HIV/AIDS & the Down Low (DL)

HIV/AIDS & the Down Low (DL)




 HIV/AIDS Data in Racial & Ethnic Groups l HIV/AIDS in African Americans:  A Special Challenge l Down Low (DL) l Group Barriers to HIV Prevention & Control l Challenges of Managing HIV/AIDS & Substance Abuse, Combined l AIDS Blanket Quilt/Names Project: Reminder of the Epidemic’s Destructive Impact  

Our Overview of HIV/AIDS  

Although there is much less publicity now about HIV/AIDS, it is still at epidemic proportions in African Americans and higher in Hispanics than in Whites. With adequate information, education, and access to high quality care, these high rates can be decreased. The HIV/AIDS section of our web site’s “Major Killers and Disablers” provides much information about HIV/AIDS  prevention, early detection and control.

Society should continue to give high priority to HIV/AIDS prevention and control in communities of color because:

  1. The cost of treating HIV and AIDS are very high, and all taxpayers pay those costs, directly or indirectly.
  2. Although effective treatment has changed AIDS from being a fatal disease to becoming a chronic disease (which people can live with for a long time), there is still no cure at present.
The Down Low (DL)

The term Down Low is most widely understood to mean keeping some information or activity private, or down low. It is also often used to describe the behavior of men who have sex with other men as well as with women, but do not consider themselves as gay or bisexual. Instead, they may refer to themselves as on the down low, on the DL, or on the low.

Although the practices of bisexual men are not unique to African-American men, the Down Low term is probably most often used regarding African-American men because it reportedly originated in the African-American community. In other words, there is an unknown, but significant, number of Hispanic and White men who are also on the Down Low/bisexual.

While some heterosexual women have become infected with HIV through sexual contact with bisexual men, the extent is not really known. For example, some heterosexual women also develop HIV infection men who are injection drug users who may, or may not, be bisexual.  Much more research is needed about the relationship between bisexual activity of men and Hiv transmission in women.

African-American and Hispanic Women are at Much Greater Risk

Today, women account for one-fourth of all new HIV/AIDS diagnoses, and the Aids rate is markedly higher in African American women than white women.


Contributing to the very high incidence of HIV/AIDS in African-American, and then Hispanic women, is the fact that an unknown but significant number of their male partners and acquaintances also have sex with men, often without the women’s knowledge. Some of these men do not consider themselves gay or bisexual. Therefore:

– African-American and Hispanic women must become better informed about how to protect themselves from HIV, and act on that knowledge; and

– The public health community, physicians and other health professionals, and researchers need to give higher priority to health education, behavioral research, and the availability of support networks for communities of color.

Not only must women of color, especially African-American women, become well informed about the Down Low, but also  increase their skills, and determination in protecting themselves and their futures. Hopefully their sense of self worth will be enough to motivate them to do so. However, if not, they will hopefully do so for the good of those they love. . . or in the reverse, do so for the good of those who love them.

Participation in women’s support groups (even two people can be a group), can also help women better protect themselves and their futures.

In 1992 and 1993, Dr. Norma Goodwin, President of Health Power, conducted an 18-month statewide strategy development action project on HIV prevention in African-Americans for the AIDS Institute of the New York State Department of Health. In addition to the AIDS Institute’s publication and wide distribution of the Final Report, it was also distributed for several years as a CDC resource of the AIDS Clearinghouse.

Key research activities were: 

  • a comprehensive literature review,
  • conduct of 48 focus groups, 
  • 92 in-depth interviews,
  • an all-day  Grassroots workshop
  • an all-day Leaders and Experts workshop,
  • analysis of  selected high profile print and broadcast commercials targeting African-Americans to identify common elements.

 Focus groups were conducted with the following African-American groups:

  • adolescents
  • gay and bisexual men and adolescents
  • heterosexual men
  • lesbians
  • prison inmates (current and former)
  • substance users
  • partners of substance users
  • women of childbearing age, including a Caribbean group
  • faith based leaders
  • other leaders and experts

 In addition, focus groups were conducted with representatives of community based organizations.

HIV prevention strategies were developed for:

  • the African-American groups listed above;
  • African-American faith leaders and communities;
  • Other African-American leaders;
  • HIV counseling and testing;
  • Community organizations; and
  • Public communication.

