For this assignment, provide a synopsis of the review of the research literature. Using the "Literature Evaluation Table," determine the level and strength of the evidence for each of the eight research articles you have selected. The articles should be c

ORIGINAL PAPER

The Health and Sociocultural Correlates of AIDS Genocidal Beliefs and Medical Mistrust Among African American MSM

Katherine G. Quinn1 • Jeffrey A. Kelly1 • Wayne J. DiFranceisco1 •

Sergey S. Tarima1,2 • Andrew E. Petroll1,3 • Chris Sanders4 • Janet S. St. Lawrence5 •

Yuri A. Amirkhanian1

Published online: 24 December 2016

� Springer Science+Business Media New York 2016

Abstract This study examined social and health-related

correlates of AIDS conspiracy theories among 464 African

American men who have sex with men (MSM). Exploratory

factor analysis revealed two subscales within the AIDS

conspiracy beliefs scale: medical mistrust and AIDS geno-

cidal beliefs. Multiple regression analyses revealed medical

mistrust and AIDS genocidal beliefs were both associated

negative condom use attitudes and higher levels of inter-

nalized homonegativity. Medical mistrust was also associ-

ated with lower knowledge of HIV risk reduction strategies.

Finally, we conducted bivariate regressions to examine the

subsample of participants who reported being HIV-positive

and currently taking HIV antiretroviral therapy (ART) to test

associations between sexual behavior and HIV treatment and

AIDS conspiracy theories. Among this subsample, medical

mistrust was associated with having a detectable viral load

and not disclosing HIV-status to all partners in the previous

3 months. Collectively, these findings have implications for

HIV prevention and treatment for African American MSM.

Keywords African American MSM � AIDS conspiracy theories � Medical mistrust � HIV risk

Introduction

Significant racial disparities persist along the HIV care

continuum and African Americans continue to be dispro-

portionately burdened by HIV. Although they represent

only 12% of the total US population, African Americans

account for nearly half of all new HIV infections [1]. If

incidence trends continue at the current rate, 1 in 16 Black

men will receive an HIV diagnosis at some point in their

lives [1]. African American men who have sex with men

(MSM) are particularly affected. Between 2005 and 2014,

HIV incidence increased 22% among African American

MSM [2] and, at the current rate, approximately half of

African American MSM will be diagnosed with HIV

infection during the course of their lives [3]. Despite

marked advances in prevention and treatment, African

Americans are less likely to receive HIV antiretroviral

medications [4], more likely to report poor adherence to

medication regimens [5–7], and are less likely to be

retained in care [8]. Additionally, mortality for persons

living with HIV is 13% higher among African Americans

than among Whites [9]. One factor that may contribute to

these persistent disparities is medical mistrust and belief in

long-standing conspiracies surrounding HIV [10, 11]. Also

conceptualized as AIDS counter-narratives [12], these

alternative explanations for the origin and spread of HIV

reflect distrust of the public health and biomedical com-

munities [13]. AIDS conspiracy theories, or speculations

about the origins of HIV and role of the government in the

AIDS epidemic, often are conceptualized as a manifesta-

tion of medical mistrust [14].

& Katherine G. Quinn [email protected]

1 Department of Psychiatry and Behavioral Medicine, Center

for AIDS Intervention Research, Medical College of

Wisconsin, 2071 N. Summit, Milwaukee, WI 53202, USA

2 Division of Biostatistics, Institute for Health and Society,

Medical College of Wisconsin, Milwaukee, WI, USA

3 Division of Infectious Disease, Department of Medicine,

Medical College of Wisconsin, Milwaukee, WI, USA

4 Department of Sociology, Lakehead University,

Thunder Bay, ON, Canada

5 Department of Psychology, Portland State University,

Portland, OR, USA

123

AIDS Behav (2018) 22:1814–1825

https://doi.org/10.1007/s10461-016-1657-6

It is not uncommon for conspiracy theories to emerge

from marginalized groups as a rhetorical strategy for

resisting dominant social representations of health and ill-

ness [12, 15], as is the case with HIV. Mistrust of medical

institutions, health care providers, antiretroviral medica-

tions, and the health care system is comparatively high

among African Americans [16, 17] and may pose a sig-

nificant barrier to accessing HIV prevention and treatment

[18, 19]. Extensive narratives regarding mistreatment of

African Americans by US health care services include

medical experimentation on African slaves, involuntary

sterilization, the Tuskegee Syphilis Study, and continued

unequal access to quality medical care. This mistrust may

lead some individuals to be suspicious of available treat-

ments and to question the authenticity of information they

are provided surrounding HIV [17].

As argued by Bogart et al., medical mistrust can

manifest at multiple levels of the socioecological

framework [20]. For example, as outlined above, insti-

tutionally-sanctioned discrimination and medical mal-

treatment have contributed to medical mistrust among

African Americans [21]. At the individual level, personal

experiences of racism and discrimination, as well as

discrimination experienced by people in one’s social

network [20], can play a role in the development and

sustainment of cultural mistrust of physicians, medical

regimens, and the health care system [22]. African

American MSM have reported experiencing high levels

of healthcare-specific racial discrimination directed

toward self, family, or friends [23], potentially influenc-

ing their perceptions of HIV providers as well as pre-

vention and treatment options.

