Part 1 of 3: Capacity Development for a Community-Academic Consortium Study of HIV infection among Asian and Pacific Islander Men Who Have Sex with Men in Seven U.S. Cities
Christian Alvez, Tri Do, Audrey Bangi, Frank Wong, and the MATH Study Consortium
ISSUE: Involving community in a research study optimizes relevance and the use of data and findings of the study. With the need for a disaggregated national data set on Asian and Pacific Islander men who have sex with men (MSM’s), participation of members of the target population, community stakeholders, and service providers is pertinent in shaping a culturally relevant study design, producing useful data analysis, and the appropriate dissemination of findings. Yet often times, community-based organizations (CBO’s) do not have the infrastructure to be a strong partner and meet levels of capacity essential in meeting quality assurance standards.
SETTING: Asian and Pacific Islander American Health Forum (APIAHF) acts as the convener and provides capacity building assistance to all 7 community-based organization partners in the Men of Asia and the Pacific Testing for HIV (MATH) study located at 5 major metropolitan areas including Los Angeles, San Francisco Bay Area, New York, Philadelphia, and Boston.
PROJECT: APIAHF collaborates with the scientific team in identifying structural components of the study, assess the needs of the CBO partners, work to address capacity gaps, and mitigate changes at the organizational and program level from housing a research study to the integration of Rapid HIV testing programs. APIAHF also work with the study’s external evaluator in an effort to integrate capacity building into the overall evaluation to gain a better look at the efficiency of the consortium model.
The MATH Study consortium is a multi-level, national research partnership that aims to collect behavioral and epidemiological data on 2000 Asian and Pacific Islander men who have sex with men (MSM) conducted at 7 community-based partner sites in 5 major metropolitan areas to reflect the HIV/AIDS epidemic in Asian & Pacific Islander communities and the community health infrastructure responding to it.
RESULTS: CBO partners in the MATH Study vary in organizational profile and levels of capacity, so building infrastructure was tailored to the needs of each site. By the start of pilot testing in 2007, after 1.5 years of capacity building efforts, all CBO partners met all local, state and federal requirements for conducting Rapid HIV testing. 4 out 7 partners previously did not have Rapid HIV Testing programs using OraQuick Advance, while 2 did not have an existing HIV testing service at all. Through their increased capacity and experience, 1 partner influenced their local planning group and health department with the introduction of OraQuick Advance in their jurisdiction, where only fingerstick technology was available, and was able to secure funding for a Rapid HIV testing service. 1 partner is also making an impact in their community planning group and local health department where they are looking to create an electronically-based data collection system using the MATH study as a model.
LESSONS LEARNED: The MATH Study consortium model provides a strong framework from which CBO’s can adopt and adapt to new science quicker and effectively impact health services in their communities. Effective use of a capacity building partner organization not only helps in capacity building efforts but also increases access of community groups to researchers, bridging science and practice to produce sustainable health systems.
Title Part 2 of 3 (MATH Study): Pilot Findings from a Collaborative Study of HIV among Asian and Pacific Islander MSM
Tri Do, Christian Alvez, Audrey Bangi, Frank Wong, and the MATH Study Consortium
Asian and Pacific Islanders (API) are among the fastest growing group of new HIV/AIDS cases in the United States, and men who have sex with men (MSM) comprise nearly three-quarters of cases among API. However, prior studies of API MSM have been limited to single cities and primarily sampled from gay-identified social venues. The Men of Asia and the Pacific Testing for HIV (MATH) Study is a five-year cross-sectional HIV social epidemiological study of 2,000 API MSM in five metropolitan areas (San Francisco Bay Area, Los Angeles, New York, Boston, and Philadelphia). For the pilot phase of the study, we sought to assess the feasibility of: (1) reaching a diverse sample using respondent-driven sampling (RDS); and (2) obtaining quality research data using a community-academic consortium model.
Eligible participants must report lifetime sexual contact with another man, API ethnicity, age = 18 years, and willingness to be tested. Participants are initially recruited from MSM venues, online outreach sites, agency programs, and API community events. Participants receive rapid oral HIV testing and counseling, complete a behavioral survey (in English, Chinese or Vietnamese), and receive instructions for referring contacts into the study. Those who test preliminary positive or indeterminate undergo phlebotomy for confirmatory testing, CD4 count and HIV viral load. All subject-related procedures are conducted at seven community agencies with technical assistance from the scientific team.
