Introduction

A recent set of reviews by Millett et al. [1, 2] found that African American men who have sex with men (MSM) engaged in comparable or lower rates of HIV-related risk behaviors than MSM drawn from other racial/ethnic groups, yet have significantly higher HIV prevalence and incidence rates than these same racial/ethnic groups of MSM. Millet’s reviews identified a set of behavioral, psychological, structural, and biological factors that might explain the higher seroprevalence rates among African American MSM which exist despite the fact that there is no evidence that African American MSM have higher rates of the traditional behavioral risk factors for HIV seroconversion. This analysis could thus inspire innovative public health initiatives to lower HIV infections among sub-populations of MSM by identifying new variables as the basis for intervention activities to lower HIV infection rates among African American MSM. However, insights of this kind could also logically be achieved by examining forces among MSM that serve to protect specific groups of MSM from HIV seroconversion that report high rates of traditional behavioral risk factors yet have far lower rates of seroprevalence than those found among other groups of MSM.

This is the case among Asian/Pacific Islander (API) MSM. Existing epidemiological data shows that API MSM engage in high levels of HIV-related risk behaviors including unprotected anal intercourse and substance use [3–5]. Yet, HIV prevalence and incidence rates have been much lower among API MSM than among MSM of other races/ethnicities, especially other racial/ethnic minority MSM [6–11]. For example, the Urban Men’s Health Study found that HIV prevalence was 16% among API MSM in San Francisco compared to 25% among Whites, 38% among Blacks, and 31% among Latinos [6]. The seven-city Young Men’s Survey found that HIV incidence was 0.0% among API MSM between 1994 and 1998 compared to 2.4% among Whites, 4.0% among Blacks, and 1.8% among Latinos [11]. Reasons for the lower HIV prevalence and incidence among API MSM are unknown.

This paper takes a similar approach to Millett et al. [1] in identifying possible reasons for the lower HIV prevalence among a racial/ethnic minority group of MSM (i.e., API MSM). Based on well-documented common risk and protective factors for HIV infection among MSM and those that may be unique to API MSM at the behavioral, biological, socio-cultural, and structural levels in the HIV and MSM literature, and discussions with and input from experts in the field, we formulated ten guiding questions that may explain the lower HIV prevalence among API MSM. We then conducted a comprehensive qualitative review of studies to seek answers to the guiding questions (Table 1).

Table 1 Summary of primary studies and answers to the guiding questions
Full size table

Methods

Two separate literature searches using PubMed, PSYCInfo, and Ovid MEDLINE were conducted to identify articles published between January 1980 and July 2009. First, using the search terms “gay,” “bisexual,” “homosexual,” “homosexuality,” “men who have sex with men,” and “MSM,” we identified all articles that mentioned sexual identity or behavior applicable to MSM. Second, using the search terms “API,” “Asian/Pacific Islander,” “Asian,” “Asian American,” and cross-referencing terms “gay,” “bisexual,” “homosexual,” “homosexuality,” “men who have sex with men,” and “MSM,” we identified all articles that mentioned sexual identity or behavior applicable to API or Asian MSM. The inclusion and exclusion of articles consisted of three major steps. First, the review was limited to quantitative studies conducted in the United States that included either a subsample of API/Asian MSM or those that were conducted among API or Asian MSM. Studies that aggregated API or Asian MSM with American Indian/Alaska Native and Multiracial MSM together as an “Other” racial/ethnic category were excluded. Second, the ten guiding questions served as a framework to further screen abstracts and identify relevant articles. Abstracts that did not pertain to any of the ten guiding questions were eliminated. Finally, relevant full articles were examined in detail. Those that did not provide an answer to the guiding questions (i.e. did not compare API/Asian MSM to MSM of other races/ethnicities quantitatively) were subsequently excluded. As a result, a total of 58 studies were included.

Results

Are API MSM Less Likely to Engage in High-Risk Sexual Behaviors than Other MSM?

Two of the most important predictors of HIV infection—multiple sex partners and unprotected anal intercourse (UAI)—were examined. Of the five studies that compared numbers of sex partners between MSM of different races/ethnicities [7, 12–15], four studies found no significant differences in numbers of sex partners between API MSM and MSM of other races/ethnicities [12–15]. The HIV Testing Survey (HITS) found that about the same proportions (26%) of API, White, Black and Latino reported two–three partners in the past 12 months; however, a higher proportion of API men (60%) reported four or more partners compared to others (47, 39, & 45%) [13].

