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Am J Public Health. 2010 December; 100(12): 2532–2540.
PMCID: PMC2978169

Hombres Sanos: Evaluation of a Social Marketing Campaign for Heterosexually Identified Latino Men Who Have Sex With Men and Women

Abstract

Objectives. We evaluated the effectiveness of Hombres Sanos [Healthy Men] a social marketing campaign to increase condom use and HIV testing among heterosexually identified Latino men, especially among heterosexually identified Latino men who have sex with men and women (MSMW).

Methods. Hombres Sanos was implemented in northern San Diego County, California, from June 2006 through December 2006. Every other month we conducted cross-sectional surveys with independent samples of heterosexually identified Latino men before (n = 626), during (n = 752), and after (n = 385) the campaign. Respondents were randomly selected from 12 targeted community venues to complete an anonymous, self-administered survey on sexual practices and testing for HIV and other sexually transmitted infections. About 5.6% of respondents (n = 98) were heterosexually identified Latino MSMW.

Results. The intervention was associated with reduced rates of recent unprotected sex with both females and males among heterosexually identified Latino MSMW. The campaign was also associated with increases in perception of HIV risk, knowledge of testing locations, and condom carrying among heterosexual Latinos.

Conclusions. Social marketing represents a promising approach for abating HIV transmission among heterosexually identified Latinos, particularly for heterosexually identified Latino MSMW. Given the scarcity of evidence-based HIV prevention interventions for these populations, this prevention strategy warrants further investigation.

In the United States, adult and adolescent Latino males represent 5.6% of the total population1 but 18.7% of HIV/AIDS cases.2 Low rates of condom use35 and limited HIV testing57 likely contribute to the risk for infection and transmission among Latinos.

Sex between men continues to account for the majority of new HIV infections in the United States.2 HIV prevention efforts have traditionally targeted gay and bisexual men. However, individuals’ self-identified sexual orientation frequently does not correspond to their sexual behavior,812 and recent research has been focused on men who self-identify as heterosexual but have sex with men. The results of studies on men who have sex with both men and women (MSMW) suggest that, regardless of sexual identity, this population is at greater risk for HIV than are men who exclusively have sex with men; likewise, MSMW are at greater risk than are men who exclusively have sex with women (MSW).11,1316 Reasons for greater risk among MSMW may include lower rates of condom use11,16 and having sexual partners who engage in high-risk sexual practices.11

Previous studies have suggested that Latino men are more likely than are White men to engage in bisexual sexual behavior9,11,17,18 but less likely than are White men to self-identify as gay or bisexual or to disclose their sexual orientation.1923 Cultural factors such as homophobia, social stigma related to same-sex practices, and sexual conservatism may inhibit Latino men from self-identifying as homosexual or bisexual.10,13,2326 The degree to which Latinos integrate same-sex sexual practices into their sexual identities may influence their risk for HIV infection.27 Latino MSMW who identify as heterosexual may perceive that they are at lower risk for sexually transmitted infections (STIs) than are gay or bisexual men, and Latino MSMW may thus be less likely to use condoms to protect themselves or their partners. Latino MSMW who identify as heterosexual may also be more likely to resort to substance use to reduce sexual inhibition, thus increasing the likelihood that they will engage in unsafe sex.19,27

Nondisclosure of same-sex sexual practices among MSMW also has significant implications for the health of their female sexual partners.9,17 More than 70% of Latinas living with HIV/AIDS in the United States were infected via heterosexual contact.2 Most cases of heterosexual transmission to Latinas are related to sex with partners who use injection drugs,28 but unprotected sex with men who have multiple partners, including MSMW, has likely contributed to a subset of HIV cases among Latina women.2,29

Social marketing involves applying the principles and techniques of commercial marketing to the promotion of behavioral change for the good of a target audience.30,31 Social marketing has been successfully used for HIV prevention with gay and bisexual males,32,33 racial and ethnic minorities,34 and youths.3538 Interventions using social marketing have been associated with improvements in HIV/STI testing32,34 and condom use.36,37,39,40 To our knowledge, no social marketing campaigns have been designed to reduce HIV risk among heterosexually identified Latino MSMW. Because of the secrecy of their sexual practices and the perceived association of HIV infection with homosexuality,24,41,42 heterosexually identified Latino MSMW are difficult to reach with HIV prevention efforts. This population is not likely to be exposed to prevention messages or programs targeted to the gay and bisexual communities.18 Moreover, interventions requiring active recruitment of heterosexually identified MSMW may fail to reach sufficient numbers or may not reach those who are most secretive about their same-sex sexual practices.41 We sought to evaluate the effectiveness of a social marketing campaign to increase condom use and HIV testing among heterosexual Latino men in northern San Diego County, California, with a special emphasis on heterosexually identified Latino MSMW.

