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KNOWLEDGE, ATTITUDES, AND BELIEFS OF AFRICAN AMERICANS IN THE CENTRAL VALLEY

CONCERNING HIV/AIDS

A Thesis Presented to the Faculty of

California State University, Stanislaus

In Partial Fulfillment

of the Requirements for the Degree of Master of Social Work

By Vintrica Grant

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CERTIFICATION OF APPROVAL

KNOWLEDGE, ATTITUDES, AND BELIEFS OF AFRICAN AMERICANS IN THE CENTRAL VALLEY

CONCERNING HIV/AIDS

by Vintrica Grant

Signed Certification of Approval Page is on file with the University Library

Dr. Kilolo Brodie

Assistant Professor of Social Work

Dr. John Garcia

Professor of Social Work

Date

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© 2013 Vintrica Grant ALL RIGHTS RESERVED

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iv DEDICATION

I would like to dedicate this thesis to three people in particular: To my dearly departed uncle Elsdon Glen Johnson, my mom Vicky Johnson and my grandmother Sara A. Johnson (Mother). As a child I bared witnessed to the strength, compassion, and incomparable love you all exuded at one of the most difficult times in our family’s history. Uncle Elsdon, we may have lost you to the battle of AIDS but through your struggles you bred a warrior who’s willing to continue the fight in your memory. Mom, during this time you showed me how to face fear and fight stigma with love. You are a true testament to the saying “love concurs all” and when you love, you love hard without discouragement, even when it hurts. I am so grateful to be your daughter. Mother, you are the rock of this family and the love of my life. We have a spiritual connection beyond explanation. Throughout my life I’ve aspired to be like you and strived to make you proud. By your example I have become aware of what giving, forgiveness and genuine love really is. You give without expecting something back, you forgive with the intention to move forward, and you love without limits. You have an amazing spirit and are the most beautiful person I have ever known. Thank you for your wisdom, laughter, and unlimited hugs and kisses. I thank you all for your sacrifice, motivation, and passion for our family. I love you.

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v

ACKNOWLEDGEMENTS

I would like to thank my professor and thesis chair, Dr. Kilolo Brodie, for her hard work, patience and meticulousness. She possesses the ability to pull greatness out of people and has truly been a significant part in my growth as a student, professional, and role model. Thank you for setting a high standard, leading by example, and believing in me. I would also like to extend thanks to my reader Dr. John Garcia for his speedy and thorough work. It was a great help in the completion of this Thesis. To Barbara Dimberg, the rock of the MSW department and all the professors whose classes I had the privilege to take throughout this program; Dr. Tynan, Dr. Bresheares, Dr. Leyva, Dr. Humble, Andrea Perkins, Jennifer Johnson, and Paul Sivak, thank you for your insight, wisdom, and dedication.

Additionally, I would like to thank the two- year cohort of the 2013 MSW graduate class for the lessons learned within the classroom setting. I have truly learned so much from a lot of my colleagues and have had the opportunity to become close friends with many of you. What a priceless experience. Also, to my cousin, Monique Dugars Jones, you were the first one in our family to strive for higher education. You convinced me to do the same, thank you for your inspiration. Finally, I would like to thank my sweetheart Sammy Neal, and my family for their love, patience, and encouragement. I could not have done this without your emotional support and understanding. I love you, thank you.

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vi

TABLE OF CONTENTS

PAGE

Dedication ... iv

Acknowledgements ... v

List of Tables ... viii

Abstract ... ix

CHAPTER I. Introduction ... 1

Statement of the Problem ... 1

Statement of the Purpose ... 3

II. Review of the Literature ... 7

Introduction ... 7

Racism and Institutional Disparities ... 7

Incarceration Induced Risks ... 10

Risky Behaviors and African American Women ... 13

III. Methodology ... 18 Overview ... 18 Research Design ... 18 Sampling Plan ... 19 Data collection ... 20 Instrumentation ... 21 Data Analysis ... 22 Protection of participants ... 22 IV. Results ... 24 Knowledge ... 24 Attitudes ... 26 Beliefs ... 29 V. Discussion ... 34 Major Findings ... 34

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vii

Implications for Practice & Policy... 37 Implications for Future Research... 39 References ... 42 Appendices ... Informed Consent ... 52 Email Sign-Up Sheet ... 55 Survey Questions ... 57

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viii LIST OF TABLES TABLE PAGE 1. Table 1 Knowledge ... 25 2. Table 2 Knowledge ... 26 3. Table 3 Attitudes ... 27 4. Table 4 Attitudes ... 28 5. Table 5 Attitudes ... 29 6. Table 6 Beliefs ... 30 7. Table 7 Beliefs ... 31 8. Table 8 Beliefs ... 31 9. Table 9 Beliefs ... 32

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ix ABSTRACT

The purpose of this study was to gain insight into the knowledge, attitudes, and beliefs that African Americans in the Central Valley of California had concerning the topic of HIV/AIDS. The primary questions of this study were: 1) What factors do African Americans believe contribute to the HIV/AIDS epidemic? and 2) How do African Americans feel about a culturally specific HIV/AIDS prevention and sex education program? This study used a quantitative design and collected data by way of an electronic survey via Qualtrics and hard copy form. The survey consisted of forty-two questions that were divided into 5 specific parts: medical history,

knowledge of HIV/AIDS and sex education, attitudes beliefs, and demographics. A total of fifty-nine participants, with an age range of 18 to 70+, completed the survey. In general, participants demonstrated knowledge on the topic of HIV/AIDS but had slightly conflicting attitudes and beliefs regarding testing and being aware of the HIV status of their partners. The results concluded that African Americans in the Central Valley believe that factors such as drugs, poverty, lack of sex education, stigma, limited access to health care, incarceration, racism and discrimination, are all daily issues that place African Americans at risk of becoming infected with HIV/AIDS. The results also show that a majority of participants have positive feelings towards the implementation of a cultural specific HIV/AIDS prevention and sex education program.

