Intervening in the HIV/AIDS Crisis: The Role of Black Psychologists

10.1177/0095798403259250 ARTICLEJOURNAL OF BLACK PSYCHOLOGY / FEBRUARY 2004Roberts, Miller / INTERVENING IN HIV/AIDS CRISIS

Intervening in the HIV/AIDS Crisis:The Role of Black Psychologists

George W. RobertsCenters for Disease Control and Prevention

Robin L. MillerUniversity of Illinois at Chicago

Over the prior 2 decades, HIV and AIDS have ravaged the Black community. Thisarticle summarizes the epidemiologic, social, and psychological impact of HIV/AIDS on individuals and affected subpopulations in the Black community. Anoverview is then provided of prevailing research on psychological and mentalhealth issues in HIV/AIDS-related prevention and care that highlights key issuesof concern to Black psychologists and areas in which Black psychologists arewell positioned to make important contributions to the field. In conclusion, spe-cific suggestions for Black psychologists to become more involved in work onHIV/AIDS are provided.

Keywords: HIV/AIDS; Blacks/African Americans; prevention; treatment; psy-chology; mental health

For more than 20 years, acquired immunodeficiency syndrome (AIDS)has brought debilitating illness and premature death to affected communities.In the United States, the beginning of the epidemic can be traced to communi-ties of gay men and injection drug users living in large cities such as SanFrancisco and New York (Cohen, 1999; Shilts, 1998). The virus that causesAIDS, human immunodeficiency virus (HIV), has spread rapidly and widelyso that now there are heavy concentrations of it in most metropolitan cities,especially among their racial/ethnic and sexual minority communities, and insome rural areas. The impact of HIV/AIDS is dramatic in most Black com-munities of larger U.S. cities. Black women, heterosexuals, youth, and menwho have sex with men (MSM) experience disproportionate effects of HIV.

JOURNAL OF BLACK PSYCHOLOGY, Vol. 30 No. 1, February 2004 138-160DOI: 10.1177/0095798403259250© 2004 The Association of Black Psychologists

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Although awareness of the epidemic’s impact is growing among Blacksand more organizations are becoming involved in addressing its conse-quences, there remain many untapped opportunities for professionals to con-tribute their expertise to halting HIV transmission and reducing the psycho-logical impact of AIDS. As highly skilled professionals and insiders to thecommunity, Black psychologists have direct knowledge of the Black com-munity’s strengths and the related challenges associated with HIV/AIDS.Black psychologists are also likely to have credible knowledge of theresearch and interventions that might be truly beneficial to Black communi-ties (Jordan, Bogat, & Smith, 2001). Communities hardest hit by HIV/AIDS,therefore, require the concentrated attention of psychologists whose skills andinsights are most directly relevant to minimizing its adverse consequences.

The purpose of this article is to discuss some of the needs that haveemerged among Black individuals and communities beset by HIV and AIDSand to highlight the particular contributions that Black psychologists mightmake in responding to these needs. We conclude by noting some of theopportunities that currently exist for increasing the involvement of Blackpsychologists in responding to the HIV epidemic in their communities.

THE HIV EPIDEMICIN BLACK AMERICA

HIV has a disproportionate impact on Black people living in America.Representing 13% of the U.S. population (U.S. Bureau of the Census, 2000),Blacks account for the majority of annual AIDS cases in the nation and 50%or more of the diagnoses in 8 of the top-10 metropolitan areas (Atlanta, Balti-more, Chicago, Ft. Lauderdale, Houston, Miami, New York, Philadelphia,and Washington, D.C.) with the highest number of AIDS cases (Centers forDisease Control [CDC], 2001a). Like the HIV epidemic sweeping Africa(Fitzpatrick, McCray, & Smith, 2004 [this issue]), disease trends amongBlack Americans are steadily worsening. More and more young people, het-erosexuals, and women are at risk of exposure to HIV (Nakashima & Flem-ing, 2003). HIV prevalence rates among Black MSM, injection drug users,and heterosexuals show no signs of abating. These rates peak among personsin their mid- to late-20s, and this is particularly true for Black American men.In fact, a recent CDC (2001b) study found HIV infection rates (32%) foryoung Black men that were as high as the rates for pregnant women in somesub-Sahara African countries (e.g., Malawi, 31%; Rawanda, 33%).

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Blacks account for the majority (more than 60%) of all heterosexuallyacquired AIDS cases in the United States. Heterosexual exposure was thepredominant mode of transmission among all Blacks who were diagnosedwith AIDS in 2001 (CDC, 2002c). Because women are more vulnerable toexposure to HIV during vaginal sex than are men, women’s rates of infectionincrease disproportionate to heterosexual men’s rates over time (Fitzpatricket al., 2004). Black women account for the majority of cumulative AIDScases among women (more than 60%), and their proportion of annual BlackAIDS cases has grown from 24% in 1993 to 34% in 2001. Their male coun-terparts account for the greatest portion of AIDS cases among U.S. Blacks,and HIV infection among Black males occurs primarily in injection drugusers and MSM. Thus, Black women in the United States are most likely to beexposed to HIV during sex with a male partner and Black men are most likelyto be exposed to HIV while using injection drugs or having sex with anotherman.