Strong evidence documents the detrimental effects of

medical mistrust and AIDS conspiracy theories for African

American men on HIV prevention and health outcomes

along the care continuum [14, 17]. Individuals who endorse

AIDS conspiracy theories may be suspicious of informa-

tion disseminated by large health care systems or govern-

ment public health agencies, and may be less willing to

participate in prevention activities [14] or follow public

health recommendations [24]. Theories implicating the

government in the origins of HIV are associated with

negative attitudes toward condoms, greater number of sex

partners [25], and inconsistent condom use [17]. Addi-

tionally, medical mistrust may render individuals less

likely to get tested [26], a concern given that early and

frequent testing is crucial to reducing HIV transmission

and engaging HIV-infected individuals into care [27].

Furthermore, race-based medical mistrust is a strong pre-

dictor of decreased willingness to use pre-exposure pro-

phylaxis (PrEP) by African American MSM [28]. Such

findings may have significant implications for HIV pre-

vention efforts targeting African American MSM,

especially with the rise in bio-behavioral HIV prevention

interventions.

Medical mistrust is also a deterrent to engagement in

medical care by HIV-infected African American MSM

[29]. Trust in physicians is associated with fewer HIV-

related outpatient clinic visits, fewer Emergency Depart-

ment visits, greater acceptance of antiretroviral therapy,

and higher antiretroviral therapy adherence

[18, 19, 30, 31]. However, African Americans living with

HIV have greater mistrust of health care providers than

their White counterparts [30]. Similarly, AIDS conspiracy

theories also are associated with suboptimal adherence to

antiretroviral medication and poorer health outcomes.

Endorsement of conspiracy theories regarding HIV treat-

ment and AIDS denialism (denial of conventional knowl-

edge of HIV and AIDS) are associated with lower

likelihood of optimal treatment adherence [31, 32]. In one

study among African American men receiving antiretro-

viral therapy, one in five participants believed people tak-

ing new HIV treatments were guinea pigs for the

government and 17% believed that antiretroviral medica-

tion was poison [31]. Not surprisingly, individuals who

believe that HIV treatment cannot be trusted have lower

long-term antiretroviral adherence [31].

Despite the growing body of literature implicating

medical mistrust and AIDS conspiracy theories in the

growing HIV disparities, this research has primarily

focused on health outcomes including HIV risk behaviors

[33], HIV testing [23], and ART adherence [34], primarily

among HIV-infected individuals. The present study adds to

this by also examining how conspiracy theories and med-

ical mistrust may also be associated with sociocultural and

community-level factors among a large sample of Black

MSM. For example, although little previous research has

studied the relationship exists between internalized

homonegativity and HIV conspiracy beliefs [35, 36],

internalized homonegativity is a documented barrier to

health care access [37] and may limit disclosure of sexual

orientation or behaviors to medical professionals. This may

stem from prior social and medical discrimination and

mistreatment or anticipation of such experiences from

within the medical community [36]. The inability to dis-

cuss sexual orientation and behaviors with physicians due

to anticipated discrimination may lead to alienation from

the healthcare community and limited engagement in HIV

prevention activities [38]. Additionally, some researchers

have framed medical mistrust among men as a conse-

quence of masculine ideology and the internalization of

cultural beliefs about masculinity [39, 40]. Masculinity

norms may limit men’s healthcare access, as accessing

health care may be seen as weak and a threat to one’s

power, autonomy, or self-control [40, 41]. Masculinity that

manifests as extreme self-reliance is related to

AIDS Behav (2018) 22:1814–1825 1815

123

underutilization of healthcare, mistrust of healthcare

organizations, and poor health behaviors [40, 41]. The

effect of such norms may be particularly prominent for

African Americans, whose masculine identities are shaped

by a unique set of sociohistorical circumstances [42], and

even more so for African American MSM, whose sexual

identities are often seen as a contradiction to masculinity

[43]. African American MSM have noted feeling a differ-

ent set of masculine expectations compared to White men,

often rooted in broader social, political, and racial power

dynamics. These perceived rigid expectations may affect

one’s sense of self and selection of sexual partners [32, 43].

Rigid expectations of masculinity can also contribute to

poor psychosocial outcomes, including internalized

homonegativity and limited gay community acculturation,

among African American MSM [35, 44]. Individuals who

anticipate discrimination or mistreatment by providers may

not seek out healthcare in order to avoid disclosure [45],

and anticipated homonegativity and discrimination from

providers may contribute to medical mistrust.

The present research assessed the social and health-re-

lated correlates of AIDS conspiracy theories among a large,

multi-city sample of African American MSM. We exam-

ined AIDS Conspiracy Beliefs to identify the potential

effects of such beliefs on prevention and treatment out-

comes at multiple levels of the socioecological model

among HIV-positive and negative African American

MSM. We hypothesized that in exploratory factor analyses,

the AIDS Conspiracy Beliefs Scale would emerge as a two-

factor model reflecting both medical mistrust and AIDS

genocidal beliefs [31]. Additionally, and given the socio-

historical context of medical mistrust and genocidal beliefs

among African American MSM, we explored their rela-

tionships with several social, psychological, and sexual

outcomes. Specifically, we hypothesized that genocidal

beliefs and medical mistrust would be associated with

greater self-ascribed masculinity, higher levels of inter-

nalized homonegativity, and more limited gay community

participation. Based on social cognitive theory [46], and

previous research [14, 17, 24], we hypothesized that

medical mistrust and genocidal beliefs would be associated

with more limited HIV risk reduction knowledge and

behavioral intentions, more negative condom attitudes, and

more negative peer norms regarding safe sex. Finally, we

hypothesized that greater endorsement of AIDS genocidal

beliefs and medical mistrust would be significantly related

to decreased use of HIV testing, greater sexual risk, and,

among HIV-positive individuals, poorer health outcomes.