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1 CHAPTER I INTRODUCTION Statement of the Problem

HIV/AIDS is a worldwide epidemic that has spiraled out of control claiming numerous lives since its discovery in the early 1980s. While the magnitude of the effects of HIV/AIDS is global, since the epidemic began, 1.7 million Americans have been infected with HIV and 583,298 have died of AIDS-related causes through 2007 (SFAF, 2011). HIV is the human immunodeficiency virus. A person with HIV may have cold or flu like symptoms or none at all. It is the virus that can lead to acquired immune deficiency syndrome, or AIDS (CDC, 2011). AIDS is the late stage of HIV infection, when a person’s immune system is severely damaged and has difficulty fighting diseases and certain cancers (CDC, 2011). According to the Center for Disease Control (2011), HIV/AIDS can be transmitted by receiving contaminated blood transfusions, organs or tissue transplants, shared drug syringes, unprotected sex and from mother to baby through birth and breast milk. HIV/AIDS has no biases and it does not discriminate. Anyone can come into contact with this virus regardless of age, race, gender, sexual orientation, and social class. Although HIV/AIDS has the capability to effect people from all walks of life, it has largely affected African Americans across the country.

African American women make up 6.3% of the population in the United States and accounted for 65% of new cases amongst women in 2007 and the largest

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share of new HIV infections, 61% (SAFA 2011). Although African American women represent disproportionate numbers of those infected with the HIV virus, African American males with HIV are dying at rates almost two times higher than infected African American females, and with an increase to three times more likely after age fifty-five. The HIV/AIDS epidemic yields inevitable problems that the social work field already addresses. Factors such as poor healthcare, poverty, and incarceration are all issues that correlate HIV/AIDS to social work. Being that African Americans are predominantly represented in the child welfare and prison systems, this prevalent issue is a problem of importance to the social work field since social work

professionals come into contact with this population on a regular basis. An issue that African Americans face with health care is their struggles of trust toward public health authorities. The history of the Tuskegee Syphilis Study, with its failure to educate the participants and treat them adequately, helped to lay the foundation for Blacks’ pervasive sense of distrust of public health authorities today (Thomas & Quinn, 1991). When people are not sure of the intentions of their doctor, ambiguity can cause fear and result in irregular to no check-ups. A deficiency of doctor’s visits puts African Americans at risk, particularly African American women because they continue to experience higher rates of sexually transmitted diseases (STDs) than any other race in the United States. The presence of certain STDs can significantly increase the chance of contracting HIV infection (CDC, 2011). Although HIV/AIDS is a condition that people are able to live fulfilling lives with, without trust in their health care provider and access to proper health care, the life of an infected

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person may not be as rewarding. Access to health care is not easily accessible for those who live in impoverished communities. Nearly a quarter of African American families live in poverty, with even higher poverty rates for single female-headed households yielding 40 percent (ADVERT, 2011). Addressing the 'social

determinants of health such as poverty and poor access to healthcare is now seen as an integral part of tackling the disproportionate impact of HIV/AIDS on the African American population (CDC, 2010)

Poor access to health care for a majority of African Americans is the result of living in poverty which could explain why African American men infected with HIV are perishing at alarming rates after age thirty- five. The need to pay attention to the social and economic context in which HIV flourishes was recognized by Barack Obama who, in his presidential campaign literature pledged to, “tackle the scourge of poverty where HIV and AIDS proliferate”(ADVERT, 2011). Conditions of poverty have influences on relationship patterns and sexual practices that encourage the spread of HIV/AIDS and a fear of stigma.

In California the coastal cities like Los Angeles, The Bay Area and San Francisco, have a larger African American, Latino, and LGBT (Lesbian, Gay, Bisexual and Transgender) population which results in more HIV/AIDS resources such as free clinic, counseling, seminars and sex education and prevention

workshops. Nevertheless in the Central Valley counties like San Joaquin and

Stanislaus have limited access to HIV/AIDS resources. Research has shown that one of the relationship patterns that effect African Americans are the male to female ratio

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which is incredibly low in the Central Valley of California. Considering that an average between Stanislaus and San Joaquin County yields approximately 4,245 more females than males which in percentage terms is about 3.2% more females than males. Taking ethnicity into account reduces the odds even more since Stanislaus County has an African American population of 3.3% out of 100 and 8.2% out of 100 in San Joaquin County. Several studies suggest that African American females

perceive that they lack control over condom use because they have insufficient power in their relationship (Fullilove, Fullilove, R., Haynes & Gross, 1990), which may partly be exacerbated by the low ratio of men to women in African American communities (Wingood, Hunter-Gamble, DiClemente, & Hearst, 1993).

African American male incarceration lowers the sex ratio (male to female), disrupts the continuity of heterosexual relationships, and increases the exposure of incarcerated men to high-risk sex amid a prison population with a high prevalence of HIV. All of these factors elevate an individual’s or group’s AIDS infection risk and does disproportionately affect the AIDS infection rates of Black women (Johnson & Raphael, 2006). Researchers at the University of California at Berkeley published a study that showed that the increasing rate of HIV in heterosexuals, particularly women, closely tracked the increasing rate of incarceration among black men during the 1980s and early 1990s. A variety of research has shown men in prison to be at high risk of HIV, those researcher theorized that many black men became infected in jail and then went on to infect their female partners upon release (Johnson &

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High-risk sexual practices, such as men who have sex with men (MSM) who also have sex with women (MSM/MSW), is suggested to be a culprit as to why African American women are so largely affected by HIV/AIDS. The portion of Black MSM/MSW is the highest at 34%, compared to 26% Hispanic MSM/MSW and 13% White MSM/MSW (Montgomery, Mokotoff, Gentry, & Blair, 2003). In a recent study of men who have sex with men (MSM) in five cities, 67% of the HIV infected Black MSM were unaware of their infection. Those who are at risk for HIV infection fear stigma more than knowing their status, choosing instead to hide their high-risk behavior rather than seek counseling and testing (ADVERT, 2011). Stigma puts African American at higher risk of infection. A study by Mallory, Harris and

Stampley (2009), found that while the risks of HIV infection were clearly defined, the context for sexual risk-taking and protection practices is poorly understood for

midlife African American women. There is no sole reason why African American women are disproportionately affected by HIV/AIDS but researchers suggest that special emphasis must be placed on reaching this population with effective HIV education and AIDS risk reduction programs (Thomas & Quinn, 1991).

Statement of the Purpose

The purpose of this quantitative study was to explore the knowledge, attitudes and beliefs that African Americans in the Central Valley of California have

concerning the issues of HIV/AIDS. The primary questions of this study include (a) what do African Americans believe are the factors that contribute to the HIV/AIDS

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epidemic, and (b) what is their attitude toward a community-based culturally specific sex education program.

