotations are provided to illuminate the themes discerned during analysis.

Results

Participants

Participants (n = 29) ranged from twenty-two to sixty-nine years of age. All participants identified as black. Among this group, the majority identified as African American (n = 19), Afro-Latino (n = 5), black Caribbean Latino (n = 3), and black “other” (n = 2). Most of the participants were born within the United States (n = 26), and two in the Caribbean, and another in South America. Among the overall sample, the majority of participants resided in Brooklyn, the borough with the highest HIV infection rates among both blacks and black MSM (NYC Department of Health and Mental Hygiene 2015). The majority of participants had high school degrees (n = 16) followed by college degrees (n = 9). Regarding sexual orientation, almost half (n = 12) identified as “gay,” eight as “same gender loving,” three selected “I don’t label myself,” and two “queer identified.” This finding suggests that the majority of participants embraced a gay identity.

Major Themes

Thematic analyses indicated agreement across all three focus groups that HIV seronegativity could be attributed to (1) possession of a strong sense of religious or spiritual connection to a high power. This led to a belief that seronegative individuals were “lucky or blessed,” their lives had purpose, and remaining HIV-negative was imperative to fulfilling their purpose; (2) seronegative individuals having social supports from family and friends and expectations from those persons that their HIV-negative status would be maintained; and (3) exercising personal agency to remain HIV negative such as engaging in seroadaptive harm reduction practices, having conversations about HIV, and serosorting and sexual positioning

Religious and/or Spiritual Beliefs

Several participants expressed the belief that having a sense of spirituality or religious beliefs was responsible for them being HIV negative. Spiritual and/or religious beliefs were sometimes tied to organized religions and in other instances associated with personal practices and philosophies. These belief systems motivated participants to engage in protective behaviors to avoid contracting HIV, so that they could fulfill their “life’s purpose,” as becoming HIV-infected would be seen as a distraction from that purpose. Most men expressed how their inner spiritual resources enabled them to negotiate condom use or assert themselves in health positive ways during sexual situations because they recognized “having a greater life purpose” and that “living fearlessly through God” enabled them to be assertive. For example, Rahsaan linked his ability to remain HIV negative to a higher calling that God has for him: “…I think it’s some kind of blessing to me [remaining HIV-uninfected], that God has something else intended for me. I know that God wants me to do big things with my life and HIV isn’t a part of it…” Another participant, Abdul described how his spiritual grounding had often enabled him to engage in safer sex in order to reduce his sexual risk, especially at those times when he “…really wanted to do raw [condomless sex].”

Likewise, Jamal echoed clear statements how his (religious) beliefs are essential for giving him the ability to remain seronegative. “…I am to the point where I also recognize for my own self, whatever I fear I will create; so I’ve learned as much as possible not to fear. Where there is God, there is no fear. So, I speak up and insist on [using] condoms with my partners…Spirit [God] won’t let me do otherwise, even if it’s what I want to do [have condomless sex].”

For some participants, having a sense of spirituality provided them with an intuition that enabled them to make wise decisions during sexual encounters. Teion indicated “…for me what works for me [staying HIV-negative] is spirituality…[it] has been the best thing for me, and if I get a sense that something is wrong…it helps me to make better decisions, like, something has gone wrong here, my spirit starts to tell me, ‘okay, something’s wrong here’ you know, even if the person is saying, ‘okay, I’m clean [HIV-negative].’”

Possessing the feeling of having purpose and worth or a sense of destiny enabled many participants to engage in consistent condom use, in other instances insist on using condoms, even when such situations were not ideal or at times awkward or when it was tempting to have condomless sex which was more enjoyable.

Access to Social Supports that Held Positive Expectations

A dominant theme emerging from all focus group discussions was that seronegative men had access to social supports that held positive expectations for them to remain HIV negative. Several men indicated that staying negative was an imperative expected by those within their family and peer networks. Such expectations and discussions from others were possible because most participants were “out” to their supports. According to Isaiah, “…it’s the other people in your life, especially your black gay friends…the experiences of people you know, who you can talk to…neg and poz people who got your back and want to see you succeed in life…and stay negative.” Such supports motivated consistent safer sex practices for many participants.

The significance of these instrumental and emotional social supports and its relationship to remaining HIV negative were verbally endorsed by the majority of participants. Having a strong connection to caring individuals who believed that these men lives mattered propelled many of them to practice consistent safer sex. Isaiah explains “…really…the supportive relationships that you have [friends and family]…really has helped me and been a support for me to stay negative.”

Another theme emerging from all three focus groups was that becoming HIV positive would be a deep betrayal to their social support network members who would be deeply disappointed, some of whom were already positive and “rooting for them” to remain negative. Eric’s sentiments captured this theme “…I have a friend who’s positive, a couple of friends (actually) cause I know a lot of great folks. And like six my age are HIV-positive. And it would feel like…I would see it as a betrayal to them if I turned…if I seroconverted or anything. Because safe sex and staying negative is something I’m very aware of…something they talk to me about a lot. They tell me to think about it a lot too.”