During one year of pilot testing, the MATH consortium recruited 72 participants. Few modifications to the protocol were made but we expended significant resources to build the community agencies’ capacities. However, this effort resulted in increasing proportions of completed data collected. Overall, 5.4% of respondent data deemed of high importance were missing.
Ten of the 72 participants were recruited by RDS. The median number of other API MSM known to participants was 18. The mean and median age were both 33.0 (SD 11.2). Only 20% reported that English was the language with which they are most comfortable, and 70% were born outside the U.S. mainland. Ethnic identification included Filipino (41.7%), Chinese (13.9%), Japanese (9.7%), Vietnamese (9.7), and Indian (4.2%), among other groups. While 36% reported lifetime bisexual behavior, 76.4% identified as gay, 8.3% as bisexual, 4.2% as straight, and 2.8% as queer.
Many (73.6%) reported prior HIV testing, although the average time since the last test was 4.6 years (median 1.6 years, SD 6.67). Twenty five individuals (34.7%) tested positive for HIV infection, including 22 who already knew they were HIV+. Three individuals (12.0% of HIV+ and 4.7% of the total sample) learned of their HIV infection for the first time. The median CD4 count in the sample was 343 cells/mm3 (range 108-704).
Based on our pilot study, were able to identify a diverse group across several demographic and HIV prevention measures, including prior testing, awareness of HIV status, and stage of infection (CD4 count). We conclude that conducting a social epidemiological study of API MSM involving complex procedures in a community-based setting is feasible and can provide quality data.
Part 3 of 3 (MATH Study): Successes and challenges of conducting a pilot study using an academic-community research consortium model
Audrey Bangi, Christian Alvez, Tri Do, Frank Wong, and the MATH Study Consortium
ISSUE: Collaborations that integrate the interests and expertise of scientific researchers and community-based organizations (CBOs) have promising potential to enhance the effectiveness and efficiency of achieving challenging health objectives. However, engaging a broad array of people and organizations in a successful collaborative process is extremely difficult.
Evaluation activities are one modality through which the barriers and facilitators of research collaborations between community and academic partners can be highlighted, particularly in understanding the HIV prevention and intervention needs of hard-to-reach populations. This presentation will describe the use and implementation of evaluation in the context of the pilot phase of a research project for Asian and Pacific Islander (API) men who have sex with men (MSM). Findings illustrate the successes and challenges of the consortium model in research development and implementation.
SETTING: This presentation details a consortium model formed between seven CBOs, two academic partners, and a national capacity building agency. These partnerships have resulted in the formation of a five-region consortium known as the Men of Asia and the Pacific Testing for HIV (MATH) Study. It integrates years of experience in delivering HIV prevention and treatment services to the API population and in conducting scientific, community-based research. An external evaluator is responsible for overseeing the evaluation of the MATH consortium model.
PROJECT: In addition to investigating the HIV prevalence and the sociocultural and behavioral correlates of infection among API MSM, the goals and objectives of consortium members were assessed using mixed methods (e.g., satisfaction surveys, organizational capacity assessments, in-depth interviews, monitoring activities). Data are triangulated to describe the following: 1) the consortium’s progress in meeting the study objectives (e.g., internal capacity building); 2) integration of research in community settings; and 3) partnership development between community and academic members.
RESULTS: Thematic analyses from qualitative data revealed several successes of the consortium model (e.g., expanded linkages between partners that improved service delivery, increased understanding of effective recruitment strategies for API MSM, policy changes in HIV testing) as well as challenges (e.g., logistical difficulties in study implementation, improving organizational capacity to conduct research). These data also informed specific areas of improvement (e.g., clarification on specific protocol activities, changes to communication mechanisms, technical assistance needs). Quantitative results indicated that the majority (90%) of respondents strongly agreed that the study’s objectives and purpose were clear and were highly satisfied with the first face-to-face meeting held with partners during the pilot phase.
LESSONS LEARNED: Evaluation results revealed that a consortium model is effective in establishing community-researcher partnerships that produce relevant data and research findings.
Such findings also allowed consortium members to reflect on successful processes encountered during the pilot phase of the project and to recognize the influence of their individual and collective assets in meeting the stud y objectives. Feedback provided an invaluable opportunity for consortium members to discuss how to effectively address problems before the start of subsequent phases of research.
Sources and Types of Homophobia Experienced by African American, Asian/Pacific Islander (API), and Latino Men Who Have Sex with Men (MSM) Living in Los Angeles
George Ayala, PsyD, Kyung-Hee Choi, PhD, MPH, & Jay P. Paul, PhD
Background: Studies have shown that experiences of homophobia are associated with increased HIV risk among U.S. MSM of color. However, few studies have explored the specific sources and types of homophobia experienced by African American, Latino, and API MSM.