METHODS

We conducted cross-sectional surveys every other month with independent samples of Latino men in northern San Diego County before (December 2005–April 2006), during (June–December 2006), and after (January–April 2007) implementation of the social marketing campaign. Approximately 260 participants were recruited per survey wave. The number of waves and our recruitment goals per survey wave were based on both statistical and budget considerations. Survey sites were selected on the basis of formative research and comprised 7 low-risk venues (a workplace, a migrant camp, a labor pickup site, 2 shopping centers, a center for the teaching of English as a second language [ESL], and a men's shelter) and 5 high-risk venues (an adult bookstore and 4 bars or clubs). On the basis of information obtained during formative assessment, we classified sites as high- or low-risk venues according to the probability of sexual risk practices occurring at or in close proximity to the venue. Venue-specific recruitment goals were established to be proportional to the size of the target population visiting each site. Formative research methods included community mapping, site enumeration activities, and interviews and focus groups with key informants (i.e., heterosexually identified Latino MSMW, gay-identified Latino men who have sex with men, community health educators and outreach workers, venue workers, and Latina women).

Sampling design, procedures, and goals were the same throughout the 3 phases of the study. The only exceptions were the exclusion of a small nightclub because of low recruitment numbers and the replacement of a dismantled migrant camp with a new one. These changes took place during the midbaseline and early intervention phases, respectively. Sampling shifts at each venue were determined on the basis of days and times when the survey sites were operating or when Latino men were present. Depending on the venue, we used different sampling procedures to maximize the representativeness of our sample. In the bars and clubs, the adult bookstore, and 1 of the shopping centers, men were consecutively intercepted and recruited from the beginning to the end of each sampling shift. In the ESL center and the men's shelter, we used a lottery system to select those to be approached for participation in the study. At all other venues, we rolled dice to randomly select potential study participants.

The eligibility criteria were self-reported Latino ethnicity, aged 18 years or older, and, for privacy purposes, being alone or in the company of other men. Participants completed a self-administered anonymous survey on a handheld computer using the Questionnaire Development Software Handheld-Assisted Personal Interview (NOVA Research Company, Bethesda, MD). Participants received a $5 cash incentive. The overall response rate was 49% (51% and 47% in low- and high-risk venues, respectively). No information was collected from individuals who refused participation. Sampling, recruitment, and data collection methods have been described in more detail elsewhere.43,44

The Hombres Sanos Campaign

Formative research guided by a social-ecological framework4547 revealed that heterosexually identified Latino MSMW identified strongly with cultural values held by the heterosexual Latino male majority, self-identified as “normal” men, and went to great lengths to keep their sexual encounters with men secret.48 Guided by this research, and following the principles of social marketing,30,49 we developed the Hombres Sanos [Healthy Men] campaign, which was intended to increase condom use and HIV testing among heterosexually identified Latino men, especially among heterosexually identified Latino MSMW. The campaign, which targeted low-acculturated, mostly Spanish-speaking Latino men, used a dual strategy. First, we recognized that heterosexually identified Latino MSMW see themselves as heterosexual men. Thus, when we developed materials to change social norms related to condom use and to promote HIV/STI testing, we aimed to attract their attention as part of the general population of heterosexually identified Latino men. These materials appealed to Latino cultural values identified through formative research, including familism and being able to protect and provide for one's family. The underlying assumption was that, given the high degree to which heterosexually identified Latino MSMW identified with the larger heterosexual majority, changes resulting in HIV testing and condom use among heterosexual Latino men would also extend to heterosexually identified Latino MSMW.

Secondly, in our marketing materials we used ecological cues that evoked contexts in which same-sex sexual practices are likely to take place among heterosexually identified Latino MSMW. These cues were designed to be highly salient for heterosexually identified Latino MSMW while also respecting their desire to keep their sexual activity with men private. Our marketing materials focused on promoting condom use during sexual encounters with men and featured condom use as a way to keep same-sex practices secret. For instance, we developed a poster that depicted the shadow of 2 men having sex projected against the wall of a public bathroom. The shadow's shape was ambiguous enough that it would go unnoticed by most people not familiar with male-to-male sexual encounters in public settings. The poster included a sequence of Polaroid photographs depicting an anonymous encounter between 2 men in a public park (Figure 1). The text included Spanish-language captions under each photograph and a tagline in Spanish reading, “Nadie más lo sabe … y con un condón, nadie lo sabrá” (“No one knows … and with a condom, no one will”). The images and text in these materials were selected to evoke risk contexts among heterosexually identified Latino MSMW while being relatively meaningless for the majority of heterosexual Latinos.

FIGURE 1
Sample graphics from printed materials: Hombres Sanos HIV/AIDS prevention campaign, San Diego County, CA, June–December 2006.

Campaign elements included Spanish-language print materials (Figure 1), radio ads and sponsorships, free condom distribution, community-based outreach, and promotional activities at local clubs. The campaign ran for 7 months and involved more than 170 community venues. Additional details about the campaign have been described elsewhere.43

Central to the promotion of HIV testing was a comprehensive male health exam offered by a collaborating local community clinic. In addition to HIV and STI testing, the male health exam included a physical examination and screening for low-stigma conditions, such as diabetes, hypercholesterolemia, and hypertension. The male health exam was intended to be a nonthreatening service allowing Latino men to get tested for HIV without the stigma typically associated with HIV testing. The male health exam was offered during extended hours of operation, and the exam fee was based on a sliding scale. Bilingual and bicultural staff provided the exam, and it was made available to any men seeking those services, regardless of legal or insurance status. Free transportation to and from the exam was also made available as needed.