Implications of this study could suggest open dialogue between parents and children, amongst teachers, community members, professionals, organizations and churches within the African American community about taboo topics that create stigma in the community. This study can also reintroduce the potential for trust to be established amongst African Americans and public health authorities which may possibly result in them getting tested regularly and being aware of their status. The rekindling of this relationship might influence more African Americans in the community to participate in studies so that more data can be collected from this population.

Ultimately, the study could encourage further research to be done in hopes that Department Public Health in every city could develop and or fund culturally specific HIV/AIDS prevention and sex education programs in conjunction with community based organizations.

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7 CHAPTER II LITERATURE REVIEW

Introduction

This chapter examines previous research concerning the potential factors associated with the spread of HIV/AIDS amongst African American communities. This chapter purposely focuses on research that suggests that racism, inequalities within healthcare, and the elements of poverty are the contributing factors as to why the African American population accounts for a majority of those infected with HIV/AIDS. Additionally, this chapter features insight into the circumstances of African Americans regarding risky behaviors related to poverty, incarceration, prison culture and the stigma associates with HIV/AIDS. Furthermore, this chapter looks into interventions that have and could further assist with preventative measures to avoid exposure to the virus and reduce the high-risk behaviors associated HIV/AIDS.

Racism and Institutional Disparities

Racism can occur even if the people causing it have no intention of

subordinating others because of color, or are totally unaware of doing so. Admittedly, this implication is sure to be extremely controversial. Most Americans believe racism is bad. But how can anyone be guilty of doing something bad when he does not realize he is doing it? Racism can be a matter of result rather than intention because many institutional structures in America that most whites do not recognize as

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more than deliberate racism. The multiple risks of African Americans men are seated in historical and socio-structural inequities (Downs, 1970).

Smedley et al., (2002) testified that embedded inequities produce unequal opportunities for health and wellness. The Institute of Medicine consensus report revealed that income is highly related to health care access and insurance coverage (Smedley et al., 2002). The 2012 U.S. Census Bureau conveyed that between 1980-2009, with the exception of years 1994-1997, African Americans accounted for the largest percentage of persons living below the poverty level in the United States compared to White and Hispanic populations. Since African Americans are more likely to be poorer than others, they are less likely to have adequate insurance coverage and access to quality health care, which makes them vulnerable to the threats of HIV/AIDS. Most studies show that even when income is similar across groups, racial and ethnic disparities remain (Smedley et al., 2002). McDonough (2004) suggests the Commonwealth Fund is a potential solution for disparity reduction within the health care system since it has produced a comprehensive state policy agenda for disparity elimination that contains a wide range of

recommendations and promising practices for states to consider improvements in their performance on minority health.

A review of literature by Bogart & Thornburg, (2005) inquiring whether HIV/AIDS conspiracy beliefs are a barrier to prevention amongst African Americans, revealed that over 75% of African American men and women genuinely believe that medical and public health institutions are trying to stop the spread of HIV/AIDS in

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Black communities. However, the government and public health entities need to work towards obtaining the trust of Black communities by addressing current

discrimination within the health care system as well as by acknowledging the origin of conspiracy beliefs in the context of historical discrimination. The most striking example of such discrimination is the Tuskegee Syphilis Study, in which the public health service studied the effects of untreated syphilis in African American men for 40 years (Thomas & Quinn 1991). Some African Americans’ negative attitudes about health care have been exhibited in the form of conspiracy beliefs. A handful of

empirical studies have observed that a significant percentage of African Americans hold conspiracy beliefs regarding HIV/AIDS, including the beliefs that HIV/AIDS is a form of black genocide.

In an article written by Johnson and Leighton (1995), the genocide of African Americans was defined as creating or tolerating the multiple destructive life

conditions of high infant mortality, limited access to health care, crushing poverty, inadequate schools and crime-racked neighborhoods, which are conditions that apply to the daily existence of poor Black Americans (Reiman 1995). Mathews (2012) spoke to the harsh life conditions of poor African Americans in the United States, by recognizing that the correlation between education and our growth in both poverty and number of prisoners is indisputable. As noted by Braitwaite & Arriola (2003), the number of incarcerated African American men exceeds the total number of Black and Hispanic men attending college in the United States. This epidemic of

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African American men and their families will escape the intergenerational effects of incarceration. African American communities are deeply affected by what happens to men through incarceration, drug-related activities and behaviors (e.g., unprotected same-sex activities) that increase HIV risks.

Incarceration Induced Risks

McClelland et al., (2002) conducted a study on HIV and AIDS risk behaviors amongst female jail detainees where they examined the sexual and injection drug use and HIV/AIDS risk behaviors of female jail detainees by private interviews. Their sample included 948 White, Hispanic and African American women ages 17-67. This study concluded that many women who used drugs, traded sex for money or drugs, were homeless and or had a mental disorder were at risk for HIV/AIDS. Although the prevalence of HIV infection among men in the general population has stabilized, HIV infection rates are higher in correctional populations than in general populations among both men and women (Glaser & Greifinger 1993). This research suggests that HIV/AIDS education in jail must become public health priority. Jail is a promising site for interventions in the struggle against HIV and AIDS because the number of women jailed is increasing and most detainees return to the community in a few days (Census 1990).

Incarceration shapes the sexual citizenship of Black men in particular ways. According to the National Urban League’s State of Black America (2005), Black men make up only 6 percent of the total U.S. population, but represent 44 percent of inmates in the nation’s state and federal prisons (comprising 819,000 inmates). Rape,

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including same-sex rape, is a widespread problem in prisons. A 2000 study of prisoners in four Midwestern states found that approximately one in five male inmates reported pressured or forced sex while incarcerated. About one in ten male inmates reported that they had been raped (Struckman-Johnson & Struckman-Johnson 2000 and 2002). As cited in the article Male Prison Rape: A search for Causation and Prevention, Scacco (1982) argues the most serious cost of prison rape to society is that it takes non-violent offenders and turns them into people with a high potential for violence, full of rage and eager to take vengeance on the society which they hold responsible for their utter humiliation and loss of manhood.

In a 1999 literature review on male prison rape, Knowles offered insight as to why prison rape occurs.

Within the study, Scacco (1982) noted a disproportionate number of Black aggressors and white victims in studies of sexual assaults in jail and in prisons. Even if the minority of prisoners are Black, the

majority of victims are white. Rape in prison is rarely a sexual act, but one of violence, politics, acting out power roles, and revenge. Drawing upon psychoanalytic theory, William Pinar offers one explanation for the male rape culture amongst African American men in prison: “straight Black men could have figured out many kinds of revenge, could they not: physically maiming for one, murder for another. But somehow Black men knew exactly what form of revenge must be once they were on ‘top’ the same form ‘race relations’ have taken (and

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continues to take) in the United States. ‘Race’ has been about getting fucked, castrated, made into somebody’s ‘punk’ politically,

economically, and yes, sexually.

