Curr HIV/AIDS Rep (2010) 7:185–193 [21]. Subsequently, health promotion interventions devel- oped for whites were extensively applied to those from other racial/ethnic groups [22]. A second generation of research focused on examining differences in race and ethnicity [23]. During this period, public health researchers commonly classified groups based upon their race/ethnicity, believing it was a valid proxy for culture [16]. Attempts by researchers to address and incorporate historical patterns of behavioral change and cultural beliefs and values that contradicted prevention messages often resulted in myopic interpretations and oversimplification of the complexities and depth of differences between ethnic groups and their risk for disease transmission. For example, attention to culture was often represented by racial/ethnic matching of program staff with intervention participants. Also, the inclusion of media resources, such as using videos and music lyrics that included African American models or was written by African American artists, was supposed to demonstrate attention to culture [16]. While ethnic match- ing may be important [24], the issue of being culturally competent to what is being communicated along with the manner in which the message is conveyed may be as important, if not more important than simply having someone who looks like the intervention participant. The inclusion and application of culture as a specific social construct in HIV intervention approaches is an innovative concept, which stemmed from the belief that by understanding cultural characteristics of a given group, public health programs would be more capable of meeting the health needs of its members [25]. Unfortunately, only theoretical models that are popular or rooted in a long history of use are commonly used in HIV interventions [12 ]. Among models that more specifically address contra- dictions of some African American cultural values and beliefs is the Sexual Health Model (SHM). Survival coping strategies that transcend risks for HIV/AIDS and need to be incorporated into behavior change efforts have been described [12 ]: 1) Adaptive Duality, or saying and doing what is perceived to be acceptable to authority figures while also engaging in behaviors and beliefs that more accurately reflect personal relationships and values; 2) Collectivist Identity that promotes placing others before oneself and perceptions of relationships with others as a sign of personal identity, born out of historical oppression and the unavailability of partners to sustain family life and protection; 3) Indirect Patterns of Communication, born out of necessity and continued as a means of communica- tion to promote social and sexual exchange, but not HIV/ AIDS prevention skills; and 4) Mistrust of Outsiders, a protective mechanism that requires outsiders to earn the trust of African Americans in order to be believable. The SHM addresses these survival patterns and promotes concepts of interconnectedness, body awareness, and sexual 187 ownership to acknowledge historical and contemporary contradictions and reframe these critical strategies. Lacking cultural elements limits the paradigms that could be developed for African Americans. Obstacles for incorporating culture into interventions include inherent abstractness, a lack of operationalized definitions of how culture can improve an HIV prevention focus, a lack of adequately tested psychometrics to assess culture and its influence on risk behaviors, and the lack of relevant training for those administering the developed interventions (ie, cultural competency) [26 ]. Another possible barrier is that reviewers of grants and journal manuscripts may be socialized to expect specific concepts promoted in tradi- tional models. Inclusion of new concepts may create barriers to securing research funding and/or to having research findings published. Concerns about introducing more relevant conceptual frameworks, familiar in ethnic studies or black psychology, may prevent investigators from trying new or different models. Thus, Afrocentric models that motivate ethnic pride and address culturally based mediators of change [16, 26 ] may not be included in interventions for African Americans. Cultural Process and Content While it may seem intuitive to include and explore how culture influences sexual decision-making by gender, racial/ ethnic group, sexual orientation and/or identification, and sexual-risk and drug-risk behaviors, there is no consensus on how to incorporate it or integrate it as a moderating or mediating variable within HIV prevention models [16]. Two primary strategies have been identified to incorporate culture in HIV prevention interventions [16]. Intervention presentation strategies refer to the communication style and process, with racial/ethnic matching of facilitators or the use of videos with models of the same race/ethnicity, as common examples [16, 22, 25, 27, 28]. The belief is that there is a decreased chance of miscommunication when information is provided by individuals who look and sound like the participants [16, 22, 25, 29–31]. Ethnic minorities must be allowed to define their own language and develop their own dialogue if they are to become empowered in regards to their health [32]. Risk reduction messages must be presented in a manner that speaks to the target population. Further, to ensure the success of the interven- tion, those who are providing the intervention must be familiar with and ideally be a member of the target population and of the surrounding community. Curriculum content involves the incorporation of cultural concepts within the intervention. Examples include the discussion of racial or ethnic pride and gender-based power differentials, especially when discussing condom use with sexual partners [29]. Content needs to include not only the