Dr. Goodwin considers many of the findings and recommendations of her research still valid, and not adequately pursued, today.

The following more detailed findings  are provided in this Section of the web site:
  •          12 Barriers to HIV/AIDS Prevention and Control in Racial/Ethnic Populations
  •          Group-specific Barriers to HIV/AIDS Prevention & Control for:
                                 –  Gay and Lesbian Persons 
                                 –  Heterosexual Men
                                 –  Heterosexual Women
                                 –  Prisoners and Parolees
                                 –  Substance Abusers (including of Alcohol and Non-injection Drugs)
                                 –  Teenagers
                                 –  Women of Childbearing Age

Following the group-specific information provided for the above groups, Health Power provides recommendations on what communities and community groups, and faith leaders should do.

The recommendations on the web site refer to communities of color rather than just African-Americans because there is a significant correlation between socioeconomic status or poverty, and the incidence of HIV/AIDS, irrespective of race and ethnicity.

This does not mean, however, that the barriers identified by Dr. Goodwin and Health Power apply to all people/communities of color. The latter observation is made because of the importance of avoiding stereotypes regarding African-Americans, Hispanics and other groups and sub-groups that are disproportionately affected by HIV/AIDS, given the multiple harmful effects of stereotyping.

Many improvements have occurred regarding HIV/AIDS in the 15 years since Dr. Goodwin conducted AIDS and African-Americans: It’s Time for Action. Noteworthy among these improvements has been the availability today of rapid testing methods, effective combination treatment, and capacity building within many organizations that serve African-American, Hispanic and other multicultural populations and communities.

Unfortunately, however, the lower overall socioeconomic status of African-Americans as compared to the general population means that many African-Americans with HIV/AIDS have less access to high quality care and follow-up.

Dr. Goodwin has a limited number of copies of AIDS and African-Americans: It’s Time for Action that can be obtained for the cost of postage and handling, paid in advance.

* A list of the more than 400 organizations and individuals who participated in this project is provided in the Final Report.

12 Barriers to HIV Prevention and Control in 
Racial and Ethnic Populations
Barrier Key Strategy/Strategies
1. Preventive health has a decreased priority because of competing needs and/or interests. a. Provide ongoing culturally relevant and “family”* centered direct, print and broadcast information, education and health services, with an emphasis on disease prevention, early detection and control.
* Traditional and non-traditional families.
2. There is widespread distrust of both the medical establishment, and the government. a. Openly discuss in various settings the historical validity of some concerns, such as the legacy of the Tuskegee Study.

b. Use culturally and linguistically appropriate health educators and service providers whenever possible.

c. Emphasize, especially with African-Americans and Hispanics who engage or have engaged in high-risk practices, the increased likelihood of poorer outcomes with delayed testing and treatment.

d. Downplay governmental involvement in direct education and service.

3. There is a prevalent stigma associated with having HIV/AIDS. a. Incorporate sensitive and informed discussion about HIV/AIDS in individual and group discussions involving persons with HIV/AIDS, members of the general population, and mixed audiences involving both groups.
4. Poverty and under-education occur frequently among persons with HIV and AIDS. a. Indicate in appropriate group settings, the high correlation between poverty and poor health status.

b. Encourage and support the informed participation of affected persons in both formal education and self-education, since increased educational achievement is associated with improved economic status and health status.

5. Many persons have inadequate skills in negotiating safer sex and other risk reduction and avoidance situations. a. Conduct skill development workshops that include: multiple sessions, improving self-esteem, and individual and small group situation-specific individual and small group practice exercises.
6. There are not enough ongoing peer and other mutual support opportunities regarding HIV/AIDS risk reduction. a. Develop and facilitate the conduct of a greater number of ongoing HIV/AIDS risk reducing peer and other mutual support opportunities.
7. There is wide opposition to condom use, in part because of concerns about population control. a. Incorporate discussion of concerns about population control in group discussions about condom use as well as the risk reducing benefits of planned condom use.

b. Discuss approaches to infection-free reproduction through pre-conception HIV testing (at two intervals), and condom use during pregnancy unless one is engaged in a monogamous relationship with an uninfected person.