Variables

Study phase (baseline, campaign, and postcampaign) was the main independent variable. The main outcomes were recent (in the previous 60 days) unprotected vaginal or anal sex with female partners, unprotected anal sex with male partners, perception of HIV risk, lifetime and previous 6 months HIV/STI testing, knowledge of HIV testing locations, knowledge of the community clinic that offered the male health exam, carrying a condom at the time of the interview (verified by a research assistant), and previous participation in the survey. Data on campaign exposure and reactions to the campaign were also collected. About 86.8% and 85.9% of the MSMW and MSW respondents, respectively, reported exposure to the campaign. Among those exposed to the campaign, 34.3% (30.8% of MSMW; 34.6% of MSW) reported having taken 1 or more HIV-preventive actions as a result of the campaign (e.g., making an appointment for an male health exam, using condoms, talking to sexual partners about STIs). Detailed results on campaign exposure and reactions to the campaign have been published elsewhere.43

Statistical Analysis

We computed summary statistics by study phase. Logistic and linear regression models were estimated to test for significant differences in study outcomes from the baseline to the campaign and postcampaign periods. The models included study phase as the main predictor, with baseline as the reference category. All models included age, marital status, educational attainment, length of residence in the United States, occupation sector, and history of imprisonment as covariates. We conducted all analyses separately for participants classified as heterosexual and as heterosexually identified MSMW. This stratification was chosen to match the dual strategy of the social marketing campaign, which comprised 2 classes of materials: those materials specifically targeting heterosexually identified MSMW and those targeting the general heterosexual Latino male population with which heterosexually identified MSMW largely identified. Heterosexual Latinos were defined as men who self-identified as heterosexual and who reported no history of sexual activity with men. Heterosexually identified Latino MSMW were defined as men who self-identified as heterosexual but who had a lifetime history of sex with men. Respondents of all other sexual orientations were excluded from analyses. All analyses were computed by using SPSS version 14.0 (SPSS Inc, Chicago, IL).

RESULTS

Of 4879 men intercepted, 2378 agreed to complete the survey. About 19% of respondents reported having participated in the Hombres Sanos survey previously. No information on frequency or dates of previous survey participation was collected. After we excluded data from repeat surveys and from participants whose sexual orientations were not heterosexual, the final sample consisted of 1763 unique heterosexually identified Latino men. Of them, 626 men completed the survey during the baseline period, 752 completed the survey during the campaign, and 385 completed the survey after the termination of the campaign. By sexual orientation, we classified 1665 (94.4%) men as heterosexual and 98 (5.6%) as heterosexually identified Latino MSMW (Figure 2). The percentage of respondents who were classified as heterosexually identified Latino MSMW within each recruitment venue ranged from 1.5% in the ESL center to 39.4% in the adult bookstore.

FIGURE 2
Participant flow diagram: heterosexually identified Latino men, San Diego County, CA, December 2005–April 2007.

Table 1 shows the sociodemographic and recruitment characteristics of the survey participants. The heterosexual subsamples were significantly different by study phase with regard to marital status, educational attainment, birthplace, length of residence in the United States, and occupation. The subsamples of heterosexually identified Latino MSMW differed significantly in length of residence in the United States (Table 1).

TABLE 1
Sociodemographic and Recruitment Characteristics of Respondents, by Study Phase and Sexual Orientation: Self-Identified Heterosexual Latino Men (n = 1763), San Diego County, CA, December 2005–April 2007

Intervention Effects for Heterosexually Identified Latino MSMW

Sexual risk behavior.

For heterosexually identified Latino MSMW, the prevalence of unprotected sex with females decreased significantly from the baseline to the campaign (adjusted odds ratio [AOR] = 0.17; 95% confidence interval [CI] = 0.04, 0.69; P = .013) and postcampaign phases (AOR = 0.06; 95% CI = 0.01, 0.45; P = .006; Table 2). The number of unprotected female sexual partners was also significantly lower during the campaign than during the baseline phase (B = −6.03; 95% CI = −11.7, −0.31; P = .039).

TABLE 2
Association Between HIV Risk Factors and Study Phase, by Sexual Orientation: Self-Identified Heterosexual Latino Men (n = 1763), San Diego County, CA, December 2005–April 2007

The proportion of heterosexually identified Latino MSMW respondents who had had unprotected anal sex with males during the previous 60 days decreased significantly during the postcampaign phase compared with the baseline phase (AOR = 0.10; 95% CI = 0.02, 0.65; P = .016). Among those reporting anal sex with males during the previous 60 days, the number of unprotected male sexual partners was also lower during the campaign than at baseline (B = −3.60; 95% CI = −6.27, −0.92; P = .01). This trend continued during the postcampaign phase, with a lower number of unprotected male partners on average (mean = 0.44) compared with the baseline (mean = 3.1) and campaign (mean = 0.71) phases. However, because of the smaller sample size, these differences did not reach statistical significance. Rates of condom carrying increased during the campaign and postcampaign phases, but these changes did not achieve statistical significance.

