There is substantial evidence in the published literature on HIV disease and AIDS that both inadequate and inaccurate knowledge related to HIV acquisition and transmission increases the risk of HIV infection. In a study of junior high school students, API adolescents had the lowest levels of knowledge compared to African-American, Latino, and White students,⁷ suggesting that API adolescents might be at increased risk for HIV infection. Among Asian Indian adolescents, although 86% answered correctly regarding modes of transmission, a substantial number retained myths and misconceptions about the role of blood donation, blood testing, use of public toilets, and being gay in HIV transmission.⁸ Likewise, Gellert et al.⁹ found high levels of knowledge regarding actual modes of transmission among Vietnamese adults, but misconceptions related to HIV acquisition through casual contact, shared utensils, and public toilets persisted in a significant proportion. In terms of gender, the authors noted that women had lower levels of knowledge than men; however, acculturated younger women (younger than 35 years) had higher levels of knowledge than less acculturated men and women and comparable levels to acculturated young men.

The risk of HIV infection is further compounded when individuals at high risk perceive themselves at low risk for contracting HIV. For instance, API MSM who perceived themselves to be at low risk for acquiring and transmitting HIV were more likely to engage in unprotected anal intercourse.¹⁰ Additionally, stereotypes in the gay community that APIs are at low risk may result in increasingly unsafe sex behavior among APIs and their partners. Choi et al.¹¹ found that API MSM were less likely to use protection during anal intercourse with API partners compared to non-API partners. The authors argue that these perceptions, in part, persist because of the low rates of HIV prevalence in the API MSM community and that earlier studies showed lower rates of unsafe sexual practices in this population. In the heterosexual API community, perceptions of AIDS as a disease of the gay and White communities continue to persist.⁶ API’s perceptions of low risk were also influenced by their HIV-negative status after unprotected sex with multiple sex partners.⁶

Compared to Western society, which values individualism, Asians strongly believe in collectivism. Typically, Asian communities believe in group harmony and therefore individuals must conform to the happiness of the group and the community. Engaging in premarital and extramarital sex is generally disapproved of in the API community, and communication on sexual matters is rarely encouraged in API families. For example, Vietnamese women (55%) were more likely than men (22%) to disapprove of premarital sex, whereas 87% of the participants, both men and women disapproved of extramarital sex.⁹ There have been reports of late initiation and low rates of sexual activity among API adolescents compared to those in adolescents from other ethnic communities.¹² Although disapproval of premarital sex might be a culturally protective factor reducing risk of exposure to HIV, it might negatively influence self-reports of sexual activity, resulting in an inaccurate picture of the extent of risk behaviors among API youth. Further, because of familial disapproval of sensitive sexual topics, API youth might seek information regarding HIV from sources that might not be helpful. The majority of Asian Indian youth in one study reported using media such as television, movies, talk shows, and magazines as information sources, but only a minority found them useful.⁸

Homophobia is widely prevalent in API communities. API gay or bisexual men are less inclined to disclose their sexual orientation to maintain family honor. In Kanuha’s study in Hawaii,¹³ API gay and bisexual men reported a constant pressure between concealing and publicly disclosing their gay identities to protect relationships with family members. API MSM may be stigmatized and ostracized in their communities, leading to social isolation. One can surmise that API MSM with HIV infection will be most affected. Stigma due to HIV can marginalize both API MSM and heterosexual APIs because of widely prevalent cultural beliefs that HIV is acquired through socially unaccepted behaviors such as homosexuality, substance use, sexual promiscuity, and commercial sex work.

API women are particularly vulnerable to HIV infection and its impact because of socio- cultural norms regarding women’s subservient roles and status in the family. Cultural beliefs regarding condom use pose a substantial risk for women. Negotiating condom use is rarely a choice for API women because of traditional male privilege in their community. Women are afraid to ask their partners to use condoms because the partner might suspect they are having an affair or label them as promiscuous or because it might imply that the partner is promiscuous. Another popular belief that sex with condoms is less pleasurable compounds the risk for API women. In the API community, female massage parlor workers are receiving some attention as a high-risk group for spreading HIV. Nemoto et al.¹⁴ found that API masseuses reported inconsistent condom use, despite knowing about the risks of contracting HIV and other STIs. Reasons mentioned by API masseuses were financial considerations, competition for customers, and demanding clients who refuse to use condoms. Besides, some masseuses believed that regular customers are safe. These women were also at risk for abuse from customers and API gangs, and several women reported instances of physical and psychological abuse. Traditionally, violence against API women was condoned and used to discipline wives and maintain prescribed roles. Research studies on violence against immigrant API women in the past decade¹⁵ attest to the persistence of these attitudes. Not surprisingly, threats of physical abuse are likely deterrents to the use of condoms in a sexual encounter.