Although previous research has examined the health effects

of genocidal beliefs among HIV-infected individuals, little

research has explored the implications for HIV prevention

among individuals who are HIV-negative or the potential

relationships between medical mistrust and sociocultural

factors including masculinity, internalized homonegativ-

ity, and gay community participation. Given the current

rise in bio-behavioral HIV prevention strategies, it is

important to understand how medical mistrust and AIDS

genocidal beliefs may affect African American MSM’s

access to prevention and treatment offered in medical

settings.

Methods

Data were collected between 2012 and 2014 as a part of

participants’ baseline assessments for ‘‘Connections

Creating Change’’ (C3), a randomized HIV prevention

social network intervention trial for Black MSM. The study

recruited social networks of African American MSM in

Milwaukee, WI, Cleveland, OH, and Miami, FL, all cities

in which HIV incidence is disproportionately high among

racial minority MSM [47–49].

In-person recruitment of each network was done to

identify ‘‘seeds’’ in community venues where Black MSM

were known to congregate. These venues were selected

based on prior ethnographic observations and community

mapping and included bars, clubs, pageants, house balls,

hangout places, and other formal and informal social set-

tings. Two field staff trained in ethnography systematically

observed in a venue to watch for ‘‘social circles’’ [50] of

racial minority men. After randomly picking one social

circle, the two staff independently observed and identified

the circle’s seed, conferring with one another until reaching

agreement about who appeared to be the center of attention

among others in his circle. All seeds were African Amer-

ican MSM. Field staff approached the seed and briefly

explained the study. Five individuals who were approached

declined to participate. Individuals who were interested in

participating were asked to provide the first names of his

close MSM friends. The seed was given study information

packets and was asked to invite into the study each friend

he had just named. These individuals constituted the net-

work’s first ‘‘ring.’’ When they entered the study, members

of the first ring were also interviewed and asked to invite

the participation of members of their own friendship

groups. These individuals constituted the second network

ring. Members of the second ring who were enrolled in the

study invited, in turn, the participation of their own friends,

the network’s third and final ring. In this way, sociocentric

networks were recruited by reaching out three waves from

each initial seed. Of 39 seeds who were consented, 35

(89.7%) brought into the study at least half of their first-

ring friends. The final sample consisted of 35 networks that

collectively included 464 participants, 230 in Milwaukee,

180 in Cleveland, and 54 in Miami, with differences due to

difficulties our community partner organization in Miami

1816 AIDS Behav (2018) 22:1814–1825

123

had with recruitment and staff turnover. Social networks

ranged in size from 3 to 47 (mean = 13.3) enrolled

members.

Participants came to a research field office for individual

assessments. Following an explanation of the study, par-

ticipants provided written informed consent, completed

assessment interviews administered by A-CASI, provided

biospecimens for HIV/STD testing, and received risk

reduction counseling. Participants received a $40 incentive

payment for completing the A-CASI interview and an

additional $40 for completing STD/HIV testing. The study

protocol was approved by IRBs of each participating

institution.

Assessment Measures

Endorsement of HIV/AIDS conspiracy beliefs was mea-

sured using a 9-item scale developed by Bogart and

Thorburn. The scale assessed endorsement of HIV-related

misconceptions, conspiracy beliefs, and medical mistrust

[17]. Respondents indicated their level of agreement with

each statement using a 5-point Likert scale (score range

from 9 to 45, Cronbach’s alpha = 0.89).

We conducted exploratory factor analysis on the nine

conspiracy beliefs items. Varimax rotation resulted in the

extraction of two factors with Eigenvalues greater than 1

(Table 1). Labels for these factors, based on items that

loaded at or above 0.5, were defined as: (1) AIDS geno-

cidal beliefs about the origin and purpose of HIV and (2)

medical mistrust. Genocidal beliefs included items that

advanced theories of genocide and alternate explanations

about the origins of HIV including, ‘‘HIV is a man-made

virus’’ and ‘‘AIDS is a form of genocide against Blacks’’.

Medical mistrust items focused on physicians and HIV

medications including ‘‘The medicine that doctors pre-

scribe to treat HIV is poison’’ and ‘‘Doctors put HIV into

condoms.’’ We confirmed that the two-factor solution was

preferable over a one-factor option. The commonly-used

RMSEA goodness–of-fit measure for a one-factor solution

was 0.187 as compared to 0.088 for a two-factor model.

Further, we re-computed the genocidal beliefs and medical

mistrust subscales based on the factor analysis, so that item

loadings less than 0.5 were set to zero. These two subscales

derived from the factor analysis comprised the main out-

come variables for conspiracy beliefs.

Demographic Characteristics

Participants responded to questions about their gender at

birth as well as their self-identified present gender (male,

female, or transgender), age, race, whether of Hispanic

ethnicity, employment status, income, highest level of

education, length of residence, and housing stability. Par-

ticipants used a 5-point scale to describe their sexual ori-

entation (from exclusively gay to exclusively straight).