In 2001, there were 151,717 Blacks living with AIDS, which accountedfor the largest proportion (42%) of the 362,827 persons estimated to be livingwith AIDS in the United States (CDC, 2002a). The large number of Blacksinfected with HIV has produced an array of health and social servicedemands on communities that are already overwhelmed by poverty, jobless-ness, violence, and high rates of death due to other diseases. Therefore, com-peting threats to individual and community survival provide the backdrop forHIV-related care services.

HIV/AIDS AND THE BLACK COMMUNITY:MEDICAL, SOCIAL, AND PSYCHOLOGICAL REALITIES

If any disease challenges psychology to demonstrate its promise, it isAIDS. The mental health implications of the HIV epidemic, along with thecomplexities of reducing behavioral risks associated with disease transmis-sion and outcomes, have produced considerable stress and strain for infectedpersons, their families, and the systems of medical care and public healthresponsible for addressing their needs (Institute of Medicine, 2001). Thesechallenges are even more profound under the weight of persistent racial andethnic disparities in health care (Institute of Medicine, 2003), pervasive pov-erty, and disproportionately high infection rates among Blacks. In the sec-tions below, we highlight research findings to emphasize the essential clini-cal and behavioral research roles Black psychologists can play in addressingHIV.

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THE MENTAL HEALTH IMPACT OF HIV/AIDS

Although advances in treatment have changed HIV from a terminal to achronic disease (see Cargill, Stone, & Robinson, 2004 [this issue]), learningof an HIV diagnosis can be an emotionally devastating event. Newly diag-nosed individuals face a myriad of decisions including whether to discloseand to whom to disclose their health status (e.g., current, former, and pro-spective sexual partners; parents, children, siblings, and other family mem-bers; friends), how to handle the range of reactions that others might haveabout their HIV status, and how to marshal adequate social, emotional, legal,and economic support to maintain their health and well-being. Being identi-fied as HIV infected may also mean coming out to family and friends as gayor as having engaged in stigmatized behaviors such as injection drug use orsex with multiple partners. As such, these decisions may involve disclosingmore than the HIV-infected person is prepared to handle and may invite deri-sion and rejection. Additionally, the HIV-infected person may experience arange of emotional reactions to their diagnosis including guilt, fear, sadness,relief, and regret, any of which complicates basic decision making and day-to-day functioning (e.g., see Siegel & Meyer, 1999).

The newly diagnosed individual must reevaluate his or her behavior interms of transmission risks to others and must learn the complexities of man-aging HIV infection (e.g., developing fluency in the language of viral load, T-cells, opportunistic infections, and highly active antiretroviral therapy), andnegotiating new relationships with medical providers to manage their careeffectively. If a medical regimen is appropriate for managing their disease,they must also come to terms with long-term adherence to the regimen andthe physical side effects associated with it (Cargill et al., 2004; Remien et al.,2003). Thus, an HIV diagnosis marks the beginning of what is often a longroad filled with significant life changes—many of which may strain the cop-ing and spiritual resources of the individual and his or her support network.The net effects of this strain can lead to chronic and severe psychological dis-tress (Martin & Dean, 1993; Salisbury, 1986; Siegel & Krauss, 1991; VanServellen, Padilla, Brecht, & Knoll, 1993).

Perhaps as a result of suboptimal adaptation to these stressors (Leserman,Perkins, & Evans, 1992; Sikkema et al., 2000), researchers have found highrates of depression in HIV-positive populations of gay men (Boland, 1997),women (Kaplan, Marks, & Mertens, 1997; Moore et al., 1999), and Blacks(Myers et al., 1997). Disease progression and outcomes may be severelyaffected by depression. For example, a recent study by Ickovics, Thayaparan,and Ethier (2000) found that depressed, HIV-infected women were morelikely to die than nondepressed women and that their times to death were


shorter. As Blacks now constitute the majority of those living with HIV/AIDS, more research is needed to identify the sequelae of specific mentalhealth conditions associated with their HIV status and to develop clinicallysound practices to help them maintain mental and physical health in the con-text of an HIV diagnosis.

Because AIDS is a stigmatized disease, people who live with it are at riskof internalizing the stigma, which can lead to deleterious psychologicalresults. Mental health treatment and social support, including support fromspiritual sources, may reduce the likelihood of internalizing AIDS-relatedstigma and buffer negative psychological health consequences for individu-als and families living with AIDS (Latkin, Tobin, & Gilbert, 2002; Lee,Kochman, & Sikkema, 2002).