8. Many persons with HIV and AIDS have experienced multiple layers of discrimination related to such factors as:

  • race and/or ethnicity
  • socioeconomic status
  • sexual orientation
  • injection drug use
  • history of incarceration

The result is less responsiveness to prevention and treatment requirements.

a. Discuss, in appropriate individual and group settings, the damaging impact on persons of having experienced multiple levels of discrimination

b. Develop and implement modified approaches in order to achieve adherence with diagnostic and treatment requirements.

9. There is an inadequacy of customized, culturally relevant, user-friendly health information, messages and services related to HIV and AIDS. a. Increase the availability and use of customized, culturally relevant, user-friendly information, messages and services related to HIV and AIDS.
10. There is a prevalence of low individual, family, group, and community esteem. a. Discuss the relationship of individual, family, group and community esteem on lifestyle and health behavior.

b. Develop and conduct, interventions which incorporate esteem building as a significant component.

11. As a result of religious conservatism, there is less faith community involvement than needed. a. Approach various faith leaders and alliances and, in coordination with them, facilitate the development and conduct of needed outreach, educational and advocacy activities, including joint activities with other faith-centered organizations.
12. There is a need for increased community leadership, organization, collaboration and advocacy related to HIV/AIDS. a. Develop and/or increase the level of active and ongoing involvement of community leaders in issues related to HIV/AIDS.

NOTE: See also the Health Power identified key group-specific barriers for the following 6 groups:


  • gay and lesbian persons
  • heterosexual men
  • heterosexual women
  • prisoners and parolees
  • substance abusers
  • teenagers

Note: While these barriers identified by Health Power apply to many people and communities of color, they do not apply to all.

Gay and Lesbian Persons

  • Prevalent community stigma regarding persons with these sexual orientations
  • Scarcity of HIV related information and services specific to their needs
  • Few HIV related peer and other mutual support group opportunities

Heterosexual Men

  • Frequent low level of consciousness that non-condom use increases HIV and other STD transmission
  • Tendency by some to dominate their female partners because of either:
    • cultural tradition, and/or
    • having limited power in “mainstream America”
  • Tendency of more men than women not to use the health care delivery system
  • Few HIV related peer or mutual support group opportunities

Heterosexual Women

  • Relative scarcity of eligible men of color influences sexual decision-making
  • Inadequate control in many male-female relationships
  • Fear of potential physical and/or psychological abuse if condom use is insisted on
  • Too few peer or mutual support group opportunities that incorporate HIV related issues

Prisoners and Parolees

  • Official denial that sex occurs in prison, thus eliminating access to condoms
  • Reported widespread availability and use of drugs in prisons
  • Negligible HIV related services to prisoners on release as well as their families or significant others

Substance Abusers (including Users of Alcohol and Non-injection Drugs)

  • Individuals are unlikely to practice safe(r) sex when “high” or “under the influence”
  • Inadequate number of drug treatment slots
  • Inadequate number of needle exchange programs that incorporate drug treatment


  • Teen idleness and hopelessness
  • Inadequate parent (and other adult) teen communication
  • Media messages glamorizing sex, violence and risk taking
  • Too few peer or mutual support group opportunities that incorporate HIV related issues

After being aware of the key barriers above, communities and community groups are urged to:

  1. Select (only) one or two barriers based on their local situation and priorities;
  2. Develop strategies for action including sources for financial and other resource support;
  3. Implement the agreed upon plan of action; and
  4. Evaluate and monitor the results. This same approach is advised for the 12 key general barriers also identified in this section by Health Power.
Key HIV/AIDS Data in Racial & Ethnic Populations

HIV/AIDS Table 1: Estimated Proportion of Persons Diagnosed with AIDS in the 50 States and District of Columbia, by Race/Ethnicity through 2005
HIV/AIDS Table 2: Percent U.S. Population and AIDS Cases (50 States and District of Columbia) by Race/Ethnicity in 2005
HIV/AIDS Table 3: HIV/AIDS Trends in Women, through 2003
HIV/AIDS Table 4: Top Ten Cumulative AIDS Cases by State/Territory through 2005
HIV/AIDS Table 5: Transmission Categories and Country of Birth of Hispanics/Latinos with AIDSdiagnosed in the U. S. During 2005
HIV/AIDS Report 6: Age-Adjusted Death Rates per 100,000 Persons by Race & Hispanic Origin for Human Immunodeficiency Virus (HIV) Disease: U.S. U.S., 2004
HIV/AIDS Report 7: Asian and Pacific Islander HIV Prevention Needs