Sexual Risk Behaviors

Participants reported sexual risk behaviors in the previous

12- and 3-months including number of sexual partners,

frequency of condomless intercourse, and sex with com-

mercial sex partners. Respondents also indicated whether

they disclosed their HIV status to partners in the previous 3

months and whether they had a sexually transmitted

infection (STI) within the last 6 months. We assessed

substance use by asking participants on how many days

they drank alcohol in the past month and the greatest

number of drinks they had in a single day. Participants who

Table 1 Endorsement of HIV conspiracy beliefs by 464 African-American MSM recruited within 35 social networks and varimax-rotated factor loadings of AIDS genocidal beliefs and medical mistrust subscales

a

HIV conspiracy belief item % Agree (strongly

or somewhat) (%)

Factor loadings for

AIDS genocidal

beliefs

Medical

mistrust

HIV is a man-made virus 34.6 0.774 -0.019

AIDS was produced in a government laboratory 14.3 0.790 0.340

HIV was created and spread by the CIA 13.0 0.749 0.367

People who take the new medicines for HIV are human guinea pigs for

the government b

12.7 0.512 0.512

AIDS is a form of genocide against Blacks 11.6 0.731 0.386

AIDS was created by the government to control the Black population 9.3 0.716 0.496

The medicine that doctors prescribe to treat HIV is poison 6.9 0.288 0.753

The medicine used to treat HIV causes people to get AIDS 3.2 0.185 0.827

Doctors put HIV into condoms 0.6 0.196 0.800

a Items that loaded strongly on one factor or the other are in bold font

b Loaded as a moderately strong item on both factors

AIDS Behav (2018) 22:1814–1825 1817

123

reported five or more drinks on this measure were defined

as binge drinkers. In addition, participants indicated whe-

ther, and on how many days in the past month, they used

heroin, other opiates, powder cocaine, crack cocaine,

amphetamines or methamphetamines, marijuana, ecstasy,

gamma hydroxybutyrate (GHB), ketamine, inhaled nitrites

(‘‘poppers’’), non-prescribed medications for erectile dys-

function, other illicit prescription drugs, and any injected

drug.

AIDS Risk-Specific Scales

AIDS risk-specific scales were based off social cognitive

theory [46], theory of reasoned action [51], and the AIDS-

specific Information Motivation-Behavior theory [52],

which postulate that HIV preventive actions are related to a

variety of psychological constructs. The assessment

included five AIDS risk-specific scales. A 9-item scale

measured knowledge of HIV risk reduction steps (sample

item: ‘‘If a man pulls out before orgasm, it protects from

getting AIDS and venereal diseases,’’ scale range 0–9). An

eight-item scale measured perceived safer sex peer norms

(sample item: ‘‘Condom use is well-accepted among my

friends’’) with 3-point scales for each statement (scale

range 0–16 Cronbach’s alpha = 0.75). The same response

format was measured condom attitudes (8 items, sample

item: ‘‘Using condoms interrupts the pleasure of sex,’’

range 0–16, Cronbach’s alpha = 0.80); risk reduction

behavioral intentions (8 items, sample item: ‘‘A condom

will be used if I have sexual intercourse with a casual

partner’’, range 0–16, Cronbach’s alpha = 0.75); and risk

reduction self-efficacy (8 items, sample item: ‘‘I am sure

that I can overcome my partner’s objections to condoms’’,

range 0–16, Cronbach’s alpha = 0.66).

Psychosocial and Sociocultural Contextual Scales

We assessed several psychological and social factors that

may be related to medical mistrust and endorsement of

HIV genocidal beliefs among African American MSM

including masculinity, internalized homonegativity, resi-

lience, religiosity, and outness. Self-ascribed masculinity

was measured with a 4-item scale adapted from Garcı́a

et al. (sample item: ‘‘I can pass as a straight man’’) [53].

Participants responded to each statement using 5-point

Likert response options from strongly disagree to strongly

agree (score range from 4 to 20, Cronbach’s alpha = 0.83).

Internalized homonegativity was assessed using a modified

version of Herek’s internalized homophobia scale, which

measures on a 5-point Likert scales participants’ level of

agreement with nine statements (sample item: ‘‘I wish I

were not sexually attracted to men,’’ score range from 9 to

45, Cronbach’s alpha = 0.86) [54–56]. Resilience,

reflecting the perceived internal capacity to handle chal-

lenging life situations, was assessed using 10 items from a

25-item scale originally developed by Wagnild and Young

in which 5-point Likert scales indicated participants’ level

of agreement with each statement (score range from 10 to

50, Cronbach’s alpha = 0.88) [57].

HIV Testing and Treatment

Participants reported whether they had ever had an HIV test,

and, if so, whether they had been tested within the past year.

All those who had ever tested for HIV were then asked to

disclose the result of their most recent test. Those respon-

dents who were HIV-positive indicated how many times they

had visited a doctor for HIV treatment in the past 6 months,

and whether they were presently taking antiretroviral med-

ications. Men who reported being on HAART were asked if

they had learned whether their HIV viral load was unde-

tectable at their most recent doctor’s visit.

Analysis

Means and standard errors (SE) were computed for key

numerical measures and relative frequencies for categorical

variables in order to characterize the overall sample. First,

we tested bivariate associations of both AIDS genocidal

beliefs and medical mistrust subscales with a series of vari-

ables in three domains: sociodemographic background;

AIDS risk-specific scales; and psychosocial contextual

scales. Generalized mixed-effects linear regression models

were conducted to analyze these associations. To control for

the interdependence of responses among members of the

same network, social network was included as a random

effect in each regression. All regression analyses conducted

were Generalized Estimating Equations for mixed-effects

models and were performed using IBM SPSS Statistics,

Version 21 (2012) software. Predictors that met a threshold

p value\0.20 in the bivariate analyses qualified for inclusion in a multiple mixed-effects regression. A backward-stepwise

procedure was used to select all fixed-effect covariates for

each subscale; an alpha of 0.05 was set as our criterion for

statistical significance. Social network was again entered as a

random effect. Variables selected as predictors of only one

subscale were subsequently entered into the final model for

the other subscale so that we were able to compare the same

covariates within both subscales.

In the final stage of the analysis, exploratory bivariate

regressions were performed to test AIDS genocidal beliefs

and medical mistrust as predictors of sexual history, sexual

behaviors, and HIV treatment outcomes. For the later

analyses, we focused on subsamples of participants who

reported being HIV seropositive and those who were cur-

rently on antiretroviral medications.