People living with HIV/AIDS often have unique social and mental healthneeds. Early programs to assist HIV-positive individuals provided servicesthat included grocery shopping, house cleaning, pet care, transportation ser-vices, food preparation, and companionship. Many people living with HIV/AIDS, such as those who are currently using drugs, those who are mentallyill, and those who are indigent, may require even more demanding support.As Rahemian and Pach (1999) described in their ethnographic study of casemanagers of hard-to-care-for clients living with HIV, people with AIDS andthose who care for them can experience extreme situational stress. It is rela-tively easy for the caregiver and the person for whom they are providing careto lose their stamina.

Among the key lessons of the HIV epidemic as it has spread in communi-ties of gay men located in the United States is that AIDS brings with it epi-demics of bereavement and survival stress. Not only do those who are actu-ally living with HIV need social support, but those who are close to them do,as well, as secondary stigma toward those who love and care for people withHIV has been well documented (Brown, Macintyre, & Trujillo, 2003). Thus,there is a crucial need to mobilize social support around people with HIV andthose who are in primary caretaking roles.

COMMUNITY CAPACITY FORPREVENTION AND CARE SERVICES

In most communities, resources and services devoted to HIV/AIDS arenot adequate to meet the needs of the individuals and groups that are mostaffected. This is often especially so within the Black community. In manyepicenter cities such as New York, San Francisco, Miami, and Washington,D.C., the largest AIDS organizations have grown out of gay and lesbianhuman rights and AIDS activism efforts (Altman, 1994). Although these


organizations serve all people, the organizations are based most firmly intheir geographic and social communities of origin. As a result, many Blackslack easy-to-access, competent services provided by Black staff and leadersin their home communities. Even in communities where more than one localorganization provides prevention or care services within the Black commu-nity, there are still too few groups working to build a local infrastructure toeducate Black citizens about AIDS; build skills to reduce risk of exposure;change norms to support low-risk behaviors; test and counsel those whomight have been exposed to HIV; provide legal, financial, nutrition, housing,support, and recreational services to those affected by HIV; and offer soundmedical care (Perrow & Guillen, 1990). Developing the capacity of indige-nous organizations to provide sustainable AIDS-related services and to cre-ate innovative, local solutions to prevention and care dilemmas is an impor-tant activity for slowing the epidemic’s spread.

The church has been a primary target of such efforts because of its central-ity to Black life, but this may have occurred at the neglect of other importantinstitutions located in Black communities and at the expense of those Blackswho are not linked closely to an institutionalized religious community.Health and human service organizations located throughout Black communi-ties including organizations such as employment-training services, criminaljustice community reentry programs, gang intervention programs, youthafter-school programs, prenatal care programs, and businesses from hair andnail salons to banks to grocers to media conglomerates can all form the foun-dation for comprehensive, community-wide, AIDS-related prevention andcare services. Without the development of such an infrastructure, the Blackcommunity will continue to tumble down AIDS’s precipice.

PSYCHOLOGICAL INFLUENCES ONRISK FOR HIV TRANSMISSION

Psychology’s importance for prevention is obvious and has been fre-quently noted (Cochran & Mays, 1989; Kelly & Murphy, 1992; Kelly,Murphy, Sikkema, & Kalichman, 1993). Psychologists’ knowledge of howto encourage and maintain behavior change is essential to successful preven-tion efforts. A diverse body of prevention research, from clinical case studiesof gay men to studies of at-risk men and women who find it especially diffi-cult to change their behavior, indicates that a broad spectrum of psychologi-cal factors can facilitate or impede an individual’s ability to reduce his or herrisk of exposure to HIV. The list of psychological and personality factorsbelieved to affect prevention-related behaviors is long and includes self-efficacy expectations, self-esteem, sensation seeking, sexual compulsivity,


locus of control, and a variety of externalizing and internalizing disordersincluding depression and loneliness (Kelly et al., 1990; Myers, Javanbakht,Martinez, & Obediah, 2003; Perdue, Hagan, Thiede, & Valleroy, 2003;Reece, Plate, & Daughtry, 2001; Sterk, Klein, & Elifson, 2003; Stokes &Peterson, 1998; Wulfert & Wan, 1993). Attitudes and beliefs about sexuality,gender roles, condoms, sexual abuse, and drug use are also high on the list ofpsychological factors that affect risk-reduction behaviors (Amaro & Raj,2000; Bowser, Fullilove, & Fullilove, 1990; Catania et al., 1992; R. Fullilove,Fullilove, Haynes, & Gross, 1990; Kelly & Murphy, 1992; National Instituteof Mental Health [NIMH] Multisite HIV Prevention Trials Group, 2001;Stall et al., 2003). These same correlates of risk are often disproportionatelyprevalent among those with the least access to and trust of mental health andmedical services (R. Fullilove et al., 1999; Rich, 2001) and those who live inthe context of urban social decay (Bowser et al., 1990; R. Fullilove, Green, &Fullilove, 2000).