Methods: From July 2005 to July 2006, we conducted 6 focus group discussions and 35 in-depth interviews with 29 African American, 28 API, and 28 Latino MSM (aged 18+) in Los Angeles. Study participants were asked to describe their experiences of discrimination in the context of their lives as MSM of color living in Los Angeles. Transcribed interviews were coded and analyzed for themes.
Results: Many African American, API, and Latino respondents reported strong ties to their communities of color, families and the church — environments in which they also commonly reported experiencing homophobia and a sense of being unwelcome due to their sexuality. In addition, these MSM of color reported homophobic experiences in their day-to-day lives in Los Angeles (e.g., at work, on the street). Respondents commonly described being called names, made fun of, judged and treated differently for being gay. Many men described social pressures to be macho or manly, and that being identified as gay meant to be perceived as feminine or less than a man. Some expressed concern about what others thought and about the level of discomfort others felt being around gay people. Most felt frustrated by the constraints these pressures imposed on being able to live their lives in an authentic manner. With a few important exceptions, homophobia seemed particularly troubling to many respondents when it occurred in relation to their families of origin. Many African American, API and Latino MSM felt uncomfortable at family functions, due to ongoing pressure from the family to marry and to have children, and fear of disgracing or being rejected by their families. Some MSM reported feeling accepted by specific family members, including mothers, grandmothers, and siblings.
Conclusions: Experiences of homophobia were commonly reported among African American, API, and Latino MSM in Los Angeles. Gender-based pressures, combined with fears about family rejection were important themes in relationship to MSM of color’s experiences of homophobia. More research is needed to better understand the potential role families can play in protecting against or perpetuating homophobia. The data suggest the need to address experiences of homophobia as part of HIV prevention strategies aimed at MSM of color.
Partner-provided social support influences choice of risk reduction strategies in gay male couples
Hard to Reach HIV+ Adolescent Males of Color who Have Sex with Males:Demographic, Behavioral, and Clinical Characteristics
Manya Magnus*, Diane Binson**, Karen Jones,* Gregory Phillips II*, James Peterson*, Blaine Parrish*, Kris Wackerman*, Robyn Schulhof***, and Julia Hidalgo*,
Background: In 2003, the Health Resources and Services Administration, HIV/AIDS Bureau funded nine Special Projects of National Significance (SPNS): 8 innovative demonstration projects and one evaluation and support center, the GWU YES Center. The purpose of the study is to identify best practices associated with outreach, linkage, entry into, and retention in care for HIV+ adolescent men of color who have sex with men (YMSM).
Methods: Culturally appropriate instrumentation was developed to collect multi-site data on demographic, behavioral, and clinical characteristics of interested among YMSM ages 13 to 24 in age at each of the sites. Data are collected quarterly by face-to-face interview. Univariate, bivariate, and multivariable methods were used to describe the sample and characteristics associated with risk reduction behavior, depression and suicidal ideation, and disclosure of HIV status. All analyses were conducted in Stata 9.0se (College Station, TX).
Results: As of 4/2007, 29 HIV+ YMSM had been enrolled in the multisite evaluation and were analyzed. The mean age was 21.1 years (sd 2.14; range 16 to 24), 92.9% were African/American, 67.9% self-identified as gay or homosexual and 14.3% as bisexual; 64.3% reported strong attraction to males and slight attraction to females or attraction to both males and females, though none reported sex with female partner last 3 months. The majority (85.7%) was very comfortable with their sexual orientation. These HIV+ adolescents reported frequent sex without a condom, with a third (34.5%) having no condom use during at least one sexual encounter in the last 3 months; 10.3% reported no condom was used at last anal sex with male. Participants had a mean of 1.48 (sd 1.50; range 0-6) sex partners during the past 3 months; 39.3% had >1 sex partner. Participants reported having disclosed their HIV+ status to at least one person (97.0%), to their mothers (75.0%), to their fathers (39.3%), and to their sex partners (48.3%). Half (50.0%) reported ever being depressed; the mean CES-D score was 40.39 (sd 8.64; range 22-61)
Discussion: HIV+ adolescent MSM of color report comfort with their sexual orientation and sexuality, yet differential disclosure rates to members of their social circles; unprotected sexual activity was common. Depression was common among this sample of HIV+ adolescents. This information suggests specific prevention with positives behavioral interventions that may be important among this unique population. As additional clients accrue, their data will be added to this presentation.