1818 AIDS Behav (2018) 22:1814–1825

123

Results

Sample Characteristics

The mean age of the sample was 27.5 (SE = 0.38) years

(Table 2). Although all 464 participants reported male

gender at birth, 7.7% (n = 36) identified themselves as

currently transgendered or female. More than 45%

(n = 210) of participants had at least some college, and

approximately 23% (n = 108) of participants were cur-

rently attending school full or part time. A large majority

(75%, n = 348) of participants described their sexual ori-

entation as mainly or exclusively gay, while another 20.7%

(n = 96) identified as bisexual. Over 23% (n = 107) of the

total sample reported that they were HIV-positive at their

last test; 31.7% (n = 147) had not been tested in the past

year; and 4.7% (n = 22) of participants indicated that they

had never been tested for HIV.

Participants reported a mean of 5.4 (SE = 0.62) male

partners in the past year and 2.6 (SE = 0.24) male partners

in the past 3 months. Almost half (n = 230) of the sample

indicated that they had condomless anal or vaginal inter-

course in the past 3 months, and 27.4% (n = 127) of par-

ticipants did not disclose their HIV-serostatus to all of their

sex partners prior to first intercourse. Five percent (n = 23)

of participants reported having intercourse with a com-

mercial sex worker in the past 3 months.

Bivariate Predictors of AIDS Conspiracy Beliefs

Table 3 presents bivariate predictors of both genocidal

beliefs and medical mistrust. As the table shows, both of

the conspiracy domains were associated with participant

sociodemographic background characteristics, HIV/AIDS

risk-specific scale characteristics, and sociocultural con-

textual factors.

Stronger genocidal beliefs about HIV/AIDS were asso-

ciated in bivariate analyses with having income of less than

$10,000 per year, lower knowledge about HIV risk

reduction steps and more negative condom attitudes, hav-

ing greater self-ascribed masculinity, and greater internal-

ized homonegativity. Strength of genocidal beliefs was also

associated with lower levels of gay community participa-

tion and resilience.

Greater HIV-related medical mistrust was significantly

associated in bivariate analyses with having low income,

younger age, and self-identifying as straight or bisexual as

opposed to gay. Similar to the bivariate correlates of

holding genocidal beliefs, greater medical mistrust was

also associated with lower knowledge of HIV risk reduc-

tion and unfavorable condom attitudes, as well as lower

gay community participation, lower resilience, and greater

internalized homonegativity.

Multiple Regression Analyses Predicting AIDS

Conspiracy Beliefs

Results of the multiple regression analyses of factors pre-

dicting both genocidal beliefs and medical mistrust are

shown in Table 4. Participants holding stronger genocidal

beliefs about HIV/AIDS had significantly greater inter-

nalized homonegativity, held more negative attitudes about

using condoms, and had lower income. Stronger levels of

medical mistrust were also associated in regression

Table 2 Description of sociodemographic background for 464 African-American MSM recruited within 35 social networks

Age in years—mean (SE) 27.5 (0.38)

Self-identified gender

Male 92.2% (428)

Female or transgender 7.7% (36)

Race

African-American 84.7% (393)

Multiracial (including African-American) 6.0% (28)

White 2.2% (10)

Native American 1.5% (7)

Other 5.6% (26)

Hispanic ethnicity 6.7% (31)

Level of education

Less than complete high school 16.6% (77)

Completed high school 38.1% (177)

Any higher education 45.3% (210)

Currently a student 23.3% (108)

Currently working 55.1% (256)

Annual income a

Less than $10,000 54.7% (254)

$10,000–$29,999 30.8% (143)

$30,000 or more 12.9% (59)

Resides in current area less than 1 year 8.4% (39)

Current housing situation is unstable 9.0% (42)

Sexual orientation b

Gay 75.0% (348)

Bisexual 20.7% (96)

Straight 4.1% (19)

Never been tested for HIV 4.7% (22)

Tested for HIV 1 year or more ago c

31.7% (147)

HIV-positive at most recent test d

23.1% (107)

a Eight participants were missing on income (four reported that they

did not know and four refused to respond) b One participant refused to respond to the question on sexual

orientation c One participant refused to respond and 22 were ineligible because

they had never been tested for HIV d Six participants refused to respond and 22 were ineligible because

they had never been tested for HIV

AIDS Behav (2018) 22:1814–1825 1819

123

analyses with greater internalized homonegativity, negative

condom attitudes, and having a recent commercial sex

partner. However—and unlike for genocidal beliefs—the

multiple regression analysis showed that those participants

who were higher on HIV medical mistrust were also

younger and had lower knowledge of HIV risk reduction

Table 3 Bivariate mixed regression models predicting

AIDS conspiracy subscales

among members of 35 African-

American MSM social networks

Fixed effects b

AIDS genocidal beliefs a

Medical mistrust a

Coefficient (t) p-value Coefficient (t) p-value

Sociodemographic background

Self-identified as female or transgender -0.096 (-0.67) 0.506 -0.315 (-1.79) 0.075