The act of rape in the ultra-masculine world of prison constitutes the ultimate humiliation visited upon a male by forcing him to assume the role of a woman (Rideau & Wikberg 1992). Men who are raped often describe symptoms that are remarkably similar to those of female rape victims, namely, a form of posttraumatic stress disorder described as rape trauma syndrome. Men express expressed

depression, anxiety, and despair, with some attempting suicide. Another devastating consequence is the transmission of HIV. However, because male rape victims are men, they still have access to masculinity and male power, if they decide to claim it. As one Texas prisoner described his experience in the rape culture: “It’s fixed where if you’re raped, the only way you can escape being a punk is if you rape someone else” (Collins 2005 p.238). Amongst those African American men who are

incarcerated, those who fit the profile of those most vulnerable to abuse run the risk of becoming rape victims. In the context of violence regulated by a male rape culture, achieving Black manhood requires not fitting the profile and not assuming the

position. In a sense, surviving in this male rape culture and avoiding victimization require at most becoming a predator and victimizing others and, at the least, becoming a silent witness to the sexual violence inflicted upon other men (Collins 2005). When some of the Black aggressors were questioned as to the reasons for making whites submit to sexual acts, their answers were usually “now it’s their turn”;

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a statement leading one to believe that there are definite socio-racial overtones to the act of sexual victimization. Scacco (1975) argues that Blacks appear to be taking out their frustrations and feelings of exploitation on other inmates in the form of sexual attacks and domination, as the oppressive characteristics of race relations in the society as a whole penetrate the relationships between Whites and Blacks inside prisons.

Carroll (1997) notes despite the interracial character of prison rape, it is obvious that the pattern is not explainable solely in the terms of conditions immediately associated with imprisonment. Many rapists in prison may not be

homosexual at all, but heterosexuals raping for power and revenge (Scacco, 1975). In American prisons, studies by sociologists suggest that more than 90% of rapes are inter-racial and may be motivated more by a need for sexual dominance over another race than by sexual passion. Many rapes are by Blacks on Whites, suggesting that it gives the lower-class Black, who has felt trod upon all his life, his one chance to dominate a white person (Starchild, 1990). Social policies of domination that result in uneducated, or underemployed, and imprisoned Blacks probably contribute to

HIV/AIDS more than failed preventions. Conditions of unemployment and

imprisonment affect patterns of dating, marriage and family in Black communities (Massey & Shibuya, 1995; Moen, 1983; Sanders, 1985).

Risky Behaviors and African American Women

Black men are in short supply due to incarceration in prison and this factor reduces the eligible pool, which means that there are more women who desire

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partners at an age when fewer exist (McAdoo,1997). The most predictive behaviors of HIV seroconversion are casual sex as evidence by multiple partners, sex with virtual strangers, or sex with nonsteady partners. Certain dating scenarios parallel Black HIV risk patterns such as risky behaviors among some poor inner-city youth that can undermine family formation as well as increase the likelihood of HIV transmission (Anderson, 1989). In 2004, Prather published a literature review regarding African American Women and AIDS that revealed the sex-ratio amongst African American men and women as one of the social factors that contributes to the African American women representing the fastest growing group of individuals infected with HIV/AIDS in the United States.

The sex-ratio imbalance in the African American community can give rise to women’s difficulty in discussing and negotiating condom use with male sexual

partners (Logan et al., 2002). The imbalance in the number of women and men results in fewer available partners; therefore, women have less interpersonal power in

relationship because men have more options available to them (Adimora et al., 2001; Albrecht, Fosset, Cready, & Kiecolt, 1997; Aral & Wasserheit, 1995; Logan et al., 2002). Lower levels of interpersonal power can interfere with women’s ability to initiate discussions about condom use, due to concerns that the topic can lead to conflict and threaten the future of the relationship (Logan et al., 2002). Because African American women are least likely to date men from other racial/ethnic groups (Staples, 1981), it is probable that the majority of heterosexual African American women have sexual contact with African American men. Thus, this social factor,

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along with high levels of risk behaviors in men (CDC, 2003b; Wohl et al., 2002), sets the stage for African American women’s high rates of exposure through heterosexual contact. In fact, several studies have demonstrated the powerful influence of partner’ risk behavior on women’s HIV risk, sometimes exerting an even greater influence on HIV transmission than women’s own behavior (Dolcini & Catania, 2000; Ickovics &Rodin, 1992; Kalichman, Rompa, Luke, & Austin, 2002).

Black men who have sex with men (MSM) and have sex with women but do not identify as gay or disclose their bisexual activities to main female partners, also known as men “on the down-low”, have been cited as the main reason for the increase in HIV infections in Black women (Millet et al., 2005). In an extensive review of three data bases available on line, Millet found 24 articles related to men “on the down-low” which revealed that Black MSM, are more likely to be bisexually active or identified and are less likely to disclose their bisexual or homosexual activities to others. Unfortunately, some of the limitations mentioned by Millet et al., (2005) were that the data from the studies used in this review provided limited insight into a population for which there is no scientific data and the population-based statistics of bisexuality among black men were only generalizable to metropolitan areas with high HIV prevalence. Nevertheless, this review concluded that the prevalence of HIV in the Black community and the greater likelihood of bisexuality among Black men placed heterosexual Black women at risk for HIV infection. It also stated that the role of bisexual active Black men in HIV transmission is a more complex issue than depictions of Black men on the down-low as sexual predators and Black women as

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uninformed victims. Millet et al., 2005 suggests that future HIV research and programmatic activities must reflect this level of complexity by focusing on the sexual behaviors and sociocultural processes that facilitate HIV transmission between Black men and women.