Matthew explained a similar motivation for his consistent condom use “…when I started having more talks about sex, about it with friends…like if I was safe and everything…they said, ‘No, you’ve got to start thinking about this [using condoms all the time].’ So then I knew I needed to start using protection [condoms] for all my activities, you know, otherwise they weren’t having it…not going to accept me not using protection and becoming poz.”

Several younger participants had disclosed their sexual orientation to their family members and reported it was their encouragement, which reminded them of the high prevalence of HIV within the young gay community and the ongoing need to practice safer sex. Purcell noted how a conversation with his mother resulted in critical support for him remaining HIV negative “…but my mother was actually the one who told me that the majority of people who are HIV-positive are people like me. I was like, what do you mean?” She said, “You know, people who you have sex with men, gay men so be very careful…”

Connection to other HIV-negative men and safe community conversation spaces

Another social support theme associated with remaining HIV negative was having connections to other HIV-negative men and access to social spaces where candid and often difficult conversations could occur about relationships involving partners with serodiscordant status. This signaled a dimension of social support, which moved away from the private realm of instrumental and emotional social support (i.e., family and friends) into the institutional realm. Participants indicated that they felt a sense of community in social spaces where they often had access to factually based HIV prevention knowledge, were sometimes made aware of available community resources, and often meet other HIV-negative men like themselves who they did not already know.

Across all three focus groups, participants noted that conversations about challenges and various strategies for remaining HIV negative occurred at some social service agencies that brought many of them together. However, participants were quick to add that many such formal spaces were diminishing, given that several HIV social service agencies were in danger of closing or had closed due to financial hardships. Many of the participants went on to reiterate their belief that the vast majority of HIV resources were directed toward positive men with fewer services or supports targeting men like them who were negative. According to Robby “…well, I wanted to say thanks because you know we are talking about the ways in which [HIV] programs have disappeared and here we are talking with negative guys about staying negative…so this in and of itself is a good intervention…” This response was suggestive that HIV-negative men are often overlooked with regard to agency-based prevention approaches.

Clayton noted, “…it’s good that this was a focus group on negative men because staying negative is…you know hard. This’ll help keep me staying negative,” to which Jonnell added, “I know man it really is.” “Kamron” described his longing for the days when community based organizations were more supportive of HIV-negative men and expressed “…and it was just about these kind of safe [agency] places…where we were able to just come together and talk about our life and improve who we are [as black men] so that we don’t put ourselves out there or we at least reduce the amount of [sexual] risk we are taking in our lives…and so there needs to be more support for HIV-negative brothas which has not happen for…oh for maybe fifteen years.” Bennett further suggested that many such supportive spaces could occur outside of formal social services spaces. “…this was the best thing for me…. because I got a little more comfortable and, and I met other neg men outside of agency spaces like…I don’t feel the need to run to them [social service organizations] all the time to feel affirmed because I know you brothas are out there.”

For many participants, a sense that others cared about their sexual health and supported them in remaining HIV negative provided significant motivation for them to continue practicing safer sex. In addition, knowing and communicating with other HIV-negative men provided another dimension of social support which enabled several participants to discuss how best to navigate conversations and challenges related to remaining negative.

Exercising Personal Agency

A common theme across all focus groups was that remaining HIV negative required personal agency. Personal agency often took the form of engaging in harm reduction practices such as sexual positioning, discussing HIV status, consistent condom use, or demanding HIV-negative proof. A common intentional seroprotective strategy employed by some participants was strategic positioning as the insertive partner or “top,” which participants believed reduced their risk of contracting HIV. Several participants endorsed the belief that being the insertive sexual partner (top) role was an effective risk reduction strategy even with an HIV-positive partner. Ricky noted “…this year it’s been six times now [that I’ve had sex] and they have all been without condoms…and in my mind, I gather because I am a top and topping it is less risky than bottoming [I haven’t gotten HIV]…I think a couple were poz…I am neg…and I know being a top puts me less at risk when having raw sex. I haven’t caught HIV so far from topping and I’ve topped poz boys before.”

Related to sexual position, another seroprotectice strategy discussed by participants was to engage in conversations about HIV status with potential sex partners with unknown serostatus. Several participants believed that having conversations about their status and then engaging in condom use or strategic sexual positioning helped them to remain HIV negative. Some participants suggested that, if a potential partner was HIV positive and physically desirable, they would still have sex with him providing certain criteria were met such as taking on the dominant sexual role (topping) or using condoms. As Christopher elaborated, “…[him being positive] wasn’t intimidating at all. He was beautiful taller than me, real cool, and so yeah, he made sure we were safe by wearing a condom.” Another participant corroborated this theme: “…I mean, I know to use condoms every time I have sex with somebody. And I’ve been with positive people before, it’s always been safe. So no, it [a partner being HIV-positive] hasn’t deterred me from having sex with positive people.”