African-American race 0.117 (1.10) 0.274 0.089 (0.68) 0.681

Hispanic ethnicity -0.062 (-0.41) 0.686 -0.055 (-0.29) 0.771

Age (in years) -0.002 (-0.45) 0.654 -0.012 (-2.05) 0.041

Currently employed -0.139 (-1.79) 0.075 -0.164 (-1.71) 0.087

Currently a student -0.034 (-0.37) 0.714 -0.001 (-0.01) 0.991

Less than complete high school -0.003 (-0.03) 0.974 -0.015 (-0.12) 0.906

Income less than $10,000 per year 0.253 (3.20) 0.001 0.300 (3.08) 0.002

Resides in current area less than 1 year 0.094 (0.68) 0.496 0.048 (0.29) 0.775

Current housing situation is unstable 0.039 (0.29) 0.774 0.016 (0.10) 0.923

Sexual orientation bisexual or straight 0.173 (1.94) 0.054 0.333 (3.05) 0.002

Never tested for HIV 0.228 (1.23) 0.219 0.353 (1.56) 0.120

Tested for HIV 1 year or more ago -0.026 (-0.30) 0.761 -0.048 (-0.47) 0.639

HIV-positive at most recent test -0.093 (-1.00) 0.319 -0.188 (-1.64) 0.102

AIDS risk-specific scales

Knowledge of HIV risk reduction steps -0.068 (-3.03) 0.003 -0.106 (-3.85) <0.001

Safer sex peer norms -0.017 (-1.49) 0.136 -0.016 (-1.12) 0.263

Risk reduction behavioral intentions -0.018 (-1.55) 0.121 -0.022 (-1.59) 0.112

Condom use attitudes -0.048 (-4.20) <0.001 -0.054 (-3.88) <0.001

Risk reduction self-efficacy -0.001 (-0.10) 0.920 -0.009 (-0.51) 0.611

Psychosocial contextual scales

Self-ascribed masculinity 0.020 (2.14) 0.033 0.019 (1.63) 0.102

Gay community participation -0.020 (-3.21) 0.001 -0.028 (-3.65) <0.001

Internalized homonegativity 0.030 (6.30) <0.001 0.033 (5.80) <0.001

Resilience -0.019 (-2.63) 0.009 -0.028 (-3.21) 0.001

Religious and church involvement 0.001 (0.08) 0.935 0.001 (0.08) 0.934

Bold indicates significant p-values a Two cases were missing on both outcome measures

b A few regression models had small numbers (eight or less) of missing cases resulting from random non-

responses

Table 4 Multiple mixed regression models predicting

AIDS conspiracy subscales

among members of 35 African-

American MSM social

networks a

Fixed Effects AIDS genocidal beliefs Medical mistrust

Coefficient (t) p-value Coefficient (t) p-value

Age (in years) -0.003 (-0.62) 0.535 -0.014 (-2.38) 0.018

Income less than $10,000 per year 0.163 (2.10) 0.037 0.163 (1.74) 0.083

Knowledge of HIV risk reduction steps scale -0.031 (-1.34) 0.180 -0.063 (-2.26) 0.025

Condom use attitudes scale -0.039 (-3.47) 0.001 -0.044 (-3.27) 0.001

Internalized homonegativity 0.026 (5.61) <0.001 0.030 (5.13) <0.001

Bold indicates significant p-values a In the initial stepwise model for genocidal conspiracy beliefs, three covariates (low income, condom use

attitudes, and internalized homonegativity) were selected. We also added two variables that were selected

in the final group of predictors of medical mistrust (age, and HIV risk knowledge). Likewise, income was

added back into the multiple regression model predicting medical mistrust

1820 AIDS Behav (2018) 22:1814–1825

123

steps. There was a trend for low income to predict higher

levels of medical mistrust.

AIDS Conspiracy Beliefs as Predictors of Sexual

Behavior and Measures of HIV Treatment

The final phase of the analysis examined whether genocidal

or medical mistrust beliefs were associated with sexual

behaviors, as well as HIV treatment engagement among the

sub-sample participants who were aware of their HIV-

positive serostatus (n = 107) or among the 85 participants

who indicated they were currently on ART regimens. The

findings of these analyses are shown in Table 5.

Logistic regression models indicated that participants

who scored higher on AIDS genocidal beliefs and medical

mistrust were more likely to have had a commercial sex

partner in the past 3 months and to not disclose their HIV

status to all of their sexual partners. None of the other

sexual history or behavioral outcomes were significantly

associated with either AIDS conspiracy subscale.

Poisson regression analyses showed that neither AIDS

genocidal beliefs or medical mistrust were significantly

associated with number of HIV medical care visits in the

past 6 months. Similarly, logistic regression models

showed that neither conspiracy beliefs scale was associated

with the likelihood that an HIV-positive participant would

be taking antiretroviral medication. However, among

participants on ART regimens, the logistic regression

revealed a strongly significant relationship between medi-

cal mistrust beliefs and reporting detectable viral load. A

one-unit increase in the standardized medical mistrust

subscale was associated with more than a threefold

increase in the odds of having detectable viral load

(OR = 3.082, 95% CI = 1.34, 7.12).

Discussion

We examined the association between AIDS conspiracy

beliefs and sexual risk, psychosocial sociocultural factors,

and clinical outcomes among a large sample of African

American MSM. As hypothesized, and in line with previ-

ous research [31], two distinct subscales emerged within

the AIDS conspiracy beliefs measure among this popula-

tion: medical mistrust and genocidal beliefs. Our findings

demonstrate the continued existence of medical mistrust

and AIDS genocidal beliefs and provide evidence that such

beliefs may partially explain the racial disparities among

the HIV care continuum.