Lifetime and recent HIV testing.

Lifetime rates of HIV testing for the heterosexually identified MSMW subsample decreased significantly during the campaign (AOR = 0.32; 95% CI = 0.10, 0.98; P = .046) and postcampaign phases compared with the baseline phase (AOR = 0.24; 95% CI = 0.05, 1.06; P = .059). A significant decrease in the rates of recent HIV testing from baseline to campaign was also observed (AOR = 0.18; 95% CI = 0.04, 0.085; P = .03).

Knowledge and risk perception.

Among heterosexually identified Latino MSMW, knowledge of HIV testing locations was higher at the postcampaign phase than at the baseline and campaign phases. However, these differences did not reach statistical significance. No significant changes were observed in the percentage of respondents who had heard of the clinic that offered the male health exam. An increase in heterosexually identified MSMW respondents’ average level of perceived HIV risk was seen, especially between the baseline and postcampaign phases. However, differences across phases did not reach statistical significance.

Intervention Effects for Heterosexually Identified Latino MSW

Sexual risk behavior.

For the heterosexually identified Latino MSW subsample, we observed no changes in the prevalence rates of unprotected sexual practices with females over the previous 60 days. The average number of unprotected female partners during the previous 60 days was significantly lower after the campaign than at baseline (B = −0.45; 95% CI = −0.75, −0.15; P = .003; Table 2). A significant increase in the percentage who reported and demonstrated condom carrying was found during the campaign (AOR = 2.28; 95% CI = 1.59, 3.27; P < .001) and postcampaign phases (AOR = 1.62; 95% CI = 1.06, 2.49; P = .026), compared with baseline.

Lifetime and recent HIV testing.

No significant differences were observed across the 3 study phases in the percentage of heterosexual respondents who reported lifetime testing for HIV, but HIV testing during the previous 6 months increased significantly from baseline to postcampaign (AOR = 3.13; 95% CI = 2.06, 4.75; P < .001).

Knowledge and risk perception.

The percentage of heterosexual respondents who knew where to get tested for HIV increased at the campaign (AOR = 1.60; 95% CI = 1.26, 2.02; P < .001) and postcampaign phases (AOR = 1.57; 95% CI = 1.18, 2.08; P = .002) in comparison with baseline. Knowledge of the clinic that offered the male health exam also increased significantly from baseline to campaign (AOR = 1.82; 95% CI = 1.44, @2.30; P < .001) and postcampaign (AOR = 2.24; 95% CI = 1.68, 2.99; P < .001). Heterosexual respondents’ average level of perceived risk for HIV was higher during the campaign (B = 0.13; 95% CI = 0.04, 0.13; P = .003) and postcampaign (B = 0.27; 95% CI = 0.17, 0.37; P < .001) phases than during baseline.

DISCUSSION

The purpose of this study was to test the effectiveness of Hombres Sanos, a social marketing intervention to reduce HIV risk among heterosexually identified Latino men in northern San Diego County, California, with a special emphasis on heterosexually identified Latino MSMW. The campaign used a dual strategy to effect changes not only among heterosexually identified Latino MSMW but also among the larger heterosexually identified Latino male population with whom this group identifies. Our results suggest that the campaign was effective in reaching both heterosexually identified Latino MSW and MSMW. Considering the modest campaign budget (about $60 000, excluding the cost of the formative research, the evaluation component, and staff salaries) and the vast geographic area targeted (more than 1000 square miles), we achieved exposure levels that compare well with levels reported by other social marketing campaigns directed at largely Latino populations.34,50 Our study's success was likely the result of extensive formative research that preceded campaign design, as well as subsequent efforts focused on community venues and platforms identified by our key informants as catering to Latino men in general and heterosexually identified Latino MSMW in particular.

Our results suggest that the intervention had a positive effect on HIV risk and risk correlates for both heterosexually identified Latino MSMW and MSW. Particularly for heterosexually identified Latino MSMW, the campaign was associated with a significant reduction in the prevalence of recent sexual risk practices with female partners and in the number of recent female partners with whom unprotected vaginal or anal sex was practiced. Similarly, the campaign was associated with a significant reduction in the number of male partners with whom heterosexually identified Latino MSMW had unprotected anal sex. Although these findings are mostly exploratory because of the small size of the MSMW subsample, the findings suggest that the campaign was effective in reducing heterosexually identified Latino MSMW's sexual risk for HIV infection and transmission.