Fourteen studies examined rates of UAI, and all found that API MSM engaged in similar rates of UAI compared to White MSM or race/ethnicity was not associated with UAI [7, 10, 13, 15–25]. The San Francisco/Berkeley Young Men’s Study found that 27% of API young men who have sex with men (YMSM) reported UAI in the past 6 months compared to 28% of White YMSM [10]. Since the introduction of HAART, rates of UAI have increased among MSM throughout the world [26, 27]. The Community Intervention Trial for Youth (CITY) found that prevalence of UAI in the past 3 months was significantly lower among Black YMSM (24%), but comparable between API (36%), White (35%), and Latino YMSM (29%) [20]. Of the three studies that measured URAI, which poses the highest risk for HIV transmission, none found significant differences in URAI rates between API and White MSM [7, 13, 23]. In particular, one study found that URAI rates did not differ significantly with partners of different races/ethnicities among Asian MSM [23].

In summary, the reviewed studies suggest that API MSM are as likely to engage in high-risk sexual behaviors as other MSM. Furthermore, findings from these quantitative studies showed that API MSM have as many sex partners as MSM of other races/ethnicities and that rates of UAI were similar across races/ethnicities and did not differ by partner’s race/ethnicity.

Are API MSM Less Likely to Abuse Substances than Other MSM?

The associations between substance use/abuse and sexual risk behaviors among MSM have been widely documented in the literature with some papers documenting an association between substance use and HIV seroconversion [28, 29]. Of the eight studies that measured any recent or lifetime substance use [17, 30–36], seven studies did not find evidence that API MSM were less likely to use/abuse substances than others [17, 30–33, 35, 36]. The San Francisco Young Men’s Health Study found that race/ethnicity was not associated with frequent-heavy alcohol use, polydrug use, or frequent drug use [31]. The National HIV Behavioral Surveillance Survey (NHBS) found that prevalence of non-injection drug use (most prevalent are marijuana, cocaine, ecstasy, poppers, amphetamine/methamphetamine, and other club drugs) in the past 12 months did not differ significantly by race/ethnicity, 37% among API, 46% among White, 44% among Black, and 38% among Latino [17]. Others examined use of specific substances, particularly methamphetamine due to its popularity among MSM as a “sex-enhancing drug” [37]. Rhodes et al. [35] found that race/ethnicity was not associated with methamphetamine use in the past 30 days among a large sample of MSM recruited from gay bars and the Internet.

No studies found racial/ethnic differences between API men and others in terms of frequency of substance use and substance use before/during sex [31, 33, 34, 38]. Halkitis et al. [33] found that API, Black and White men reported similar numbers of days of methamphetamine use in the past 6 months. Substance use before/during sex may be a more salient risk factor for UAI as its effects are more immediate on sexual behaviors. Stueve et al. [38] examined event-level substance use and sexual risk behaviors, and found that race/ethnicity was not associated with being “high” during last sexual encounter with a non-main partner and UAI or URAI. A few studies compared rates of injection drug use across races/ethnicities with mixed findings [7, 10, 39]. While Lemp et al. [10] found API MSM were significantly less likely to have injected any drugs in the past 6 months, Berry et al. [39] found no racial/ethnic differences in injection drug use among MSM.

In summary, the reviewed studies showed that substance use/abuse is as prevalent among API men as among men of other races/ethnicities. However, more studies are needed to examine situational and event-level substance use (substance use during a specific sexual encounter or a given episode, e.g., substance use during the last anal intercourse) among MSM in general, particularly among API men. Although two out of the three studies found API men were less likely to have injected drugs, considering the very low prevalence of injection drug use among MSM, it is reasonable to argue that racial/ethnic differences in injection drug use cannot account for the observed racial/ethnic disparities in HIV prevalence.

Do API MSM Have Lower Rates of Sexually Transmitted Diseases than Other MSM?

Sexually transmitted diseases (STDs) facilitate the transmission and acquisition of HIV and have been consistently documented in the MSM literature for their associations with HIV infection [40, 41]. Of the six studies reviewed [7, 39, 42–45], only one found that prevalence of lifetime STD was significantly lower among API men (13%) compared to White (32%), Black (26%), and Latino (29%) [7]. All three studies conducted in San Francisco found similar rates of STDs across races/ethnicities [39, 42, 43]. Using STD surveillance data, McFarland et al. [43] examined the incidence of rectal gonorrhea and early syphilis among MSM from 1999 to 2002, and found that incidence rates for the two STDs were lower among API MSM in 1999 but rapidly surpassed that of White MSM thereafter. In addition, NHBS surveys found that prevalence of STD testing in the past year did not differ by race/ethnicity [17].