Blacks have borne the brunt of persistent race-based social and economicinequity, which, in turn, has created unique mental health concerns. Anascent but evolving line of research pioneered by psychologists such asVickie Mays, Susan Cochran, Ilan Meyer, Rafael Diaz, George Ayala, Greg-ory Herek, and Alex Carballo-Dieguez, among others, has identified objec-tive and subjective experiences of oppression as correlates of HIV riskbehavior. In each of these researchers’ empirical work, self-reported experi-ences of oppression resulting from poverty, racism, homophobia, and sexismis associated with engagement in high-risk sexual and drug use behaviors andpoor psychological health (Cochran & Mays, 2000; Corliss et al., 2002; Diazet al., 2001; Mays & Cochran, 2001; Meyer, 1995). The impact of oppressionon risk-taking behaviors is believed to be mediated through factors such aspoor self-image, internalization of negative social attitudes and beliefs heldby dominant society, and perceived powerlessness in relation to others. Peo-ple who carry the weight of oppression may be especially vulnerable to rage,despair, despondence, and systemic mistrust borne out of historical and per-sonal experiences in which consequences seldom follow from events inseemingly ordered ways (Fanon, 1963; Hardy & Laszloffy, 1995; Triandis,1976).

Research on trauma is another related and key area for understanding theprevention-related mental health correlates of HIV among Blacks. Throughlife histories of women in inner-city neighborhoods, male and female sub-stance users, and people living in neighborhoods characterized by violenceand social destabilization, Robert and Mindy Fullilove and their colleagueshave shown strong synergies among experiences of traumatic life events,posttraumatic stress disorder, and sexual and drug use risk patterns (M.


Fullilove, Fullilove, Smith, & Winkler, 1993; M. Fullilove, Golden, Fulli-love, & Lennon, 1993; M. Fullilove, Lown, & Fullilove, 1992). Amongurban African Americans, violence, sexual risk taking, and substance usefrequently co-occur (Buss, Abdu, & Walker, 1995; Johnson, Cunningham-Williams, & Cottler, 2003; McNair & Roberts, 1997; Rich, 2001). The co-occurrence of objective urban social decay and traumatizing social environ-ments may call for context-specific prevention strategies (Gasch, Poulson,Fullilove, & Fullilove, 1991). Clinically meaningful interventions withBlacks may require unique strategies to work through psychological damageresulting from oppression and trauma (A. Jones, 1991). Black psychologistshave an essential role to play in developing and studying ecologicallyinformed and clinically competent strategies for prevention of HIV amongBlack Americans. Additionally, by investigating the structural roots of men-tal health factors relating to HIV risk, Black psychologists can stimulatesocial change to eliminate oppression, urban social decay, and the economicand social inequities that give rise to racial disparities in exposure to HIV.

HIV TESTING

HIV testing is a major strategy for prevention. Testing provides the meansby which individuals can learn their serostatus and, if they are HIV positive,make behavioral changes to prevent infecting others and care for their health.The CDC estimates that the majority of new HIV infections result from per-sons who are HIV-infected but do not know it (CDC, 2003a). In addition,there is evidence that knowing one’s serostatus can be an important motiva-tion for taking preventive actions with partners of unknown or HIV-negativeserostatus (CDC, 2000). Prenatal testing in combination with antiretroviraltreatment of pregnant women and their babies has also led to reductions inHIV transmission to newborns and infants (CDC, 2002b). Although testingactivities have recently increased in Black communities, many high-riskindividuals avoid HIV testing and significant numbers of HIV-positive per-sons are unaware of their HIV status. Blacks do not seek out testing at highrates, even among those who report behavior that may put them at risk ofexposure to HIV. For example, in two recent studies, 91% to 93% ofyoung HIV-positive Black MSM were unaware of their serostatus (CDC,2002c).

Once tested, Blacks are the least likely to return to get their results. HIV-infected Blacks are more likely than other HIV-infected people to learn oftheir infection when they become ill (CDC, 2003b). Late testing and diagno-sis of HIV infection is a key factor in disease morbidity and death rates ofBlack Americans (Smith et al., 2000). However, very little research address-


es why Blacks do not avail themselves of testing services. In general, theresearch does suggest that men and women who have recently engaged inhigh-risk behavior and who also recognize that these behaviors may have putthem at risk are most likely to get tested (Anderson, Carey, & Taveras, 2000).