How Do U.S. Ethnic Minority Men Who Have Sex with Men (MSM) Manage Racism and Homophobia?
Choi, K, Paul, J, Ayala, G
BACKGOUND: Experiences of social discrimination have been shown to be associated with stress and poor physical and mental health. However, little is known about how U.S. MSM of color manage their experiences of discrimination due to both race and sexuality.
METHODS: We conducted 6 focus group discussions and 35 in-depth interviews with 29 African American, 28 API, and 28 Latino MSM (aged 18+) recruited in Los Angeles, CA during July 2005-July 2006. Participants were asked about their experiences of being ethnic and sexual minorities in Los Angeles and how they managed related stigma. Transcribed interviews were coded and analyzed for themes.
RESULTS: We identified 10 strategies employed by MSM of color for managing experiences of racism and homophobia. These strategies included (1) doing nothing in or ignoring the immediate situation; (2) concealment of homosexuality (“I just keep my business to myself.”); (3) active efforts to “pass” or pretend to be straight; (4) selective or gradual disclosure of sexual and ethnic minority status; (5) educating others (correcting people’s ignorance about race/ethnicity and homosexuality); (6) acting as a role model or earning respect from people for one’s achievements as a means to counter stereotypes; (7) disassociation from social settings associated with stigmatization (e.g., the mainstream gay community; family gatherings); (8) selective social affiliation (e.g., hanging out with persons of one’s own race/ethnicity); (9) drawing strength and comfort from one’s faith and spirituality; and (10) direct confrontation (e.g., challenging prejudices, being unapologetic about minority status).
CONCLUSIONS/IMPLICATIONS: MSM of color in Los Angeles used a variety of strategies to manage discrimination, some to avoid stigma and mitigate stress associated with experiences of racism and homophobia, but others to challenge those norms and values that provide the basis for discriminatory acts. The data suggest these various management strategies are selected based upon a complex set of criteria to preserve a sense of well-being in situations, which vary in degree of threat. More research is needed to understand the efficacy of these management strategies in mitigating negative health and mental health consequences of stigmatization and discrimination.
Experiences of Racism among African American, Asian/ Pacific Islander (API), and Latino Men Who Have Sex with Men (MSM) Living in Los Angeles
Choi, K, Ayala, G, Paul, J
BACKGOUND: Studies have shown that experiences of racism are associated with an increased HIV risk among U.S. MSM of color. However, less is known about how these experiences compare across different ethnic minority groups.
METHODS: From July 2005 to July 2006, we conducted 6 focus group discussions and 35 in-depth interviews with 29 African American, 28 API, and 28 Latino MSM (aged 18+) in Los Angeles. Study participants were asked about their experiences of being African American, Latino, API and gay or bisexual in Los Angeles. Transcribed interviews were coded and analyzed for themes.
RESULTS: African American, API, and Latino respondents all reported experiencing racism in Los Angeles from the mainstream gay community, sex partners, and society in general (on the street, at work and from police). Respondents commonly described feeling unwelcome and unvalued by the mainstream gay community, which in Los Angeles was identified by respondents as being situated in West Hollywood. Specifically, African American, API and Latino respondents reported feeling invisible, being patronized, sexually objectified, and/or rejected for sex, having difficulty finding lover relationships, and being self-conscious about their body types or physical appearance. Respondents also expressed concern about negative race-based stereotyping of ethnic minorities by society in general (e.g., African Americans are inarticulate, Latinos are uneducated, APIs are subservient). Differences in the reported experiences of racism in the mainstream gay community were tied to race-based stereotypes that are specific to African American, API, and Latino communities. For example, API MSM reported feeling least sexually desirable and assumed to be sexually passive; African American MSM reported being called names on the street, seen as physically threatening, and assumed to be a criminal; and Latino MSM reported being ethnically and economically homogenized, assumed to all be Mexican gardeners or janitors. African American respondents had the most to say about institutional forms of racism (police harassment and discrimination in the work place) than their counterparts.
CONCLUSIONS/IMPLICATIONS: Experiences of racism were commonly reported among African American, API, and Latino respondents. The degree to which these men’s experiences in the mainstream gay community mirrored their experiences in the larger Los Angeles community, and the types of racism they experienced showed some variation. More research is needed to better understand differences in reported experiences of racism in this population. The data suggest the need to address experiences of racism as part of HIV prevention strategies aimed at MSM of color.