In summary, the reviewed studies suggest that API MSM have similar rates of STDs as other MSM. However, the literature of STDs among MSM, particularly among API MSM, has its limitations. No data exist for HIV and STD co-infections among API MSM, which is an important indicator of HIV transmission due to the synergistic effects of both diseases [41]. Moreover, no study investigated STD treatment-seeking behaviors or sexual risk behaviors during STD treatment among varying ethnic groups of MSM.

Are API MSM More Likely to Know Their HIV Serostatus, Hence Less Likely to Expose Their Partners to HIV, than Other MSM?

HIV testing has been a cornerstone of HIV prevention as it links positive MSM to medical care and treatment, and has been recommended as a routine test for MSM engaging in high-risk sexual behaviors. Of the 11 studies reviewed, none found that API men were more likely to have ever been tested for HIV or are tested more frequently than other MSM [7, 13, 17, 39, 44, 46–51].

Rates of ever testing for HIV were high (about 90%) across races/ethnicities among community samples of MSM while lower (about 80%) among an Internet sample of MSM [13, 17, 48]. Rates of testing during the preceding year were generally lower for all racial/ethnic groups of MSM, clustering around 60% [17, 46, 49]. The Young Men’s Survey found that race was not associated with testing within the past year (API vs. White vs. Black vs. Latino = 49% vs. 56% vs. 53% vs. 52%) [49]. Helms et al. [47] found that API men were significantly more likely to have never had a HIV test than White men; however, longer or shorter inter-test interval did not differ between API and White men. Four studies examined unrecognized HIV infections and found no evidence that API men were less likely to have unrecognized infections than White men [7, 47, 50, 51]. The NHBS surveys conducted in Los Angeles and San Francisco found that only Black race was independently associated with unrecognized HIV infection [51].

In summary, rates of HIV testing behaviors among API MSM are similar to other MSM. Recently, increasing attention has been focused on acute/early HIV infections as they may be contributing to as much as half of new infections among MSM each year [52–54]. Future research in this area should investigate racial/ethnic differences in rates of acute/early HIV infection and examine sexual risk behaviors among those diagnosed with the infection.

Are API MSM More Likely to Utilize HIV Prevention Intervention Services than Other MSM?

HIV behavioral interventions remain a front-line component of HIV prevention efforts. Reviews of HIV behavioral interventions among MSM in the US found that these interventions are efficacious in reducing sexual risk behaviors [55].

Two studies examined reach and coverage of HIV prevention intervention services among MSM [17, 50]. The NHBS surveys found that similar proportions of racial/ethnic groups of MSM reported receiving free condoms (API vs. White vs. Black vs. Latino = 84% vs. 78% vs. 81% vs. 82%), individual-level interventions (API vs. White vs. Black vs. Latino = 12% vs. 11% vs. 20% vs. 19%), and group-level interventions (API vs. White vs. Black vs. Latino = 5% vs. 5% vs. 14% vs. 10%) [17]. In the YMS study, MacKellar et al. [50] found that race/ethnicity were not associated with receiving HIV counseling. One study found that racial/ethnic minority MSM were significantly less likely to have disclosed their sexual orientation to their health care providers compared with White MSM [56]. Hence, racial/ethnic minority MSM may be less likely to receive MSM-specific interventions at the provider-level.

In summary, the two reviewed studies found that API MSM are not more likely to utilize HIV prevention intervention services than other MSM.

Do Some Ethnic Groups Within the API MSM Population Engage in Higher Rates of Risk Behaviors than Others?

Since early in the HIV/AIDS epidemic, it was reported that some ethnic groups within the API population were disproportionately affected than others [57]. Data from HIV/AIDS case reports from 1985 to 2002 showed that most HIV/AIDS cases were among APIs born in Philippines, Vietnam, and India [58]. However, reasons for such disparities between ethnic groups among the API population are unclear.

Of the nine studies reviewed [3–5, 59–65], seven did not find evidence that ethnicity was associated with HIV-related risk behaviors [3, 4, 59, 60, 62–64]. Choi et al. [3, 4, 60, 62] found that ethnicity was not associated with UAI, UIAI, URAI, or being high or buzzed during sex. Nor was ethnicity associated with having multiple partners or having UAI with drug or alcohol [64]. The other two studies found some differences between ethnic groups. For example, Operario et al. [5] found that Koreans and Vietnamese reported more club drug and polydrug use.