Fear of HIV positive results and denial of risk may be important factors inunderstanding why some people do not get tested (Kellerman et al., 2002;Vermund & Wilson, 2002). Among Blacks, other issues may also be impor-tant. Blacks may have deep-rooted concerns that testing efforts will be usedby the government to further stigmatize them and as a means to solidify insti-tutional discrimination (Dalton, 1989). Mistrust of how their blood might beused and beliefs about when and where it is safe to have blood drawn mightalso play a role in Blacks’ low rate of testing (Quimby, 1993). Research andclinical intervention to better understand reluctance to pursue testing is anurgent priority, as delayed treatment may result in unknowing transmissionof HIV to others, rapid physical decline, and premature death.

SPECIAL NEEDSOF BLACK POPULATIONS

In addition to the psychosocial issues wrought by HIV and AIDSdescribed earlier, we now highlight two critical areas for addressing HIVamong Black Americans. We also argue that the unique knowledge base thatmost Black psychologists possess is essential to progress in these areas.

CULTURALLY GROUNDED THEORETICALFRAMEWORKS TO GUIDE PREVENTION AND CARE

There is widespread agreement that behaviors related to the transmissionof HIV and to the management of HIV-related disease are informed by cul-ture, variously defined as the sum of the norms, values, practices, and ways oflife of a socially demarcated group of individuals (see review by Wilson &Miller, 2003). Researchers and practitioners routinely express the desire tocreate programs and services that are informed by culture, but they seldomuse extant theory or empirical evidence to do so (Kreuter, Lukwago,Bucholtz, Clark, & Sanders-Thompson, 2003; Wilson & Miller, 2003). As aresult, AIDS research has not yet gone far enough in considering how cul-tural understanding might inform the selection of intervention theory, modesand processes of intervention, or intervention content.


Wilson and Miller (2003) recently reviewed all of the HIV preventioninterventions in the scientific literature that claimed to have been developedwith the explicit goal of being culturally appropriate. They noted thatresearchers used two primary strategies to create an appropriate intervention.The first strategy was to make sure that the actors and facilitators who deliv-ered the intervention resembled in appearance and language the people towhom the intervention was delivered. Creating an appropriate intervention inthis case was operationalized in terms of similarities between theinteventionist and the target population. The second strategy was to anchorthe content of the intervention in the values, beliefs, and experiences of thetarget population, occasionally using empirical research to guide the anchor-ing process. In this kind of intervention, researchers typically made sure thatthe content of stimulus materials reflected themes believed to be salient in thegroup’s experience of risk taking.

What is noteworthy about the findings of the review, in addition to a rela-tive absence of systematic attempts to research the culture of the groups forwhom these programs were created, is the total absence of discussion regard-ing whether the aims of the interventions were consonant with or sought tochallenge fundamental cultural beliefs. In other words, few investigatorsconsidered whether and how the selection of intervention goals and strategiesmade cultural sense.

Critics of public health approaches in response to HIV have long arguedthat the promise of prevention cannot be realized until we can reconcileindigenous and cross-cultural knowledge and locate prevention within theframes of reference of the Black community (Dalton, 1989). Very few exam-ples of best-practice HIV prevention programs that are derived from Blackframes of reference exist in the scientific literature (for a thorough review ofrigorously assessed behavioral interventions published through 1998, seeSemaan & Sogolow, 2002). The programs that have benefited from scientificscrutiny and praise are not cultureless, although they are often presented asculturally generic phenomena (Beatty, Wheeler, & Gaiter, 2004 [this issue]).To the contrary, each of these programs was derived from a culturallyanchored set of values, beliefs, attitudes, and norms about how particularsocial and behavioral problems are understood and best addressed (seeBeatty et al., 2004). A case in point is the use of HIV prevention strategiesthat were developed for White gay men as models for preventing transmis-sion in other groups. Many organizations that have emerged primarily fromthe Black community are challenging this overreliance on previous preven-tion approaches and calling for community-specific strategies that acknowl-edge racial and ethnic differences among gay men as well as emanate from


the shared ethnicity between Black gay men and their heterosexual counter-parts who are at risk for HIV transmission. The cultural assumptions embed-ded in existing prevention programs and frameworks merit explicit articula-tion so that they may be examined for potential effectiveness in preventingHIV infections in diverse populations.

For more than 3 decades, Black psychologists have advanced a culturallybased theory for the purpose of explaining attitudinal and behavioral mani-festations of psychological and mental health (cf., Boykin & Toms, 1985; A.Jones, 1991; R. Jones, 1972, 1980). Relying on traditional African philo-sophical principles and concepts of time, unity, kinship, and spirituality,Black scholars have posited the notion that psychological health is perceivedand determined by one’s cultural experiences. Thus, they argue that thebehaviors and mental functioning of Blacks have often been subject to biasand misinterpretation by outside observers and researchers (Akbar, 1991;Guthrie, 1976; Nobles, 1991). Moving beyond this critique of traditional the-ories and research about Blacks, members of the Association of Black Psy-chologists (1997) have offered culturally relevant theories and approachesthat suggest a relationship between HIV risk behaviors and cultural disinte-gration or domination. Yet, there has been little specific application of theirwork to HIV preventive and clinical interventions. Two exceptions are worthnoting. Belgrave and her colleagues (Belgrave, 2000; Belgrave, Townsend,Cherry, & Cunningham, 1997) used African-centered cultural enhancementsin their interventions with adolescents and those at risk for substance use andHIV transmission. A second example is the culturally specific model for thedelivery of technical assistance to Black community-based AIDS organiza-tions discussed by Foster, Phillips, Belgrave, Randolph, and Braithwaite(1993).