On the other hand, the campaign did not seem to have any significant impact on other cognitive and behavioral variables, such as knowledge of HIV testing locations, knowledge of the clinic that offered the male health exam, perception of HIV risk, and condom carrying. Moreover, HIV testing rates among heterosexually identified Latino MSMW changed in an unexpected direction, with a reduction in lifetime and recent testing rates following implementation of the campaign. The decrease in lifetime HIV testing rates observed for heterosexually identified Latino MSMW is puzzling. It is possible that the samples recruited in the 3 study phases represented different subpopulations of heterosexually identified Latino MSMW or extreme groups within the same population. In addition, these variations may be attributable to overlap between the baseline phase of our study and another observational study focused on high-risk Mexican migrants that was taking place in northern San Diego County during the baseline period.51 The latter study involved HIV testing, and it is possible that some survey respondents had been tested as part of that study before the social marketing campaign started. That earlier testing would have translated into inflated HIV testing rates among this population during the baseline phase of our study. Our survey included questions on participation in that study, but the results did not vary when we adjusted our analysis to control for this factor. Future studies with larger samples of heterosexually identified Latino MSMW and comparison communities would be needed to better test the effects of similar campaigns on HIV testing practices among heterosexually identified Latino MSMW.

We targeted heterosexual Latino men as part of our dual campaign strategy to achieve changes in heterosexually identified Latino MSMW. Our results suggest that Latino MSW responded positively to the campaign, with improvements in behavioral and cognitive variables that may reduce their risk for HIV infection. Specifically, the campaign was associated with increases in heterosexual Latinos’ perception of HIV risk, knowledge of testing locations, condom carrying, and knowledge of the community clinic that offered the male health exam. The improvement observed in these variables during the campaign period remained in place during the 4-month period following the termination of the campaign, suggesting that these changes in knowledge and behavior were maintained beyond the duration of the intervention. The campaign did not seem to trigger immediate changes in sexual behavior or HIV testing rates for Latino MSW. However, we did observe improvements in the number of unprotected female partners for vaginal or anal sex and in recent HIV testing rates at the postcampaign phase for Latino MSW.

The Hombres Sanos campaign was implemented gradually, and it involved an increasing number of promotional activities and a growing number of community venues over time. Intensified efforts toward the end of the campaign may have triggered more HIV testing among heterosexual Latinos at that time relative to the first months of the intervention. Last-12-month HIV testing rates were 6.4% in June 2006, 6.8% in August 2006, 5.7% in October 2006, and 11.8% in December 2006 (months during which the campaign was in place); last-12-month HIV testing rates were 12.4% in January 2007 and 32.2% in March 2007 (after campaign termination; data not shown). As more heterosexual Latino men were tested over time, social modeling influences may have continually increased the likelihood of HIV testing even after termination of the campaign, resulting in higher rates of testing at the postcampaign phase. Progressive adoption through modeling processes would be consistent with the Diffusion of Innovations Theory,52 and such a process has been the premise of previous peer-based HIV prevention interventions.53,54 Alternatively, it is possible that changes in sexual behavior and testing rates during the postcampaign phase were unrelated to the campaign. Replications of this intervention and more rigorous evaluations would be needed to determine whether the campaign itself accounts for the changes observed among Latino MSW, as opposed to other extraneous factors.

Baseline rates of unprotected sex with female partners were twice as high for heterosexually identified Latino MSMW as for the heterosexual subsample. Differences in the risk profiles of MSMW and MSW Latinos in the Hombres Sanos study have been reported previously.44 Further research with larger samples of heterosexually identified Latino MSMW and stronger methodological designs (e.g., randomized community trials, multiple-baseline quasi-experimental designs, and so on) is necessary to investigate the reasons for such differences and the potential of social marketing to reduce HIV risk among low-acculturated heterosexually identified Latino MSW and MSMW.

In general, the results of our study suggest positive (albeit small) changes in HIV risk among heterosexual Latinos following the introduction of the Hombres Sanos campaign. The public health impact of an intervention is determined not only by its level of effectiveness but also by its ability to reach the target population.55 Considering the high levels of campaign exposure achieved among heterosexual Latinos (85.9%; data not shown), these relatively modest effects could nonetheless translate into large public health benefits.

This study is limited by the lack of a comparison community, the small size of the heterosexually identified Latino MSMW subsample, a lack of information on individuals who refused participation, and differences in the sociodemographic profiles of the study samples. The latter could reflect changes in the Latino male population because of migration patterns. It is also possible that the samples were drawn from different populations of Latino men. Our analyses were adjusted for sociodemographic variables, but the potential for bias resulting from unmeasured confounders still remains.

The secrecy and stigma surrounding same-sex practices among heterosexually identified Latino MSMW makes recruitment and collection of sexual behavior data from this population challenging. Reliance on self-reports carries risks for recall bias and socially desirable answers. Our study tried to mitigate some of these concerns by using targeted sampling in selected community venues, intercept survey methods, brief recall periods, and self-administered, anonymous questionnaires. Misclassification of heterosexually identified Latino MSMW as heterosexual Latinos may have occurred as a result of underreporting of same-sex sexual practices and of our particular classification criteria. We used lifetime versus recent sexual practices and did not consider oral sex, frequency or timing of sex, or whether same-sex sexual behaviors were consensual. Heterosexually identified Latino MSMW may represent a very heterogeneous group with respect to the factors above. Our results for the intervention effects could have been different if the study had used different criteria or had included a larger sample of MSMW.