In summary, there is strong evidence that ethnicity was not associated with HIV-related risk behaviors. The reasons why a few ethnic groups within the API MSM population are more affected by HIV/AIDS than others remains unknown.

Do API MSM’s Sexual Networks Place Them at Lower Risk for HIV Infection than Other MSM?

The transmission and spread of STDs/HIV within a community in part depends on the underlying structure of the network of sexual contacts, also known as the sexual network, which may have a greater impact than individual risk behaviors [66–69]. Studies of sexual networks intend to describe the transmission dynamics of STDs/HIV within and across “core” (high-risk) and “peripheral” (low-risk) groups. Since HIV prevalence is higher among White/Black/Latino MSM, older MSM, and those engaging in casual sex, API MSM would be at lower risk for HIV infection if their sexual network is mostly composed of other API men, partners of similar ages, and main partners.

Only a few studies examined the structure of MSM’s sexual networks and these findings are complex. Of the three studies that obtained data on respondents’ partner status, none found significant differences in partner status between MSM of different races/ethnicities [7, 17, 70]. YMS Phase II conducted in Los Angeles found that similar proportions of API, White, Black, and Latino YMSM (47, 52, 45, & 49%) reported any non-steady anal-sex-partners in the past 12 months [7]. Two studies examined age differences between respondents and their partners [7, 39]. Berry et al. [39] found that API MSM were more likely to have a partner within 10 years of their own age compared with White MSM (81.1% vs. 67.6%). However, when the age difference was measured at 5-year intervals, only Black MSM reported a significantly higher proportion of partners from a different age group than White MSM [7]. Of the three studies that examined partner’s race/ethnicity, all found that API MSM were not more likely to have partners of the same race/ethnicity [7, 39, 71]. Bingham et al. [7] found that 87% of API MSM reported anal-sex partners of a different race/ethnicity compared with 73% of Black, 48% of Latino, and 37% of White MSM. These findings of race mixing patterns among API MSM were similar to the results of a study focusing on API men where it was found that about two-thirds of API participants’ sex partners were non-API men [62]. However, API MSM were more likely to have UAI with an API partner than with a non-API partner.

In summary, findings from these studies revealed a rather complex picture of API MSM’s sexual networks. Although the data showed that a majority of API MSM seek sex partners beyond their own racial/ethnic group, all of these studies were conducted in two gay concentrated urban cities and may not be generalizable to sexual mixing patterns among API MSM in other places. In addition, the findings of age mixing patterns were not conclusive and the methodologies used had limitations [72].

Do API MSM Engage in Higher Rates of Seroadaptive Behaviors than Other MSM?

Seroadaptation—broadly defined as diverse community-originated behavioral strategies undertaken to reduce HIV transmission or acquisition risk by deliberately selecting sexual partners of the same HIV serostatus or by modifying sexual practices depending on knowledge of one’s own and one’s partner’s serostatus—has been hypothesized to explain the observed discrepancies in UAI, STDs, and new HIV infections [73–76].

One study that examined serosorting found that rates of serosorting (limiting unprotected sexual partners to those of the same HIV status) across races/ethnicities were similar: API vs. White vs. Black vs. Latino = 30% vs. 41% vs. 24% vs. 35% [77]. In multivariate analysis, race/ethnicity was not independently associated with serosorting. Honest disclosure and discussion of one’s own and sex partner’s serostatus are critical to effective seroadaptive behaviors. Of the two studies that examined whether participants have asked or discussed serostatus with sex partners, both did not find significant associations with race/ethnicity [7, 78]. Among MSM attending Denver Metro Health Clinic, 40% of Asian, 38% of White, 39% of Black, and 32% of Latino reported having a discussion of serostatus with 100% of partners [78]. Meeting sex partners on the Internet has been hypothesized to facilitate serostatus disclosure because the Internet affords one anonymity [79, 80]. As suggested by qualitative interviews with API MSM, the Internet is a major venue for API MSM to meet sex partners [81]. Hence, if API MSM are more likely to use the Internet to find sex partners, they may be more likely to know their partners’ serostatus. We did not find any study that directly measured the relationship between meeting sex partners online and serostatus disclosure, however, two studies examined whether there were racial/ethnic differences in where MSM met their partners and found no differences [21, 70]. Horvath et al. [21] found that race/ethnicity was not associated with having met partners exclusively online, exclusively offline, or both online and offline.