In other instances, participants engaged in sex with positives based on open HIV disclosures and sexual positioning, such as assuming the top role in order to reduce the risk of infection. Omar, nearly shouting, exclaims “I don’t have sex with anybody that doesn’t know what their status is and won’t use a condom. Um, I’m the reciprocal person [bottom], so from my knowledge it’s much more dangerous being on the bottom than on the top. Um, so I am very mindful of the fact of—I’m the only person I have for me. I can’t answer for no one in this room but me and the choices that I make. And I’m not choosing that [getting HIV]…never!”

Xavier explains similarly, “…I also don’t have sex with anybody that doesn’t know their status. Um, and if I’m feeling like they aren’t being totally honest with me no [sex] will happen…we’ll have to do something else.” Most of the study participants stated that they initiated “the talk” about serostatus with new partners: “…like you know, asking them what their status is and making clear that you’re not going to have sex with them if they don’t know their status is…”(Vondell). Because HIV testing was readily available, most participants believed gay men could easily know their HIV status and as such were very comfortable asking unknown sexual partners their status: “…I think it [the messaging] makes me want to ask people their status more because getting tested is easy to do. So I ask…about HIV status even though sometimes that can be a mood changer in the moment” (Rodney).

Most men ascribed to the notion that consistent and correct condom use was important to remaining HIV negative. Marvin expressed this belief: “…I always bring some condoms…I’m the one…I bring it up first [using condoms]…I always bring it up…I always bring my own condoms too.” In some instances, participants demanded to see “the papers” from potential sexual partners. Several participants affirmed Vondell’s statement when he elaborated on requesting proof of HIV-negative serostatus. “…I used to have a lot of sexual partners you know, so not only did I reduce that, but I was just proactive in everything that I did and I asked questions. You know, now if you don’t have [HIV test] papers, I don’t wanna [have sex]…you know like the saying goes, if it’s not in writing it’s not real.” Several participants who adopted receptive (i.e., bottomed) versus insertive sexual roles were more insistent on having their top sexual partners show them their HIV-negative paperwork and were uncomfortable having sex with HIV-positive individual or persons with undocumented HIV status, given the belief that this sexual position make them more vulnerable to contracting HIV. In many such instances, these persons demanded proof that a potential partner was HIV negative: “…he has to show me his papers and I show him mine.” In contrast, other participants felt it was important not only to ask about a causal partner’s HIV status but also to use condoms, regardless of what his answer was or the paperwork produced. Najeem corroborated response illustrated this theme: “…I wouldn’t care if someone did show me [an HIV-negative test] paperwork…I’m not [having sex] without a condom. I mean, I can’t. I’m forty-seven years old; I’ve come this far…I’ve lost family members; I’ve lost friends to this shit. I just can’t.”

The notion of reverse stigma, a minor theme, was also evidenced in participants’ responses. While several participants indicated that they did not sexually stigmatize HIV-positive men, many described that they felt stigmatized by and often discriminated against by positive sexual partners because of their negative status. Several HIV-negative men discussed how they felt marginalized not only by the HIV service community but also by HIV-positive men. Andre added, “…in social situations, I feel awkward telling most guys my [HIV-negative] status…a lot of the time ‘coz they be positive and reject negatives.” The findings revealed that many HIV-negative BMSM in this study struggled discussing and disclosing being HIV-negative due to fear of being rejected by HIV-positive men. Another endorsed Andre’s statement saying “I…I feel like if I say, “I’m proud I’m negative,” someone’s gonna think I’m blaming positives for getting HIV. That’s not true, but I’ve seen it happen before…and I’m open to dating positive guys, I have been in two relationships with positive guys. I’m not scared of getting HIV…I know how to protect myself. But it’s just hard to talk about…a lot of the time with poz men” (Bobby).

In summary, major themes emerging from the focus group data indicated that a combination of psychological, social, and behavioral-based factors were associated with how BMSM believed they were able to maintain their HIV-negative status. These reasons coalesced around the importance of faith, connection to others, and having positive social supports. Moreover, participants felt that they had personal agency that motivated them to engage in HIV harm reduction practices.

Discussion

Existing studies have documented that sexual positioning, consistent condom use, and conversations about HIV status are common strategies employed by MSM populations for reducing sexual risks (Vallabhaneni et al. 2012; Van de Ven et al. 2002; Velter et al. 2015). This study has corroborated and expanded this literature by documenting that spiritual and/or religious beliefs and access to both private (family and friends) and institutional social supports are reasons also attributed by BMSM for their HIV-negative status. Research based on heterosexually identified youth and African American females has documented that high religiosity is associated with decreased drug and sexual risk behaviors (Corbin, Voisin, and Snell 2009; Miller and Gur 2002; Sinha, Cnaan, and Gelles 2007; Zaleski and Schiaffino 2000). These findings also document that religiosity and spiritual beliefs are central to BMSM engaging in protective behaviors that reduce their risk for contracting HIV.