The direct relationship between poverty and Black incarceration rates also means stigma management, particularly amongst black males who have engaged in situational homosexuality while incarcerated but attempt to mask this past and establish regular heterosexual relationships upon release (Amankwaa, Bavon & Amankwaa, 2001; Majors & Billson 1992). Similarly, masking is likely to occur when males strive to avoid the stigma of the gigolo, injectional drug use (IDU), or prostitution labels but are engaging in such activities nevertheless. These are a few scenarios likely to increase sexual risk-taking and thereby potentially increase the total number of HIV infections in Black communities. In an article on conflict Transformation, Stigma, and HIV-preventive Structural Change, Miller et al.,(2012) stated that even the most comprehensive and society-wide HIV/AIDS education and risk-reduction campaign is not going to eliminate all risk behavior. Parallel efforts must be stepped up to combat the poverty, racism, sexism, and homophobia that contribute to the behaviors.

The relationship between HIV, poverty and geography has been extensively documented (Auerbach, 2009). The article Precious, Black Women, Neighborhood HIV/AIDS Risk and Institutional Buffers by Watkins-Hayes et al., (2011) stated that, given the social complexity of the AIDS epidemic in poor Black urban communities,

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scholars and policymakers must consider neighborhood context to address high infection rates by acknowledging the institutional resources and deficits of the areas. Institutions serve as buffers against (or facilitators of) such macrostructural forces as poverty, racism, sexism and homophobia that effect HIV transmission. Neighborhood institutional resource theory suggests that community organizations are key sights in translating individual attitudes, strategies, and behaviors into neighborhood-level resources and opportunities through organizational networks specialized knowledge, and ability to bundle resources (Jencks & Mayer, 1990; Small, 2009). AIDS service and advocacy organizations as well as medical providers offering HIV/AIDS prevention and treatment services, are the most engaged and effective institutions operating in communities. Less conventional settings such as churches, salons and barbershops, and, in some cases, prisons, have also been constructively deployed in HIV prevention and treatment efforts (Grinstead et al., 2001; Linnan & Ferguson, 2007; Watkins-Hayes et al., 2011).

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18 CHAPTER III METHODOLOGY

Overview

HIV/AIDS is a worldwide epidemic that has acquired a great deal of attention and resources. However, in the United States, African Americans represent alarming numbers of those affected by HIV/AIDS. Some of the same variables that contribute to the continuous spread of this epidemic overseas are the same here in the United States. Poverty, poor access to health care, and lack of education are all factors that play into the spread of this disease. Although people are able to live with this illness, limited access to resources can reduce the chances of a prolonged life (ADVERT, 2011).

This study looks into the knowledge, attitudes, and beliefs that African Americans in the Central Valley of California have regarding the issues of HIV/AIDS. The major research questions of this study are: (a) what do African Americans know and believe are the factors that contribute to the HIV/AIDS epidemic? and (b) what is the attitude of African Americans toward a community-based culturally specific sex education program?

Research Design

This study utilized a quantitative design in order to reflect how African Americans in the Central Valley feel about HIV/AIDS prevention, sex education, and the implementation of a culturally specific program of this nature. Participants were asked questions regarding the different aspects associated with the risks of HIV/AIDS.

This study employed a quantitative research design to collect samples from African American community members in the Central Valley of California, specifically Fresno County, Kern County, Kings County, Madera County, Sacramento County, San Joaquin

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County, Stanislaus County and Tulare County. A descriptive, cross-sectional survey was utilized in order to effectively measure the knowledge, attitudes, and beliefs of a larger population that otherwise is too complex to observe all together (Rubin & Babbie, 2005). The survey includes forty-two questions that consist of demographic questions, multiple choice, rating scales, and matrix choices. The content of the survey questions were guided by literature about the topic of HIV/AIDS specific to African Americans and questions utilized in the study: Knowledge Attitudes and Beliefs in the Central Valley Regarding the Human

Immunodeficiency Virus (HIV) and HIV Testing (Babikova, 2011).

The data for this study was collected by means of hard and digital copies of the surveys via Qualtrics, for the convenience of time and availability of the participants and, researcher. The reason a quantitative design was chosen is because it allows the feasibility of the purpose of this study to be tested. If the populace feels that there is no need for and HIV/AIDS prevention education program, then there will likely be no demand for it in that particular geographic area.

Sampling Plan

The participants of this study had to be at least 18 years old or older, African American and reside in the Central Valley of California specified as; Fresno County, Kern County, Kings County, Madera County, Sacramento County, San Joaquin County, Stanislaus County and Tulare County . This study used non-probability and snowballing sampling. Purposive sampling would have been suitable since the researcher selected a sample on the basis of their knowledge of the population, its elements, and the nature of the research aims (Rubin & Babbie, 2011). Although this would have ensured the data collected from a specific population, a weakness of this type of sampling is the possibility of social desirability bias. If participants are attempting to answer the questions in a way that does not reflect the truth, this

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would have caused a systematic error which could have skew the accuracy of the data. There were various risks when comparing availability and quota, and although all of them had unique ways of collecting data, the risks with purposive sampling had fewer when considering the approach that was used to reach this population.

To target the desired population the researcher gathered contact information from The Black Chambers of Commerce of the cities within the Central Valley. The focal point for recruitment of participants were Black owned businesses, community-based organizations within the Black community such as The NAACP, Black Greek letter fraternities and

sororities such as Delta Sigma theta Sorority incorporated whom allowed me to set up a table at the Nikki Giovani event on campus this past March where I collected a lump sum of my data will also be focal points for recruiting participants.

Data Collection

The researcher personally made contact with Black owned business, community based organization, and churches by email, phone or in person to request permission to recruit participants from their customers, members or constituents for the researchers study. After given consent, the researcher then designated a date and time to be present to distribute and collect the survey. Participants had the option to take the survey in person or sign up with only their email address to receive a link to the survey. The e-mail contained information about the researcher, the informed consent form, and the embedded survey link which directed them to the Qualtrics website where the participants anonymously complete the survey in ten to fifteen minutes.

For those who chose to take the survey in person, they had the opportunity to win various prizes like free haircuts, ten to twenty dollars off beauty supply items and gift cards through a raffle. Participants were given a packet that included the informed consent which

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they signed and return to the researcher, the survey and a raffle ticket. The participants had to write down their name and phone number in order for to be contacted if they won and weren’t present at the time of the drawing. The participants were made aware that the study is set up so that the researcher had no way of linking the data to specific participants. The researcher continued this process of collecting data for one month. The researcher also continue to send out participation requests (letters and posters) via email and Facebook on a weekly basis up until the last week of data collection.

