MSM transmission

            MSM is the most prevalent mode of transmission in New Hampshire, accounting for 48% of cumulative AIDS cases. The correlation coefficient between cumulative AIDS cases and average driving distance to the nearest gay bar is -0.894. Combined, this information suggests that there is an unmet need for prevention services among this population. While MSM-acquired AIDS cases declined from 1995-2000, the decline was the largest among white men and the smallest among black men (24). This maybe partially accounted for by the emergence of men identifying as being on the "down low". Men on the down low are characterized as being black, closeted about their sexuality, having sex with both men and women, and never or inconsistently using condoms with sexual partners. In one study, men self identifying as being on the down low rarely informed their partners that they had engaged in sex with another male (25). Because not all men who have sex with men identify as gay, programs need to be developed that include HIV/STD testing, risk reduction, condom use, and health care referral services without specifically targeted gay identified men (26). 

            Prevention programs aimed at the MSM population need to promote disclosing their previous same sex encounters with female partners. This disclosure would likely increase condom use with female partners. Black men identifying as “down low” indicated that using condoms is seen as a sign of being "unclean" or a sign of having multiple sexual partners (27). This perception is directly related to the low levels of condom use in the down low population (28). Behavior change interventions in small group setting have been shown to be four times more effective in increasing condom use than didactic lectures (29).

            Programs targeting MSM in rural areas face challenges different from those in urban areas. Programs in urban areas generally rely on known gay bars or organizations for the recruitment of participants. These public venues typically don't exist in rural areas or are likely to be well hidden. The lack of a public venue for MSM to gather is linked to the need to be discreet and cover one's identity. Men indicated that they would feel uncomfortable participating in an HIV prevention program because they felt like they would be "outing" themselves. Also, there is considerable stigma in rural associated with being gay (18). Because anonymity is non existent and there are very limited forms of "gay media", health service announcements targeting the MSM population must be placed in mainstream media where most of their viewers are likely to be heterosexual (30). One viable method of accessing the rural MSM population is through the internet. Rural MSM are known to frequent gay-oriented sites on the internet to socialize and to meet sexual partners. Internet based programs and outreaches are advantageous in a rural area because they don't require program participants to gather in a public place or with other individuals who could be identified as gay.

            Topics of the program should include general issues relating to dating and sexuality as well as information about HIV/AIDS (30). This combination of programming allows for the introduction of condom negotiation strategies within the framework of a relationship, something not typically addressed in harm reduction programs.

            A randomized trial of an Internet HIV prevention program targeting rural MSM showed that participants significantly increased their knowledge about HIV/AIDS and held much more favorable opinions of safer sexual practices. Participants viewed an interactive module with graphics showing conversations between an HIV negative man and an HIV positive man. The conversations were geared to disseminate information of particular interest to MSM residing in rural areas that they would most likely not have access to. This program indicated that Internet based programming is a cost effective way to reach MSM populations in rural areas (31). This is a strategy that New Hampshire would benefit from.