Seroadaptive behaviors also include men having sex partners of a different serostatus but do not engage in unprotected sex. Hence, we reviewed seven studies that reported serodiscordant unprotected sex among MSM [6, 15, 82–86]. Xia et al. [15] found that API men were less likely to have serodiscordant UAI in the past 12 months (API vs. White vs. Black vs. Latino = 0% vs. 9% vs. 17% vs. 19%). Five studies examined unprotected sex among HIV-positive and HIV-negative MSM separately and found that race/ethnicity was not a significant correlate of unprotected sex. In the Urban Men’s Health Study, Schwarcz et al. [6] found that race was not associated with UIAI among HIV-positive MSM with serodiscordant non-primary partners (API vs. White vs. Black vs. Latino = 0% vs. 17% vs. 16% vs. 19%) or URAI among HIV-negative MSM with serodiscordant non-primary partners (API vs. White vs. Black vs. Latino = 7% vs. 5% vs. 7% vs. 6%).

In summary, it is unclear whether seroadaptive behaviors are more prevalent among API MSM than other MSM because: (1) the majority of the reviewed studies included very small subsamples of API MSM or HIV-positive API MSM (n ≤ 15) [6, 15, 77, 78, 82, 83]; (2) definitions and measures of seroadaptive behaviors have been refined and expanded in the past few years [73, 87]; (3) contextual factors (e.g. disclosure and discussion of serostatus, intention to engage in seroadaptive behaviors) were very limited in almost all studies.

Do API HIV-Positive MSM Have Better Access to Medical Treatment and Care than Other MSM?

Linking HIV-positive persons to medical treatment and care is an important part of HIV prevention as HIV-positive persons on antiretroviral therapy have lower viral load and hence reduces HIV transmission if they engage in high-risk sexual behaviors [88–90]. Research on access to HIV treatment and care as well as adherence to HIV drugs is scarce among MSM in general and absent for API MSM in particular. We did not locate any study regarding HIV treatment and care that included a subsample of API men. However, we included one study that measured trends in AIDS incidence and survival among MSM as a proxy to them receiving HIV treatment and care [91]. Using AIDS case reports from all states in the US, Blair et al. [91] found that between 1996 (when HAART was introduced) and 1998, AIDS incidence declined among all racial/ethnic groups of MSM, but to a greater degree among API men (43%) compared with White (39%), Black (23%) and Latino (35%) men. Accordingly, AIDS deaths declined among all MSM, 69% among API, 65% among White, 53% among Black, and 60% among Latino. From 1996 to 1999, AIDS rate (per 100,000) was lowest among API (9.1, 6.3, 5.2, & 5.5) compared with White (17.9, 12.9, 11.0, & 9.9), Black (66.2, 56.2, 50.7, & 49.3), and Latino (39.3, 31.8, 29.0, & 27.3). However, survival rates of at least 24 months after diagnosis of AIDS in 1997 were similar across races/ethnicities (API vs. White vs. Black vs. Latino = 95% vs. 94% vs. 89% vs. 94%).

In summary, we could not directly address this question from the literature. Despite the importance of HIV treatment and care, research among API MSM in regards to access to treatment and care, quality of care received, as well as adherence to treatment is very limited.

Are API MSM Less Acculturated into American and/or Gay Culture, Which may Lead to Lower Risk Behaviors?

Studies of API MSM showed that 50–75% of the participants were born outside of the US [3, 59, 61, 63]. Some empirical evidence suggests that higher acculturation to gay culture or more connection to gay community may increase MSM’s risk behaviors, e.g. substance use [92]. Hence, it may be that foreign-born API MSM, who make up a majority of API MSM, engage in lower HIV-related risk behaviors.

Ten studies examined the relationship between nativity (birthplace) and UAI, substance use, and HIV infection [3–5, 59–63, 65, 93] with mixed findings. Choi et al. [3, 4, 60, 62] found that nativity was not associated with UAI, UIAI, or URAI. Yoshikawa et al. [65] found that US-born APIs reported higher rates of UAI with primary partner, but no difference in rates of UAI with secondary partners. In terms of substance use, one study found that nativity was not associated with frequent drug use, club drug use, or polydrug use [5] while the other found that US-born APIs were more likely to be high or buzzed during sex [4]. In addition, US-born API MSM were more likely to be HIV infected than foreign-born API MSM (4.1% vs. 2.0%) [61].