Instrumentation

The tool utilized in this study was a forty-two question survey that consists of multiple choice questions, matrix of choice questions, rating scales and multiple text box questions. Out of the forty-two questions three addressed medical history. Twelve asked questions to gain insight to about the participant’s knowledge about HIV/AIDS. Twelve addressed the attitudes of the participants regarding HIV/AIDS policy, prevention practices, and contributing factors to the spread of the disease; seven explored the participants’ beliefs about knowing their HIV status and if knowing their status can have an effect on their community; and the final eight questions coved demographic information.

The questions in the survey (see Appendix B) were arranged to access the knowledge, attitudes, and beliefs of African Americans regarding the need/demand for a culturally specific sex education program consisting of African American facilitators and African American health practitioners. Accuracy of the instrument was ensured by using content validity which is the degree to which a measure covers the range of meanings included within the concept (Rubin & Babbie, 2011). It is necessary to establish the operational definition of sex education, facilitators, and practitioners. This study used an approach referred to by Crepaz (2009), to define sex education and how it would be

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implemented using gender-or-culture specific materials, addressing empowerment issues, providing skilled training in condom use and negotiation of safer sex, and role-playing to practice applying skills learned. The term “facilitator” was defined as a person who is

responsible for leading a group in dialogue or coordinating the work of a group or discussion. The instrument used was necessary to provide a general idea of how African

Americans in the Central Valley feel about the risks of HIV/AIDS and if they believe there is a need for a culturally specific sex education program for their community. This information is essential in determining the steps are needed to proceed with an approach to challenge and change the status of the HIV/AIDS epidemic among African Americans.

Data Analysis

Data was collected and analyzed in two ways. First the data was sorted and analyzed within the Qualtrics website to provide any significant findings and demographic frequencies. Finally, the data was transferred to the Statistical Package for the Social Sciences (SPSS) computer program where it was coded into a data base and thoroughly analyzed. The researcher used univariate statistical tests to examine and summarize the collected data. Descriptive statistics were used to analyze the results and determine any relationships

between variables. The results of the data were presented via frequency tables and graphs that summarize the participant’s knowledge, attitudes, and beliefs concerning HIV/AIDS.

Protection of Participants

Participation in this study were recruited on a voluntary basis. Those who chose to participate were informed of their rights and responsibilities when given the consent form. The participant did not encounter any harm as a result of their participation in this study. To avoid inappropriate disclosure of data, an anonymous survey took take place online with Qualtrics ensuring participants’ confidentiality. The data was stored in a password-secured

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website and the SPSS database information is located in a virtual computer system managed by California State University Stanislaus, both electronic sources were accessible only to the researcher by a login ID and password. Although there was no way to track individual

participants to the data collected, the information will stay secured on file for six months after the completion of the study. The email addresses collected (see Appendix A) were be

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24 CHAPTER IV

RESULTS

This chapter exhibits the results of a survey using univariate analyses to gain insight to the knowledge, attitudes, and beliefs that African Americans in the Central Valley have regarding HIV/AIDS. Both electronic and hard copies of the survey were administered and yielded a total of 59 participants. Of the counties defined as the Central Valley in this study, only Fresno County, Kern County, Merced County, Sacramento County, San Joaquin County and Stanislaus County yielded participants, 53% of them resided in Stanislaus County.

Participants’ ages ranged from 18-71+ years old, with 50% being age 31-40 or

younger. The majority (79%) practiced some form of Christianity. A large percentage of the participants were heterosexual (98%) with the exception of one whom

identified as polysexual, defined as being attracted to multiple genders or sexes. Over half of the participants were female (64%). Males represented only 36% of the sample.

Knowledge

There were 12 questions that asked participants to rate their knowledge about HIV/AIDS (see Table 1). Five percent of the participants felt that they had “no knowledge of the topic”, and another 5% believed that they had “poor knowledge of the topic”. However, the majority of participants (61%) rated themselves as “knowing the topic fairly well.” Thirty percent of the participants were confident that they

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“knew the topic very well.” When asked about gender and culture specific sex education that addresses empowerment issues and negotiation of safer sex, 90% of participants felt that they had “sufficient knowledge and skill of these practices”, whereas only 10% of participants felt that they did not.

Table 1 Knowledge

Item Response Percentage

Rate your knowledge about HIV/AIDS

Do you feel you have sufficient knowledge about sex education

No knowledge of the topic Poor knowledge of the topic

Know topic fairly Know topic very well

Yes No 5.0 5.0 61.0 30.0 90.0 10.0

The results of this study revealed that African Americans in the Central Valley appear to be knowledgeable about HIV/AIDS. Out of five of the primary knowledge question features in table 2, two generated correct answers that fell below 90%. For example, the question regarding whether it is possible to get infected with HIV

through oral sex, 85% of participants considered that to be true. The same case for the question inquiring if a person can get prescription medication to cure HIV, 12% of participants believed that a person could. Further findings regarding participant knowledge are highlighted in Table 2.

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Table 2 Knowledge

Item Response Percentage

It is possible to get infected with HIV through oral sex?

A person can get prescription medication to cure HIV.

HIV goes away on its own after a while, as long as you have a good immune system.

Taking showers or douching before unprotected sex with an HIV infected person will lower the chances to get infected with HIV.

People infected with HIV might not show any symptoms or signs for a few years after infection.

True False True False True False True False True False 85.0 15.0 12.0 88.0 5.0 95.0 5.0 95.0 92.0 8.0 Attitudes

In addition to examining the knowledge of the participants, this study also looked into the attitudes they had regarding HIV/AIDS. Overall, 98% of participants believed that incarcerated African American males were at risk of becoming infected with HIV. Although an overwhelming majority of participants acknowledged that incarcerated African American males are at risk of becoming infected with HIV, 16% of them, all except one (a male), did not believe inmates should be tested upon their release from prison.

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Table 3 Attitudes

Item Response Percentage

Do you think incarcerated African American males are at risk for HIV/AIDS?

HIV African American males should be tested for HIV/AIDS upon their release from prison.

Yes No Strongly Disagree Disagree Neutral Agree Strongly Agree 98.0 2.0 13.0 3.0 14.0 24.0 46.0

The views of HIV not being seen as a homosexual disease was emphasized by 88% of participants disagreeing. The two percent of participants who “agreed” that HIV was a homosexual disease were all male. The view that HIV/AIDS was an important topic within the participant’s community was apparent by their agreement of 85%.