In addition to further elucidating the ways in which cultural theory maylead to effective practice and intervention with Black Americans, Black psy-chologists can shed important light on how to manage the value and norma-tive conflicts that may arise when HIV-related interventions pit personal andprofessional cultural beliefs against the cultural beliefs of those whom HIVprofessionals are seeking to help. For example, what happens when effectiveprevention programs require Blacks to overcome key cultural values orbeliefs such as those that favor sexism or heterosexism? Can indigenous cul-tural beliefs that contribute to the virulence of the epidemic in the Black com-munity be modified without undermining positive cultural beliefs? Blackpsychologists are uniquely positioned to clarify what are appropriate culturalframeworks for preventive interventions and articulate linkages and discon-nections between frequently applied theories of behavior change and the cul-tural contours of Black American life. Black psychologists may also be best


positioned to challenge those cultural perspectives that may actually fuel theepidemic in Black communities.

ADDRESSING HIV-RELATED STIGMAAND ITS CONSEQUENCES

Among the skills many psychologists obtain as part of their training is theability to help individuals confront prejudicial beliefs and feelings and tothink through the consequences of those beliefs and feelings for others. Atboth the individual and community level, Black psychologists can play animportant role in generating dialogue about the beliefs, feelings, and valuesthat challenge the Black community to openly address its gay, lesbian, bisex-ual, and transgendered members; its mixed feelings about controversial buteffective approaches to HIV such as needle exchange; and the impact of sci-ence and racism on how the disease has been portrayed in and understood bythe community (Dalton, 1989).

The divisiveness of AIDS, which separates the Black community intomarginal subpopulations (e.g., injection drug users, gays) and respectablemembers, paralyzes mobilization around AIDS as a common cause forBlacks (Cohen, 1999). In her analysis of the Black community’s response tothe AIDS epidemic, Cohen (1999) suggested that taking transformationalpolitical leadership on AIDS requires Black leaders to address issues—gen-der, sexuality, social class—that are not considered Black enough to make itonto a narrowly defined, race-based political agenda. Breaking throughstigma is necessary to the development of responses to AIDS that are sensi-tive to the concerns of those who are most affected by it (M. Fullilove &Fullilove, 1999) and in mounting a viable and effective social and politicalresponse to the epidemic.

HIV stigma includes fear of illness, contagion, and death but also extendsto include stigma related to prostitution, drugs, sexuality, and sexual identity(Brown et al., 2003). Several authors have argued that the Black commu-nity’s response to AIDS reflects multifaceted resistance borne out of histori-cal circumstances unique to the Black experience in the United States (Dal-ton, 1989; Quimby, 1993; Stevenson, 1994). Among the primary causes ofAIDS inertia cited by these authors are unease at the government and scien-tists’ attempts to trace the human origins of AIDS to Africans and the resul-tant fear of stigma attached to the Black community for its perceived role instarting the epidemic; acute mistrust of larger society stemming from histori-cal experiences such as the Tuskegee syphilis experiments; widespreadhomophobia borne in part out of religious and sex-role conservatism and inpart out of sexual racism; paralysis from the multiple, debilitating effects of


drugs on Black communities; and rejection of colonialist approaches to HIVprevention and testing in which solutions are imposed on communities fromwithout (Dalton, 1989; Quimby, 1993).

According to Stevenson (1994), the legacy of scientific racism, in whichscience has been used to endorse racist propaganda, further impedes theemergence of an AIDS agenda that would benefit the Black community. Dal-ton (1989) noted that effective approaches to HIV in the Black communitywill not be realized until the social meaning of the epidemic is forthrightlyaddressed including the pervasive mistrust of American institutions. Blackpsychologists can play a leadership role in further investigating barriers tocommunity responses to AIDS and advancing these discussions among otherprofessionals, within Black communities, and across a wide range of service,research, and government settings. By providing an empirical basis for thisdialogue, Black psychologists can help peel back the layered and interlacedAIDS-related stigmas that give way to community inaction and poor mentalhealth outcomes among those who are living with HIV.

