One of the most fearsome problems in addressing the AIDS epidemic in Philadelphia is the infection of the African American community. Blacks represent 55% of the17, 932 AIDS cases in Philadelphia.[i] Yet, this is the demographic that may be the most difficult to reach. A recent study done by Bogart et al. confirmed that African Americans continue to hold conspiracy theories regarding the government since the infamous Tuskegee Syphilis Experiment.[ii] The authors conclude that, “conspiracy beliefs may be a barrier to HIV prevention efforts, particularly for black men.”[iii] It is also difficult to know where to attack the HIV epidemic among the Black population. Should prevention methods reach out to the growing number of at-risk Black women? Or should prevention focus more closely on informing Black men of the consequences of risky behavior? Essentially, HIV prevention policy for African Americans must be culturally sensitive and address the most vital issues.

            The answer to alleviating the HIV burden for the Black community seems to be in confronting the source of the problem. One phenomenon contributing to the increase in HIV infections in Blacks is men on the “Down Low.” According to the CDC, The term is often used to describe the behavior of men “who have sex with other men as well as women and who do not identify as gay or bisexual”[iv]  In their article, Wolitski et al. state that “D-L identified MSM in this study were at greater risk than non-DL MSM for acquiring HIV from, or transmitting it to, female partners”[v] Thus, men who are on the “down low” put themselves and their female partners at risk. Another startling finding of this study states that “One-in-four (28%) DL-identified MSM had unprotected vaginal sex during this [30 day] period.”[vi] This suggests that men who have sex with men on the down low do not feel that they are doing anything wrong. A study done by Darrel Wheeler confirms this misconception stating, “Using condoms with primary partners, especially a female partner, was seen as unnecessary or at least suggestive of being unclean or involved with others sexually.”[vii] Both studies found that men on the down low are reluctant to define their sexual relations as “gay” and are less willing to tell their female partners about them. This has disastrous implication for HIV prevention, because it indicates that prevention methods must overcome socially difficult problems.  
             

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              So it seems that reaching the portion of the Black community on the “down low” will be the most effective way of keeping the AIDS epidemic at bay. The goal, according to Wolitski, is to “encourage these men to take action to reduce the risk that their behavior poses to themselves and their female partners.”[viii] Now, what are the best ways to mobilize this target group? This is a tricky question to answer due to the documented suspicion that Blacks have toward the medical community. Bogart et al. found that 53.4% of 500 Black participants believed that a cure for AIDS is being withheld from the poor.[ix] Yet, even within this study there is a glimmer of hope. 26.6% of the participants believed that “AIDS was produced in a government laboratory” but only 1.6% believed that “Doctors put HIV into condoms,” suggesting that Blacks have a higher level of trust in their primary care doctors. In fact, the CDC recommends that primary care should include “a brief sexual risk behavior checklist that can be administered by a clinician”[x]. However, this solution has an unfortunate problem. The poorest of the Black community, those that need the help the most, are not likely to have a primary care doctor at all. Therefore, it is necessary that health clinics and hospitals across the city administer a routine HIV-risk evaluation on all patients. If a patient appears to be at risk, it would then be the responsibility of the physician to offer risk reduction methods and educate the patient on the dangers of his behavior. The CDC recommends “three major components: screening for HIV transmission risk behaviors and STDs, providing brief behavioral risk-reduction interventions in the office setting and referring selected patients for additional prevention interventions and other related services.”[xi] Using all three methods would be the most effective approach of using a clinical setting to promote HIV risk-reduction. To make this program as effective as possible, it would be crucial that the physician is able to communicate with the patient in an honest and trustworthy way. Wheeler found that Black men had “fear of expressing themselves to people with different understandings of the situation.”[xii] Therefore, doctors at inner-city clinics and hospitals ought to participate in a workshop, run by the AACO, which familiarize them with different cultural and social ways of life. It is important that medical staffs have little stigma or prejudice that may interfere with treating their patients, so that their message of prevention is accessible to everyone.

            Additionally, establishing and standardizing this program throughout hospitals and clinics in Philadelphia would ensure that not only men on the “down low” are getting attention. This system would benefit women who are infected or at risk of being infected, and more specifically it would address an increasing immigrant population. In E.E. Foley’s article, Foley studies the stigma that is attached to African immigrants living with HIV in Philadelphia. Foley states, “It seems possible that with culturally sensitive HIV/AIDS education and outreach programmes African immigrant communities could develop a compassionate response to people living with AIDS.”[xiii] Coaching medical care workers on sympathizing with a patient’s cultural background would increase the likelihood of effecting a change in the risk-taking behaviors of all possible patients. Ideally, this program will be extremely cost-effective because AACO already funds HIV testing and condom distribution in hospitals across the city. Instead, the thorough assessment of patients in emergency rooms and clinics would enhance existing outreach initiatives.