This study revealed mixed associations between sexual

risk and both genocidal beliefs and medical mistrust among

African American MSM. Medical mistrust and genocidal

beliefs about the origin of HIV were associated with neg-

ative attitudes about condom use, which included

Table 5 Bivariate regression models predicting sexual behavior and HIV treatment outcomes by AIDS conspiracy subscales

Fixed Effects AIDS genocidal beliefs Medical mistrust

IRR/OR (95% CI) a

p-value IRR/OR (95% CI) a

p-value

Sexual behavior outcomes

Had an STD in the past 6 months 1.08 (0.73, 1.59) 0.700 1.17 (0.87, 1.57) 0.312

Has a main male partner 0.85 (0.68, 1.08) 0.185 0.88 (0.72, 1.06) 0.177

Had any unprotected intercourse (UI), past 3 mo. 0.94 (0.74, 1.17) 0.566 0.91 (0.76, 1.09) 0.302

Had UI with 2-plus partners, past 3 months 0.99 (0.75, 1.32) 0.963 0.99 (0.79, 1.25) 0.949

Had UI with non-main partner, past 3 months 1.23 (0.97, 1.56) 0.089 1.12 (0.93, 1.36) 0.237

Had commercial sex partner, past 3 months 2.03 (1.01, 2.32) 0.043 1.38 (1.01, 1.90) 0.049

Did not disclose HIV-status to all partners, 3 months 1.30 (1.02, 1.66) 0.035 1.30 (1.07, 1.58) 0.010

HIV treatment outcomes

Number of visits to a physician for HIV treatment in past 6 months b

0.929 (0.79, 1.09) 0.356 0.937 (0.81, 1.08) 0.371

Currently on antiretroviral treatment c

0.632 (0.31, 1.30) 0.210 1.117 (0.63, 1.98) 0.702

Had a detectable viral load at last doctor’s visit d

1.815 (0.83, 3.97) 0.134 3.082 (1.34, 7.12) 0.009

Bold indicates significant p-values a Exponentiated regression coefficients and their 95% confidence intervals were incidence rate ratios (IRR), computed from Poisson regressions

modelling the number of doctor visits, and Odds Ratios (OR), computed from logistic regressions modelling the dichotomous antiretroviral

treatment and viral load indicators b The analysis was performed for 105 of 107 HIV seropositive men who reported the number of doctor visits

c The analysis was performed for all 107 HIV seropositive men

d The analysis was performed for 76 of 85 men who reported that they were currently on HAART. Nine participants, who indicated that they did

not know or were not informed of their viral loads, were omitted from the analysis

AIDS Behav (2018) 22:1814–1825 1821

123

statements such as ‘safer sex is boring’ and ‘condoms show

that you don’t trust your partner.’ Such findings are in line

with previous research, which has demonstrated an asso-

ciation between stronger AIDS conspiracy beliefs and

inconsistent condom use [14, 17, 31]. However, in this

study, the associations with negative attitudes about con-

dom use did not translate into lower condom use or greater

number of sexual partners. Individuals who have negative

attitudes toward condoms and believe condoms interfere

with the pleasure and intimacy of sex, may, nevertheless,

recognize their importance and continue to use them.

Additional research should discern any differences in

condom use by partner, as pleasure-related attitudes toward

condoms have been found to be partner specific [58]. AIDS

genocidal beliefs and medical mistrust were also both also

positively associated with having a commercial sex partner

in the previous 3 months. Additionally, medical mistrust

was significantly associated with having a lower knowl-

edge of HIV risk reduction strategies. Yet, contrary to our

hypotheses and previous research [59], neither medical

mistrust nor genocidal beliefs were associated with

reductions in HIV testing. Previous research has delineated

multiple dimensions of medical mistrust and has found that

experiences of systematic discrimination were associated

with decreased HIV testing [26]. These personal experi-

ences may have more effect on individual access to pre-

vention and treatment services than broad mistrust or

beliefs, although additional research is needed.

Several demographic and sociocultural factors were also

associated with either genocidal beliefs or medical mis-

trust. Individuals who were younger or had higher levels of

medical mistrust and genocidal beliefs were associated

with having an income under $10,000 a year. These find-

ings are important, as young African American MSM and

individuals of low socioeconomic status have dispropor-

tionately high rates of HIV incidence and prevalence

[60, 61]. These particularly vulnerable populations face

discrimination, mistreatment, and exclusion from the

medical and public health communities [13, 29, 62], which

can contribute to medical mistrust and the formation of

genocidal beliefs about the origin of HIV. Such findings

highlight the need to tailor prevention services to vulner-

able populations, including young African American

MSM, who may be less likely or able to access HIV pre-

vention care in traditional healthcare settings. As hypoth-

esized and in line with previous research [63], regression

analyses revealed that both medical mistrust and genocidal

beliefs were associated with internalized homonegativity.

Internalized homonegativity, or the internalization of

societal anti-gay attitudes, has been found to limit an

individual’s coping mechanisms, social support systems,

and access to community resources [44, 64], which may be

important factors in challenging genocidal beliefs and

improving trust with the healthcare community. Addition-

ally, internalized homonegativity can limit healthcare

access and delay entry to care among MSM [65, 66],

compromise access to prevention services [66], and serve

as a barrier to HIV testing [67]. Collectively, our findings

suggest HIV genocidal beliefs and medical mistrust may

interfere with HIV prevention efforts for African American

MSM. Individuals who endorse conspiracy beliefs about

the origin or treatment of HIV may be similarly skeptical of

HIV prevention messaging, including public health efforts

to promote PrEP. Recent research suggests PrEP use

among African American MSM may be significantly

impacted by medical mistrust [28, 68], as PrEP requires

regular engagement with a healthcare provider. Efforts to

improve PrEP uptake among African American MSM

should anticipate and address medical mistrust as a

potential challenge with PrEP implementation.