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Table 4 Attitudes

Item Response Percentage

HIV/AIDS is a homosexual disease. HIV/AIDS is an important topic in my community. Strongly Disagree Disagree Neutral Agree Strongly Agree Strongly Disagree Disagree Neutral Agree Strongly Agree 72.0 16.0 9.0 3.0 0.0 8.0 2.0 5.0 29.0 56.0

When it comes to the attitudes that African Americans in the Central Valley had regarding a culturally specific HIV/AIDS prevention and sex education program, results show that a majority of participants (83%) would support a program of this nature. Table 5 shows more detail.

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Table 5 Attitudes

Item Response Percentage

If there was a cultural specific sex education prevention program for Blacks/African Americans, I would....

Not associate with it Not support it Not agree with it Not participate in it Refer someone to it Support it Volunteer for it Participate in it 2.0 3.0 2.0 3.0 46.0 83.0 41.0 39.0 Beliefs

In addition to examining the knowledge and attitudes that participants had concerning HIV/AIDS, this study explored specifically what the participants believed to be the reasons behind African American women representing 65% of new HIV infection cases and why African American men infected with HIV are dying at almost two times the rate of African American women. For the women, the most frequently selected factors that participants believed were the causes for the current HIV status of African American women were drugs (63%) and lack of sex education (80%). The following participant qualitative responses (18%) speak to a suggested need for sex education and empowerment for African American women: “lies, partner has it and did not tell, low self-esteem, using sex as validation for their beauty, sleeping with partners that do not disclose that they have HIV, culture, women not asking men to wear a condom, pride, down low brothas, believing it can’t happen to you, and scared of knowing”. When comparing the factor percentages between the women and men,

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participants showed lack of sex education to be more of a significant factor for women than men.

Table 6 Beliefs

For the men, participants selected higher percentages within the drugs, poverty, stigma, and limited access to health care as the major contributing factors as to why African American males infected with HIV are dying at two times the rate of African American women. The following qualitative responses pertaining to men (18%): “lies, they are having sex with infected partners (men & women), sex with men on the down low, not getting treated, pride, not getting checked, and incarceration”,

highlights the concerns and attitudes of the participants regarding risky behaviors and confinement of African American men an obvious issue.

Item Response Percentage

Which of the following do you believe are reasons why African American Women account for 65% of new HIV infection cases in the nation?

Drugs Poverty

Lack of sex education Stigma

Limited access to health care Other 63.0 47.0 80.0 27.0 48.0 18.0

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Table 7 Beliefs

Item Response Percentage

Which of the following do you believe are reasons why African American males with HIV are dying at rated almost two times higher than infected African American females?

Drugs Poverty Lack of sex education

Stigma

Limited access to health care Other 73.0 55.0 68.0 38.0 67.0 18.0

This study also wanted to look into the views that participants had regarding HIV testing. Participants reflected strong feelings around the belief that if individuals are healthy, they do not need an HIV/AIDS test. Ninety-two percent of participants believed that having good health should not preclude anyone from being tested. The participants’ beliefs towards people knowing their HIV status was highlighted when 90% of them agreed that everyone should be aware of their own HIV status.

Table 8 Beliefs

Item Response Percentage

I believe everyone needs to know their HIV status.

I believe if individuals are healthy they don’t need an HIV/AIDS test. Strongly Disagree Disagree Neutral Agree Strongly Agree Strongly Disagree Disagree Neutral Agree Strongly Agree 5.0 0.0 5.0 22.0 68.0 58.0 34.0 6.0 2.0 0.0

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Consequently, a slightly lower percentage of participants (87%) felt that was

important for them to know the HIV status of their partners, and 77% of participants believe that HIV/AIDS testing is not for them if they practice safe sex.

Table 9 Beliefs

In general, this study revealed that African Americans in the Central Valley are knowledgeable when it comes to the basic information concerning

HIV/AIDS. They also have supportive attitudes towards a cultural specific HIV/AIDS prevention and sex education program for African Americans. The participants

identified the same factors that take precedence over the issues that African

Americans face on a daily basis as the same factors that puts them at risk of becoming infected with HIV/AIDS. Though most participants believed that African American males should be tested upon their release from prison, 16% of participants disagreed.

Item Response Percentage

I feel it’s important for me to know the HIV status of my partner.

I believe if I practice safe sex, HIV/AIDS testing is not for me.

Strongly Disagree Disagree Neutral Agree Strongly Agree Strongly Disagree Disagree Neutral Agree Strongly Agree 10.0 0.0 3.0 12.0 75.0 37.0 40.0 9.0 9.0 5.0

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There is a slight contradiction with attitudes about testing prisoners upon release. Participant seem to be well aware of the risks that take place behind prison walls but display hesitation with the idea of recidivists knowing if their health has been

compromised or not. There is also slight inconsistencies with participant’s beliefs on people being aware of their HIV status and knowing the HIV status of their partners. In general 90% of participants believed that everyone should know their HIV status where a slightly lower percentage of participants (87%) felt that it was important for them to know the HIV status of their partner.

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34 CHAPTER V DISCUSSION

This chapter offers an overview of the three principal findings from this study regarding the knowledge, attitudes, and beliefs that African Americans in the Central Valley have concerning HIV/AIDS. These findings are linked to prior research to highlight parallels, differences, and to elaborate on how these findings reflect the wants and needs of the African American population in the Central Valley. Limitations of the study will be discussed as well as implications for the field of social work, future research suggestions, and recommended social work action.

Major Findings

The first of the three major findings of this study coincided with some of the same barriers that many African Americans face on a daily basis – challenges with drugs, poverty, lack of sex education, and limited access to health care. These are the same factors that African Americans in the Central Valley believe, puts African Americans at risk of becoming infected with HIV/AIDS. The explanations offered by the participants for the reasons African American men contract HIV/AIDS illustrate the possibility of the continued mistrust that many African Americans have toward health care providers. This ambivalence of African Americans towards seeking medical care is consistent with the literature, especially when the Tuskegee Syphilis study is considered. This study also revealed that a majority of the participants believed that incarcerated African American males were at risk of HIV/AIDS

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infection, and a smaller percentage agreed that African American males should be tested upon their release from prison. It appears African Americans are fearful of sharing their HIV/AIDS status (if known), and afraid to inquire about a sexual partner’s status. This quandary can lead to deadly consequences.