Birthplace is a crude measure of acculturation. Matteson [63] found that birthplace was not associated with risk taking, but high acculturation to Asian culture was associated with high functioning in terms of safer sex. A study conducted among Latino YMSM also found that those connected to their ethnic community had lower rates of sexual risk behaviors [94].

In summary, the reviewed studies suggest that nativity was not associated with UAI among API MSM, but with substance use and HIV infection. The association between nativity and HIV infection may be confounded by the fact that most API MSM immigrated from countries with lower HIV prevalence than that in the US. Very limited evidence suggest that high acculturation to one’s own ethnic culture may have protective effect. Certainly, refined measures of acculturation to American/gay/ethnic cultures are needed to examine the relationship between acculturation and HIV-related risk behaviors among API MSM.

Conclusions

Taken together, trends emerging from the reviewed studies suggest that traditional individual-level factors—unprotected anal intercourse, substance use, STD prevalence, rates and frequency of HIV testing, and utilization of HIV prevention services—do not appear to be related to the lower HIV prevalence among API MSM. This finding is consistent with reviews by Millett et al. [1, 2] that individual HIV-related risk factors cannot account for the greater HIV prevalence among Black MSM. Indeed, we found some evidence from the literature that socio-cultural and structural factors might be the more critical forces in determining racial/ethnic disparities of HIV among MSM. For API MSM, these factors include the structures of sexual networks, access to and reception of medical care and treatment among HIV-positive men, and influences of different levels and types of acculturation. Moreover, emerging risk reduction strategies adopted by MSM, such as seroadaptive behaviors, could play a role.

There are several limitations to this review. First, caution should be exercised in interpreting the results of this review. We do not provide any definite answers to the ten guiding questions because most of the included primary studies did not seek to examine racial/ethnic group differences as a primary aim, their sampling methods and measures varied, and there may be unobserved mediators/moderators. Second, instead of conducting a meta-analysis, we were only able to qualitatively synthesize the results from the literature. This was in part due to the small sample sizes of API MSM included in the primary studies which would preclude meaningful sub-group analyses. Third, because the primary studies used different reference groups, we could not define a specific racial/ethnic group as a consistent comparison group in this review. Finally, the ten guiding questions are not exhaustive. Restricted by the small number of studies that included API MSM subsamples, we were not able to examine some other possible reasons, such as co-occurring psychosocial conditions (i.e. syndemics), distal factors (e.g. childhood sexual abuse and experiences of homophobia), and community HIV viral load.

Despite these limitations, this review points to important areas of research for API MSM and MSM in general. Previous research of API MSM primarily focused on individual-level risk factors of HIV infection, while largely ignored socio-cultural and structural factors. Given that HIV intervention models for MSM tend to focus on individual-level determinants, addressing socio-cultural and structural factors that appear to be protective for API MSM in this review may work to increase the efficacy of these interventions. Such interventions might address socio-cultural factors such as race-based discrimination which may affect partner selection hence the organization and structures of sexual networks, with increased intervention work in those sexual networks with the highest rates of HIV infection. Another possibility is that API MSM are “better shoppers,” meaning that they may choose partners more carefully. That said, diversity within the API communities in terms of ethnicity, socio-economic status and immigration-based discrimination should also be recognized and could influence the observed HIV disparities among API MSM. Structural factors such as poverty at the neighborhood or social network level could determine access to and reception of medical care and treatment among HIV-positive men. Again, intervention work could be tailored to better function within these disadvantaged groups, particularly to lower community viral load within specific sexual networks. While some of these factors are common to all MSM, others are unique to API MSM. To understand the differential impact of these factors on HIV infection across racial/ethnic groups of MSM, future studies should include sufficient sample sizes of API MSM to allow for cross-race comparison and sub-group analysis. Beyond this, better theories of resilience and measurement of strengths and protective factors are needed. What could be the sources of resilience and strengths exist within API MSM and their communities? Do Asian cultural values such as collectivism and emphasis on stability provide stronger and wider support networks for API MSM, which could buffer other adversities (e.g., racism)? Formative research should be conducted to identify potential resources of resilience and strengths.

Although this review emphasizes factors that might be protective against HIV infection among API MSM, it must be acknowledged that HIV prevalence and incidence rates are increasing among API MSM [95]. Understanding both risks and strengths will benefit API MSM in particular but also others. It has been suggested that interventions are most likely to succeed and be effective when they are designed to support and enhance naturally occurring sources of resiliency and strengths in addition to addressing risk factors and weaknesses [96].