As with other multidimensional interventions, it is difficult to ascertain the individual contributions of the different elements of the Hombres Sanos campaign and to identify its “active” ingredients. Our marketing strategies included a health exam designed to appeal to low-acculturated Latino men; it is possible that the availability of this service was enough to affect HIV testing rates, regardless of our health communication efforts intended to increase HIV testing and condom use. Future research needs to disentangle these effects and examine the individual and synergistic effects of these 2 intervention elements.

An important strength of this study is the external validity of our findings.56 Both the campaign and the male health exam were developed collaboratively among the academic and community clinic partners and were carefully designed to be consistent with and integrated into the HIV prevention and outreach activities routinely conducted by the community clinic. We built on the expertise of the clinic staff, including bicultural and bilingual health educators and outreach workers, and capitalized on the trust and reputation that this community-based agency had built among the target population. Such elements made this intervention more likely to be adopted by the clinic staff, to appeal to the target audience, and to effect changes that were sustained months after the campaign ended. This intervention model and its effects could be easily translated to other community-based agencies catering to Latino populations.

In conclusion, our results suggest that blanketing the community with a social marketing campaign like Hombres Sanos is a feasible, promising approach to abating HIV transmission among heterosexually identified Latino MSMW, an underserved population that is very hard to reach. Furthermore, our study suggests that this type of intervention could also reduce HIV risk among heterosexual Latino men. Given the scarcity of effective interventions to reduce HIV rates among heterosexually identified Latino MSW and MSMW, our findings warrant further research to test the effectiveness of similar interventions to promote condom use and HIV testing among both populations. In addition, future studies should be designed to disentangle the individual contributions, as well as the combined effects, of a media campaign and HIV testing services integrated into male-oriented prevention services designed to be accessible to Latinos regardless of language, income, documented status, availability of transportation, or schedule.

Acknowledgments

This study was supported by grants awarded to A. P. Martínez-Donate and F. Sañudo by the California HIV/AIDS Research Program, University of California (AL04-SDSUF-804 and AL04-VCC-805); by a Materials Development Grant awarded to A. P. Martínez-Donate and F. Sañudo by the California AIDS Clearinghouse; and by intramural support from the Center of Behavioral Epidemiology and Community Health at San Diego State University.

We gratefully acknowledge the assistance of graphic designers Luis Shriner and Ashley Kerns; Vista Community Clinic outreach workers Ovidio Ruiz, Elva Leal, and Julio Quintero; and all the individuals who served as key informants for this study.

Human Participant Protection

All study procedures were reviewed and approved by the San Diego State University institutional review board and by the Social and Behavioral Sciences institutional review board at the University of Wisconsin–Madison.