Overall, findings highlighted participants’ beliefs that existing HIV programs were more geared toward HIV positives versus negatives. HIV-negative BMSM felt there were fewer community programs focused on their HIV prevention needs and that in many instances they were being marginalization within the BMSM and social services communities because they were HIV negative. Collectively, these findings suggest that HIV resiliency reflected both a combination of internal belief systems as well as external supports that were both proximal and institutional enabled participants to engage in a number of HIV risk reduction practices.

Interestingly, the notion of stigma emerged from the data in different ways. Several HIV-negative participants expressed the belief that they were experiencing reverse stigma by HIV-positive persons who may have felt that their virus was viewed by negative individuals as a result of reckless or irresponsible behaviors. In other instances, some HIV-negative individuals were also inclined to reject or stigmatize positives as potential sex partners based on HIV fear and stigma. In other cases, there were strong underlying pressures to avoid HIV disappointment or stigma from support confidants who were championing for them to remain negative.

Despite the significance of these findings, several study limitations warrant mentioning. Overall, findings are preliminary and may not apply to participants from other geographic locations or sociodemographic groups. Given the convenience sample and possible self-selection bias, the study sample is not representative of the larger BMSM population in NYC, especially given that the majority of participants were recruited from networks of social service providers. In addition, although not a requirement, a large number of participants bought HIV-negative documentation to the focus groups, but the HIV status of all participants was not verified. However, given the exploratory nature of this study, we found the current approach acceptable because HIV testing results are only accurate within a three-month time frame. However, future studies will need to confirm serostatus and should consider using a larger number of participants with variability by age cohort. For instance, it would be important to explore whether belief systems and practices related to remaining HIV negative differed by generational status. For instance, older men who experienced the onslaught of the HIV/AIDS epidemic, prior to the onset of more effective antiretroviral treatments and preexposure prophylaxis (PrEP) may hold belief systems and practices different from those of younger BMSM. Future studies should also conduct individual interviews to both confirm and expand the themes discovered in these focus groups. Finally, larger and more diverse samples might explore whether the themes identified in this study may differ based on other dimensions such as socioeconomic status, religious affiliation, and sexual identities.

Implications for Practice

Spirituality and religion have long occupied a buffering role for African Americans in the United States (Holt et al. 2013; Mattis and Jagers 2001). Current study findings have identified religion/spirituality as a significant protective factor for BMSM with regard to reducing sexual risk behaviors and promoting HIV prevention. Therefore, prevention programs for negative BMSM might incorporate an emphasis on core concepts such as purpose, self-worth, personal capital, and agency which may support HIV harm reduction practices.

Notably, this study was conducted two years prior to widespread public health campaigns supporting PrEP. Therefore, future HIV program initiatives might support and train BMSM on how to have conversations about PrEP use in addition to discussions about HIV status. Participants were acutely aware of the diminishing social supports for HIV-negative men within many social service agencies. Therefore, HIV campaigns and other social movement approaches might capitalize on the use of social media for organizing virtual and in-person “meet up” groups for HIV-negative men within social spaces that could support those conversations. Such meet up groups would provide social supports for encouraging and facilitating BMSM to consistently practice safer sex, help to alleviate reverse stigma and discrimination attached to being HIV negative, and challenge false notions that there are few seronegative BMSM in their communities. Such social media approaches might also provide access to up-to-date and accurate education and skills-based approaches related to HIV risk reduction approaches.

Overall, findings also suggested that participants upheld the belief that HIV testing was readably available. Therefore, HIV prevention initiatives and services that target BMSM should not only also use culturally based messages and images that positively promote HIV testing but also educate persons within these communities about the various locations and options for testing (e.g., traditional blood or rapid oral tests). They should also address possible concerns related to confidentiality, as the fear of HIV stigma is a known barrier to testing uptake and engagement in HIV treatment and care (Nanín et al. 2008).

Finally, overall study results indicated that remaining HIV negative, to a large extent, required personal individual agency on the part of individuals. Therefore, social marketing campaigns such as HIV Stops with Me, which emphasize personal responsibility and have been successfully implemented in NYC, might be effective initiatives to fund, promote, and expand (Better World Advertising 2006). Results also indicated that participants were quite aware of the importance of black theology as an empowerment to BMSM remaining HIV-negative. Therefore, some progressive black churches might collaborate with public health departments and other community based agencies to educate and promote HIV risk reduction approaches, especially in communities with high HIV incidences.