STRATEGIES FOR INCREASING THEINVOLVEMENT OF BLACK PSYCHOLOGISTS

The HIV/AIDS epidemic has dealt a terrible blow to Black communities.High rates of infection are the result of a myriad of individual, social, andstructural factors that have severe physical and mental health consequences.Psychologists are needed more than ever to investigate the complex interplayamong these factors and to develop clinic-based and community-based inter-ventions to minimize their effects on disease transmission and outcomes. Inthis section, we discuss ways that Black psychologists can increase their con-tributions to the work on HIV by accessing opportunities that are alreadyunderway.

PARTNERSHIPS FOR CAPACITY DEVELOPMENT

HIV-related, community-based organizations, health departments, andother government and human service institutions often struggle to find pro-fessional partners who are competent to assist them in critical organizationalareas such as program evaluation, program development, leadership devel-opment, cultural competence, and board management. Organizations such asthese want Black psychologists in their volunteer corps; on their rosters ofstaff specialists and consultants; on their boards of directors and advisory


boards; on the panels that review materials, programs, and requests for pro-posals; and on the committees that shape local policy such as the citywideHIV prevention and care planning groups. Additionally, many congressionalrepresentatives at the state and federal level have citizen advisory committeeson AIDS and would welcome the involvement of Black professionals onthese committees. Organizations such as the National Minority AIDS Coun-cil (www.nmac.org) can link you to organizations in your area that are inneed of partners with your skills.

Federal agencies, as well as state and local health departments, provideopportunities that bring community-based organizations and technicalexperts together for the purpose of planning and implementing more effec-tive HIV prevention and care programs. The National State and TerritorialAIDS Directors (NASTAD) works with state and local AIDS programs tostrengthen their partnerships with communities of color. In addition, the Sub-stance Abuse and Mental Health Services Administration (SAMHSA; www.samhsa.gov), the Health Resources Services Administration (HRSA; www.hrsa.gov), and the CDC (www.cdc.gov) support technical assistance andcapacity-building assistance programs designed to increase the ability ofcommunity-based organizations to deliver scientifically based interventionsand services to highly impacted populations. More information about theseprograms can be obtained by visiting agency Web sites.

RESEARCH DEVELOPMENT

There are many talented Black psychologists conducting basic andapplied AIDS-related research. However, there is much more research to bedone than these individuals can do alone. Research on individual, group, andcommunity risk and protective factors among Blacks and on effective modesof prevention, treatment, and care are essential areas in which Blackresearchers can conduct culturally specific studies that will benefit their com-munities. Federal agencies such as the CDC, the HRSA, and the NationalInstitutes of Health (NIH; www.nih.gov) provide funding for much of thisresearch. Some of this research can be initiated by researchers themselveswho are connected to affected communities and who have insights and skillsrelated to their HIV prevention and care needs. Other research opportunitiesare identified by federal agencies in consultation with scientific experts inrelevant disease and population areas. For example, the Office of AIDSResearch at the NIH convenes panels of experts in AIDS research to developan annual plan for HIV-related research. This plan identifies critical researchquestions and gaps that agency units such as the National Institutes of DrugAbuse (NIDA) and the NIMH may use to develop solicitations for research


proposals (copies of this plan can be obtained at www.nih.gov/od/oar/public/pubs/fy2004/ix_racialethnic.pdf).

Scientific review committees at the NIH, the HRSA, and the CDC provideanother means by which Black psychologists might increase their involve-ment in developing research that will benefit highly impacted communities.These committees are convened at different times during the year to reviewapplications that are submitted by professional peers working in the area ofHIV/AIDS research. Through their involvement on these committees, Blackpsychologists can influence the quality and type of research that is conductedwith and among persons at risk and infected with HIV. Federal agencies havea number of efforts underway to increase the representation of minority sci-entists on these review panels. Further information about these opportunitiescan be obtained by visiting agency Web sites and by seeking informationthrough professional psychological organizations.

Finally, special research initiatives exist at several federal agencies tostimulate further research and involvement of minority investigators inscientific studies related to AIDS. For example, the CDC offers a capacity-building research initiative that is designed to assist minority researchers athistorically Black colleges and universities in the development of AIDSresearch projects. Successful applicants develop research studies in partner-ship with CDC scientists and initiate a program of AIDS research that willlikely make them more competitive in seeking later funding support.

PROGRAM TRANSLATION

Currently, translating research to practice is a priority for governmentagencies and for many state and local health departments responsible forHIV prevention, care, and treatment. Several efforts are underway to studyhow to translate empirically validated programs to practice settings. Forexample, the CDC supports several major initiatives to replicate programsthat have scientific evidence of effectiveness (e.g., see Neumann & Sogolow,2000). Among the major questions requiring further attention in the transla-tion field are how best to adapt programs to new settings so that the core ele-ments of the program remain intact, whether science-based programs areequal to or better than what they replace or complement in a practice environ-ment, what is necessary to succeed in transferring and sustaining evidence-based programs, and whether evidence-based programs have beneficial orharmful consequences for the practice settings into which they are imported(Kelly et al., 2000; Miller, 2001; Miller & Greene, in press). Translationresearch is particularly urgent in Black communities, as so few of the


evidence-based programs currently in translation were originally developedfor Black audiences.