References

1. US Census Bureau 2006–2008 American Community Survey 3-Year Estimates. United States; sex by age (Hispanic or Latino); males. Table generated using American FactFinder, available at: http://factfinder.census.gov. Accessed September 17, 2010
2. Centers for Disease Control and Prevention Cases of HIV Infection and AIDS in the United States and Dependent Areas, 2007. HIV/AIDS Surveillance Report vol. 19 Atlanta, GA: US Department of Health and Human Services; 2009
3. Apostolopoulos Y, Sonmez S, Kronenfeld J, Castillo E, McLendon L, Smith D. STI/HIV risks for Mexican migrant laborers: exploratory ethnographies. J Immigr Minor Health. 2006;8(3):291–302 [PubMed]
4. Essien EJ, Ross MW, Fernandez-Esquer ME, Williams ML. Reported condom use and condom use difficulties in street outreach samples of men of four racial and ethnic backgrounds. Int J STD AIDS. 2005;16(11):739–743 [PMC free article] [PubMed]
5. Rhodes SD, Yee LJ, Hergenrather KC. A community-based rapid assessment of HIV behavioural risk disparities within a large sample of gay men in southeastern USA: a comparison of African American, Latino and White men. AIDS Care. 2006;18(8):1018–1024 [PubMed]
6. Ehrlich SF, Organista KC, Oman D. Migrant Latino day laborers and intentions to test for HIV. AIDS Behav. 2007;11(5):743–752 [PubMed]
7. Fernandez MI, Collazo JB, Bowen GS, Varga LM, Hernandez N, Perrino T. Predictors of HIV testing and intention to test among Hispanic farmworkers in South Florida. J Rural Health. 2005;21(1):56–64 [PubMed]
8. Millett G, Malebranche D, Mason B, Spikes P. Focusing “down low”: bisexual black men, HIV risk and heterosexual transmission. J Natl Med Assoc. 2005;97(suppl 7):52S–59S [PMC free article] [PubMed]
9. Montgomery JP, Mokotoff E, Gentry A, Blair J. The extent of bisexual behaviour in HIV-infected men and implications for transmission to their female sex partners. AIDS Care. 2003;15(6):829–837 [PubMed]
10. Wolitski RJ, Jones K, Wasserman J, Smith J. Self-identification as “down low” among men who have sex with men (MSM) from 12 US cities. AIDS Behav. 2006;10(5):519–529 [PubMed]
11. Pathela P, Hajat A, Schillinger J, Blank S, Sell R, Mostashari F. Discordance between sexual behavior and self-reported sexual identity: a population-based survey of New York City men. Ann Intern Med. 2006;145(6):416–425 [PubMed]
12. Pathela P, Blank S, Sell RL, Schillinger JA. The importance of both sexual behavior and identity. Am J Public Health. 2006;96(5):765. [PMC free article] [PubMed]
13. Brooks R, Rotheram-Borus MJ, Bing EG, Ayala G, Henry CL. HIV and AIDS among men of color who have sex with men and men of color who have sex with men and women: an epidemiological profile. AIDS Educ Prev. 2003;15(1, suppl A):1–6 [PubMed]
14. Prabhu R, Owen C, Folger K, McFarland W. The bisexual bridge revisited: sexual risk behavior among men who have sex with men and women, San Francisco, 1998–2003. AIDS. 2004;18(11):1604–1606 [PubMed]
15. Los Angeles County Department of Health Services, Office of AIDS Programs and Policy County of Los Angeles HIV Prevention Plan 2000. Los Angeles, CA: Los Angeles County Department of Health Services, Office of AIDS Programs and Policy; 2000
16. Munoz-Laboy M, Dodge B. Bisexual Latino men and HIV and sexually transmitted infections risk: an exploratory analysis. Am J Public Health. 2007;97(6):1102–1106 [PMC free article] [PubMed]
17. Chu SY, Peterman TA, Doll LS, Buehler JW, Curran JW. AIDS in bisexual men in the United States: epidemiology and transmission to women. Am J Public Health. 1992;82(2):220–224 [PMC free article] [PubMed]
18. Doll L, Petersen L, White C, et al. Homosexually and nonhomosexually identified men who have sex with men: a behavioral comparison. J Sex Res. 1992;29(1):1–14
19. Jeffries WL. Sociodemographic, sexual, and HIV and other sexually transmitted disease risk profiles of nonhomosexual-identified men who have sex with men. Am J Public Health. 2009;99(6):1042–1045 [PMC free article] [PubMed]
20. Mason HR, Marks G, Simoni J, Ruiz M, Richardson J. Culturally sanctioned secrets? Latino men's nondisclosure of HIV infection to family, friends, and lovers. Health Psychol. 1995;14(1):6–12 [PubMed]
21. Munoz-Laboy MA. Familism and sexual regulation among bisexual Latino men. Arch Sex Behav. 2008;37(5):773–782 [PubMed]
22. Zea MC. Latino HIV-positive gay men's narratives on disclosure of serostatus. Paper presented at: 127th American Public Health Association Annual Meeting; November 7–11, 1999; Chicago, IL
23. Zea MC, Reisen C, Diaz R. Methodological issues in research on sexual behavior with Latino gay and bisexual men. Am J Community Psychol. 2003;31(3–4):281–291 [PubMed]
24. Carrillo H. The Night Is Young: Sexuality in Mexico in the Time of AIDS. Chicago, IL: University of Chicago Press; 2002
25. Diaz RM. Latino Gay Men and HIV: Culture, Sexuality, and Risk Behavior. New York, NY: Routledge; 1998
26. Doll LS, Beeker C. Male bisexual behavior and HIV risk in the United States: synthesis of research with implications for behavioral interventions. AIDS Educ Prev. 1996;8(3):205–225 [PubMed]
27. Déaz R. Trips to fantasy island: contexts of risky sex for San Francisco gay men. Sexualities. 1999;2(1):89–112
28. The HIV/AIDS epidemic in the Latino community Centers for Disease Control and Prevention Web site. Available at: http://www.cdc.gov/hiv/resources/reports/slcp/epidemic.htm. Updated May 4, 2007. Accessed September 20, 2007
29. HIV/AIDS among Hispanics/Latinos Centers for Disease Control and Prevention Web site. Available at: http://www.cdc.gov/hiv/hispanics/resources/factsheets/hispanic.htm. Updated August 21, 2009. Accessed February 18, 2010