The second major finding revealed that African Americans in the Central Valley appeared to be knowledgeable on the topic of HIV/AIDS and preventative practices. There was a small percentage of the participants who were misinformed about facts and myths associated with HIV/AIDS.. Based on literature provided by the Centers for Disease Control & Prevention, the Surgeon General, and others federally-funded sources, it seemed as though some of the African American respondents in this study were reliant on inaccurate or unfounded information. Unfortunately, some put their trust in non-reputable resources and make assumptions based off content that is not factual. In light of Magic Johnson’s miraculous medical status since his public HIV announcement in 1991, and the current news on March 3, 2013, regarding an infant deemed cured of HIV, it is easy to see how one could believe that there is in fact a cure for HIV. Misconceptions like those mentioned reflects a need for a trusted relatable resource that not only provides current information about HIV/AIDS, but also an open dialogue about in depth issues surrounding this epidemic and possible preventions/solutions to the problem.

The third major finding was that an overwhelming majority of the participants of this study would support a culturally specific HIV/AIDS prevention and sex educations program for African Americans. This finding is significant to HIV/AIDS

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preventative approaches since studies have shown cultural-specific program approaches to be effective, especially when dealing with such a sensitive and controversial topic. Even though prevention is the ultimate goal of most HIV/AIDS programs, addressing the needs of those who are living with this disease is just as important. Something that became shamefully apparent within the process of this study was the lack of local resources for those living with HIV/AIDS. Case

management services, referrals and transfers are sometimes not available and prolong the process of receiving treatment. According to Dr. Tony Sillemon of the Summit Alta Bates East Bay AIDS Center in Oakland California, twenty percent of their patients come from the Central Valley. Traveling over one-hundred miles for services needed on a frequent basis can be inconvenient and out of reach for some, which discloses a degree of neglect to the HIV/AIDS infected population. There is a wide void in the Central Valley when it comes to sufficient HIV/AIDS resources which is a public threat and should be of public concern.

Limitations

Before assessing the implications of this study, a reflection of its limitations must be acknowledged. In total, this study had four limitations: absence of local studies on the topic of HIV/AIDS, the instrument, recruitment device, and lack of demographic diversity amongst participants. In terms of studies and existing literature on the topic of HIV/AIDS specific to the African American population, most were from southern states like Mississippi and Georgia. Research conducted in California, primarily concentrated on African American communities in Southern California and

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in the San Francisco Bay Area. Secondly, the length of the survey itself (42

questions) may have caused limitations to the study as some of the participants did not finish it or skipped questions. Also, the digital form of the survey oftentimes did not register the selected option when clicked the first time which caused variations in questions answered. Additionally, the sign-up sheet left in various business locations used to collect email addresses from the participants was shown to be problematic because some of the written information was illegible. Furthermore, the

demographics concerning the participants’ religion and sexual orientation was limited to mostly Christians and heterosexuals. This study regrettably did not make additional efforts to recruit participants specifically from the Lesbian Gay Bisexual Transgender and Queer (LGBTQ) community and unfortunately does not reflect the knowledge, attitudes, and beliefs of persons with numerous other sexual orientations.

Implications for Practice & Policy

The very same factors that the participants of this study believed to be the reasons why African Americans are so largely affected by the HIV/AIDS epidemic, are all reoccurring daily issues that correlate HIV/AIDS to the field of social work. Inevitable interaction between social workers and the African American population occurs frequently. The patterns of disproportionality are local and national issues that need direct attention. Research about these occurrences must be implemented and examined by social workers, law enforcement, and elected officials as well as addressed in conjunction with community members. According to the National Association of Social Work, the ethical responsibilities that social workers have to the broader society are to promote the general welfare of society, from local to global levels, and the development of people, their communities and their

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environment. Research has shown that poverty, discrimination, racism, and stigma are all circumstances that influence risky behaviors that constitute the spread of this disease. According to Miller (2012) in order to reduce the impact of this disease [HIV/AIDS], simultaneously efforts have to be put into place.

Raising awareness about legislation that has a direct effects on HIV/AIDS policies are all initial steps towards fighting the spread of this disease. Continued public education about the Affordable Care Act of 2010 is needed in impoverished areas so people are aware of the services that are available to them. Prior to this new law, those with pre-existing conditions like HIV/AIDS, were denied health care insurance. After 2014 insurance companies will not be allowed to deny coverage to anyone regardless of a health conditions or income (DHHS, 2013). The current California Senate Bill SB249 introduced by Senator Mark Leno in February of 2013, is another piece of legislation that will have a direct impact on the services provided to the HIV/AIDS community it. This bill would allow the sharing of HIV information between authorized qualified entities to share health records with the Department of Public Health (DPH) for the purpose of enrollment without disruption in Medi-Cal, the bridge programs, Medicaid expansion programs, and any insurance plan certified by Covered California, as well as extend the protections that now apply to only blood test to all types of HIV tests (Leno, 2013).

Existing federal laws under the Health Insurance Portability and

Accountability Act (HIPAA), specifies privacy protections for patients’ protection of health information, except as specified or as authorized by the patient in writing. The

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prohibitions on disclosure of HIV information has become not only somewhat

redundant because of other privacy laws that protect all medical information, but also is an impediment to HIV positive patients in transition to new health coverage

systems. These restrictions cause serious problems not only for patients trying to access health care, but also providers trying to coordinate such care (Leno, 2013). Attentiveness to legislation that has a major impact on health care and policy can be used to mobilize the African American community in the fight against the spread of HIV/AIDS. Engagement in the process of making change and implementing

programs is in the African American community are all things that should involve them.

Implications for Future Research

There is a definite need for continued HIV/AIDS research in the Central Valley, specifically for the African American population. Future studies would have a significant advantage if the methodology were to implement Participatory Action Research (PAR) which would give the African American community the opportunity to act effectively in their own interest. Additionally, the use of qualitative research on the knowledge, attitudes, and beliefs that African Americans have concerning HIV/AIDS could reveal more insight on this issue. Exploration about the effects of incarceration and its impact on heterosexual relationships and risky sexual behaviors in the African American community should be included in future research as well. Efforts to recruit participants from the LGBTQ community would be of great benefit in subsequent studies and could potentially assist in eliminating stigma

associated with HIV/AIDS. Furthermore through PAR and qualitative research, a community forum could be developed to further assess unique wants and needs. Finally, per the results

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of this study, it seems necessary to have an empowering element along with the sex education portion of an HIV/AIDS prevention program. The issues of self-esteem, unacknowledged self-worth, combined with unsafe sexual practices amongst African American women is something that future research should focus on. Such research might reveal effective methods in intervention strategies with HIV/AIDS prevention.

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