Several public health agencies support activities to translate scientific the-ory and findings to HIV prevention and care programs at the communitylevel. The HRSA and the CDC provide translation support through HIV/STDprevention and care training centers that are affiliated with academic institu-tions across the country. They also work directly with national minority orga-nizations to hold trainings on effective interventions to enhance preventionand care effectiveness. In addition, the CDC conducts special trainings onspecific interventions that are packaged specifically for use by community-based organizations serving high-risk groups such as MSM, injection drugusers, youth, and women. The NIMH is particularly interested in researchthat addresses the effectiveness of programs when they are imported intocommunity settings. These activities provide an important arena for Blackpsychologists to learn more about the benefits of linking science and prac-tice, and provide an opportunity for Black psychologists to apply their skillsin efforts to better bridge science and programs in communities of color.

PREDOCTORAL AND POSTDOCTORAL GRADUATE TRAINING

Too few Black graduate students think of AIDS as the focus of theirresearch or clinical expertise. Although AIDS intersects with so many issuesthat are fundamental to scholarship on Black community life, AIDS is typi-cally not addressed in coursework, in clinical practica, or in master’s and doc-toral theses. Black psychologists can develop courses that are devoted toAIDS or can add modules on AIDS to existing courses. Students can beencouraged to seek community placements in AIDS-related agencies or tovolunteer in these settings. Finally, the increased participation of faculty inresearch endeavors related to AIDS will bring greater opportunities for stu-dents to develop their graduate-level theses in this area.

In addition to encouraging student educational experiences related toAIDS, Black psychologists can encourage graduates to seek AIDS-relatedpostdoctoral training in one of the many AIDS-related training programsthroughout the country. Several programs exist specifically to train ethnicand racial minority professionals including programs offered at AIDSresearch centers such as the Center for AIDS Prevention Studies in San Fran-cisco. Similar AIDS research centers exist in Los Angeles (Center for HIVIdentification, Prevention, and Treatment Services; http://chipts.ucla.edu/),Milwaukee (Center for AIDS Intervention Research, http://www.cair.mcw.edu), and New York (The HIV Center for Clinical and Behavioral Studies,


http://hivcenternyc.org), each of which offers a variety of training opportuni-ties. Programs such as these can assist early- and mid-career professionals tobecome AIDS scholars.

The federal agencies supporting many of these training and academic cen-ters also have research training programs that provide funding and placementopportunities for scientists of color. The NIH offers a minority research sup-plement program that pairs minority scholars with scientists already fundedthrough their extramural program as well as limited opportunities to workwith scientists there at the agency. The CDC’s HIV prevention research fel-lowship program for scientists of color provides 2-year placement opportuni-ties within the agency for investigators to collaborate on behavioral scienceand epidemiologic research projects. These and other opportunities can pro-vide Black psychologists with greater access to research priorities, funding,and skills. In addition, Black psychologists, at varied professional levels, andthe communities that they serve may benefit from greater exposure to federalinitiatives that are responsible for producing a major portion of the HIV-related research conducted in the nation.

CONCLUSION

HIV/AIDS presents a great number of challenges and opportunities forBlack psychologists. Behaviors that place individuals at risk for HIV infec-tion arise from multiple factors interacting in complex ways. Efforts to mod-ify these behaviors also require strategies that take their complexity intoaccount and target the context of individual and group risks (Sumartojo, Doll,Holtgrave, Gayle, & Merson, 2000). Psychologists possess an arsenal of the-ories and methods that may form the basis of behavior-change strategies forthe reduction of risks associated with HIV transmission (Des Jarlais &Semaan, 2002).

In addition to modifying behaviors that place individuals at risk for HIVtransmission, there is a growing need for clinic- and community-based ser-vices and support to address the multiplicity of psychosocial stressorsaccompanying HIV status and AIDS. The chronic and severe nature of thesestressors may be influenced by marginalization, threats to self-esteem, andtrauma associated with racial and ethnic-group status. Psychologists andother mental health professionals are urgently needed to intervene to mitigatethe adverse psychological consequences related to living with HIV/AIDS.

The impact of the epidemic on Black communities will grow unless Blackpsychologists can marshal their resources, talents, and energies to change the


conditions and consequences associated with it. Black psychologists have anurgent role to play in shaping our national response to AIDS. The Black com-munity and the nation cannot escape the present trajectory unless this role isactualized to the benefit of those living with and at risk for HIV infection.

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Intervening in the HIV/AIDS Crisis: The Role of Black Psychologists

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