30. Andreasen AR. Marketing Social Change. San Francisco, CA: Jossey-Bass; 1995
31. Weinrich NK. Hands-On Social Marketing. Thousand Oaks, CA: Sage; 1999
32. Montoya JA, Kent CK, Rotblatt H, McCright J, Kerndt PR, Klausner JD. Social marketing campaign significantly associated with increases in syphilis testing among gay and bisexual men in San Francisco. Sex Transm Dis. 2005;32(7):395–399 [PubMed]
33. Lombardo AP, Leger YA. Thinking about “Think Again” in Canada: assessing a social marketing HIV/AIDS prevention campaign. J Health Commun. 2007;12(4):377–397 [PubMed]
34. Olshefsky AM, Zive MM, Scolari R, Zuniga M. Promoting HIV risk awareness and testing in Latinos living on the US-Mexico border: the Tu No Me Conoces social marketing campaign. AIDS Educ Prev. 2007;19(5):422–435 [PubMed]
35. Geary CW, Burke HM, Castelnau L, et al. MTV's “staying alive” global campaign promoted interpersonal communication about HIV and positive beliefs about HIV prevention. AIDS Educ Prev. 2007;19(1):51–67 [PubMed]
36. Kennedy MG, Mizuno Y, Seals BF, Myllyluoma J, Weeks-Norton K. Increasing condom use among adolescents with coalition-based social marketing. AIDS. 2000;14(12):1809–1818 [PubMed]
37. Plautz A, Meekers D. Evaluation of the reach and impact of the 100% Jeune youth social marketing program in Cameroon: findings from three cross-sectional surveys. Reprod Health. 2007;4:1. [PMC free article] [PubMed]
38. Ross DA, Changalucha J, Obasi AIN, et al. Biological and behavioural impact of an adolescent sexual health intervention in Tanzania: a community-randomized trial. AIDS. 2007;21(14):1943–1955 [PubMed]
39. Cohen DA, Farley TA, Bedimo-Etame JR, et al. Implementation of condom social marketing in Louisiana, 1993 to 1996. Am J Public Health. 1999;89(2):204–208 [PMC free article] [PubMed]
40. Eloundou-Enyegue PM, Meekers D, Calves AE. From awareness to adoption: the effect of AIDS education and condom social marketing on condom use in Tanzania (1993–1996). J Biosoc Sci. 2005;37(3):257–268 [PubMed]
41. Goldbaum G, Perdue T, Higgins D. Non-gay-identifying men who have sex with men: formative research results from Seattle, Washington. Public Health Rep. 1996;111(suppl 1):36–40 [PMC free article] [PubMed]
42. Earl WL. Married men and same sex activity: a field study on HIV risk among men who do not identify as gay or bisexual. J Sex Marital Ther. 1990;16(4):251–257 [PubMed]
43. Martínez-Donate AP, Zellner JA, Fernández-Cerdeño A, et al. Hombres Sanos: exposure and response to a social marketing HIV prevention campaign targeting heterosexually identified Latino men who have sex with men and women. AIDS Educ Prev. 2009;21(suppl 5):124–136 [PubMed]
44. Zellner JA, Martínez-Donate AP, Sanudo F, et al. The interaction of sexual identity with sexual behavior and its influence on HIV risk among Latino men: results of a community survey in northern San Diego County, California. Am J Public Health. 2009;99(1):125–132 [PMC free article] [PubMed]
45. Hovell MF, Wahlgren DR, Adams MA. The logical and empirical basis for the Behavioral Ecological Model. : DiClemente RJ, Crosby RA, Kegler MC, editors. , Emerging Theories in Health Promotion Practice and Research. 2nd ed San Francisco, CA: Jossey-Bass; 2009:415–449
46. McLeroy KR, Bibeau D, Steckler A, Glanz K. An ecological perspective on health promotion programs. Health Educ Q. 1988;15(4):351–377 [PubMed]
47. Stokols D. Establishing and maintaining healthy environments: toward a social ecology of health promotion. Am Psychol. 1992;47(1):6–22 [PubMed]
48. Fernández-Cerdeño A, Martínez-Donate AP, Zellner JA, Sañudo F, Hovell F, Sipan C. El reto de los “hombres hombres”: riesgo y prevencion del VIH/SIDA en la tangente de un circulo gay “Latino” en San Diego, California [The challenge of the “men men”: HIV/AIDS risk and prevention at the tangent line to a Latino gay circle in San Diego, California]. Paper presented at: Segundo Coloquio Internacional de Estudios Sobre Varones y Masculinidades, Primer Congreso Nacional de la Academia Mexicana de Estudios del Género de los Hombres; June 21–23, 2006; Guadalajara, Mexico
49. Andreasen AR. Social Marketing in the 21st Century. Thousand Oaks, CA: Sage; 2006
50. Darrow WW, Biersteker S. Short-term impact evaluation of a social marketing campaign to prevent syphilis among men who have sex with men. Am J Public Health. 2008;98(2):337–343 [PMC free article] [PubMed]
51. Sanchez MA, Hernández MT, Vera A, et al. The effect of migration on HIV high-risk behaviors among Mexican migrants. Paper presented at: 17th International AIDS Conference; August 5, 2008; Mexico City, Mexico
52. Rogers EM. Diffusion of Innovations. 2nd ed New York, NY: Free Press; 1983
53. Kegeles SM, Hays RB, Coates TJ. The MPowerment Project: a community-level HIV prevention intervention for young gay men. Am J Public Health. 1996;86(8):1129–1136 [PMC free article] [PubMed]
54. Kelly JA, St. Lawrence JS, Stevenson LY, et al. Community AIDS/HIV risk reduction: the effects of endorsements by popular people in three cities. Am J Public Health. 1992;82(11):1483–1489 [PMC free article] [PubMed]
55. Glasgow RE, Vogt TM, Boles SM. Evaluating the public health impact of health promotion interventions: the RE-AIM framework. Am J Public Health. 1999;89(9):1322–1327 [PMC free article] [PubMed]
56. Dzewaltowski DA, Estabrooks PA, Klesges LM, Bull S, Glasgow RE. Behavior change intervention research in community settings: how generalizable are the results? Health Promot Int. 2004;19(2):235–245 [PubMed]

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