Importantly, our study also demonstrated that for HIV-

positive patients on ART, medical mistrust is significantly

associated with having a detectable viral load. Such find-

ings are consistent with previous research that has shown

trust in healthcare providers to be linked to antiretroviral

adherence and good mental health [18, 19]. Enhancing the

degree to which African American MSM trust their health

care providers may improve prevention and treatment,

thereby reducing associated racial disparities in HIV [30].

There is evidence that patients perceive less stigma from

HIV care specialists, suggesting that although medical

mistrust is a broad, historical experience affecting African

American MSM, mistrust may be less likely to occur in

HIV-specific settings [29]. Medical mistrust has numerous

dimensions and it is possible that different aspects of trust

affect medical access differently. Medical mistrust in this

study did not differentiate between type of provider or

provider setting. Furthermore, it is important to consider

the differing implications of trust in providers, trust in

medications, and trust in the broader healthcare system.

Individuals may trust their individual provider, with whom

they have built a relationship, but remain skeptical of

pharmaceuticals, the government’s role in health care, and

the broader public health system. Distinction between

global medical mistrust and personal trust in a provider is

important, as having a provider in whom one trusts can

mitigate the effect of distrust in the broader medical system

[29].

This research offers several implications for HIV pre-

vention and treatment interventions. Through the lens of

the socioecological framework, medical mistrust and HIV

conspiracy beliefs manifest at multiple levels and thus,

require a multi-level approach, including interventions at

the structural, interpersonal and individual levels [20, 69].

For example, broader social-structural interventions are

needed to address the root causes of AIDS conspiracy

1822 AIDS Behav (2018) 22:1814–1825

123

theories. To dismiss such beliefs as ignorance or approach

such beliefs through dissemination of accurate public

health and medical information is insufficient. Rather,

efforts should seek to establish and repair trust between the

African American community, the federal government, and

the medical and public health communities and address the

broader effects of medical mistrust on social and racial

disparities of health. Additionally, while the presence of

AIDS conspiracy theories among African Americans may

be partially rooted in legacies of distrust and mistreatment

of minority populations by the federal government [17, 70],

the existence of medical mistrust also points to the

importance of more recent individual experiences of

racism, homonegativity, and discrimination within the

medical system. Interventions should also seek to improve

health care settings, including expanding local, commu-

nity-based health settings, sharing medical decision-mak-

ing, and incorporating health educators and social workers

to improve personal relationships and trust in medical care

[71]. At the individual level, efforts to improve patient-

provider communication may be beneficial in counteract-

ing negative patient experiences and decreasing medical

mistrust; patients report being suspicious of providers who

use medical jargon and fail to provide adequate time for

patients to ask questions [72]. Finally, interventions at any

level should acknowledge the history of medical mistrust,

the continued racism and discrimination individuals expe-

rience within the health care system, and the continued

existence of AIDS genocidal beliefs [73].

Conclusion

Despite the importance of these findings, they should be

considered in light of the study’s limitations. This study is

cross-sectional and as such, we cannot determine causality.

Although our sample was drawn from three cities, our

results may not be generalizable to other US cities.

Recruitment from the three cities was done in collaboration

with community-based organizations and although we

provided training for field staff, differences in organiza-

tional structure and culture resulted in varied recruitment

numbers by site. Additionally, in-person recruitment was

conducted by field staff, which identified ‘seeds’ at local

congregating spots of African American MSM. Individuals

who publicly identify as gay, bisexual, or other MSM or

spend time within these locations may be different from

other African American MSM. Selection bias may also

have influenced whom field staff identified as ‘seeds.’

Additionally, there are inherent biases in ethnographic

observation. Although two field staff trained in ethnogra-

phy consulted with each other to identify seeds, their

observation and identification of seeds may have been

influenced by a number of factors including the given

social context and inherent field staff biases.

Clinical measures (medication adherence, engagement

in care, and detectable viral load) were self-reported. Par-

ticipants may have misreported adherence or misunder-

stood lab results. Future research should use clinical

indicators to examine factors that influence HIV treatment

and care. We also had a limited sample of HIV-infected

participants and HIV-infected participants receiving ART

and future research should continue to explore these issues

among larger samples. Finally, although this study high-

lights the existence and correlates of medical mistrust and

AIDS genocidal beliefs, it did not differentiate types of

medical mistrust (provider vs. broader public health system

mistrust) or provide context for that mistrust. Qualitative

research with African American MSM may provide context

and greater explanation for medical mistrust and AIDS

genocidal beliefs among African American MSM.

The persistence of medical mistrust and AIDS genocidal

beliefs highlights the need for continued efforts to ease

social anxieties around HIV prevention and treatment and

increase efforts to build trust between the medical com-

munity and African American MSM. Public health efforts

to address racial disparities in HIV must maintain a focus

on rebuilding trust with the African American community

while acknowledging historical abuses and legacies of

racism that have damaged trust and engagement with the

healthcare system.

Acknowledgements This research was supported by Grants R01- MH089128 and P30-MH52776 from the National Institute of Mental

Health. We would like to thank the study participants and their

willingness to participate in this research. We would also like to thank

the partners of the Connections Creating Change study team at the

Center for AIDS Intervention Research, the AIDS Taskforce of

Greater Cleveland, and the South Beach AIDS Project.

Compliance with Ethical Standards

Conflict of interest The authors of this study have no conflicts of interest to disclose.

Ethical approval All policies and procedures in this study were reviewed and approved by the Institutional Review Board at the

Medical College of Wisconsin. All procedures performed in studies

involving human participants were in accordance with the ethical

standards of the institutional and/or national research committee and

with the 1964 Helsinki declaration and its later amendments or

comparable ethical standards.

Informed consent We received written informed consent from all participants in this study.

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