Situational Gay Identity, Sexual Silence, and HIV Prevention among Latino Men who have Sex with Men
Margery Lazarus, Diane Binson, Bill Woods, Robert Siedle-Khan, and LeRoy Blea
Background/Objectives: To recruit participants for an intervention with Latino MSM who do not identify as gay, this study aims to identify strategies used by Latino men to disclose their sexual interest with other men, for partner selection and for social acceptance and support, in situations that vary in acceptance to expressing a gay identity. While some men express a consistent internalized sexual identity, many others have pursued sexual desires with other men while avoiding public expression of a gay identity. Interventions to reach Latino MSM for HIV prevention may fail to attract such “non-gay identified” men. Class expectations and social pressure to respect family obligations (respeto, familismo) and masculinity (machismo) affect the expression of sexual identities for many Latino men who have sex with men (Carrillo 2002; Diaz and Ayala 2000).
Methods: Trained bilingual male interviewers used a semi-structured interview guide to inquire about Latino men’s early sexual experiences and the transitions between their sexual identities in birth countries and in the US. In Northern California, 62 Spanish-speaking Latino men were recruited in venues where men go to meet other men for sex and through networks of similar men who frequented these venues. Venues included gay bars, straight bars where men go to find male sex partners, parks, adult book stores, and a bathhouse. Hour-long interviews were conducted at a public health clinic and recorded in Spanish or English. For this analysis we selected text that discussed issues of identity, partner selection, and family support and translated the text into English using situational analysis (Clarke 2005) and coding software Atlas.ti.
Results: Most of the men migrated to the US from Mexico (66%) and other Latin American countries (32%). For many men, sexual silence started from childhood experiences of sex with older men, affecting their experience of difference and communication with their families about their sexual desires at odds with familial expectations. In their search for sexual partners, men chose venues that could signal their interest without demanding an overt expression of sexual identity. In “straight” venues, men communicated sexual interest through body language and ritualized exchanges that did not jeopardize their public expression of a male sexual identity. In mixed venues with both straight and gay-identified men, men relied on trusted networks of men who they confided their preferences, plus non-verbal communication of their interests. In families, some men initiated the erosion of sexual silence by confiding their preference to a trusted sibling or parent.
Conclusions/Implications: Latino men who do not identify as gay may be recruited through social networks of gay-identified partners or through programs targeting Latino men at venues where men go to find sexual partners, rather than target men directly through their sexual identity as “gay” or “MSM”.
Internet Sex Ads for MSM and Partner Selection Criteria: The Potency of Race/Ethnicity Online
JP Paul; G Ayala; K-H Choi
BACKGROUND: Use of the internet as a fast and efficient means of accessing sexual partners has grown in popularity among MSM, and has been linked with sero-sorting, number of sexual partners, sexual risk behavior, and STDs. The commodification of sexual partner choice via the Internet allows for specification of frank and detailed characteristics for a prospective sex “hook-up” in ads and personal profiles–including dictating desired race/ethnicity. Understanding the impact this may have on MSM of color, directly and indirectly affecting partner selection processes, is important to understanding their sexual networks and sexual decision-making.
METHODS: Between July 2005 and July 2006, we conducted 6 focus group discussions and 35 individual qualitative interviews, with 28 Latino, 28 API, and 29 African American MSM in Los Angeles. They were asked about their experiences as MSM of color in Los Angeles, including those related to sexual partner formation. Audiotapes were transcribed and coded for themes.
RESULTS: Men reported frequent use of the Internet for partner selection. All MSM of color encountered experiences online where race/ethnicity was explicitly stated as either an inclusion or exclusion criterion. In some cases, where a profile or ad did not explicitly identify such partner criteria, rejection on the basis of race/ethnicity could occur with brusque detachment in subsequent communications about “hooking up.” Distinct racial stereotypes underlying these exclusion criteria were identified by all respondents. API and African American men were most likely to report experiences of exclusion, but Latino men also were made acutely mindful of others’ stereotypic expectations of their sexuality. API men reported being made to feel desexualized and lowest on the sexual hierarchy; African American men experienced sexual rejection as a facet of others’ overarching discomfort with/distancing from their race/ethnicity. The lack of face-to-face contact inherent in Internet usage to find sexual partners was reported as making such rejections easier. However, having such preferences repeatedly identified explicitly in online profiles distressingly amplified the sense of marginalization and objectification among all MSM of color. Online profiles which specified a preference for given men of color, led to mixed reactions among respondents to the potential for being fetishized. For some, this possibility was repugnant; for others, this was at times a source of agency, providing a means to achieve their ends of sexual connection.
CONCLUSIONS/IMPLICATIONS: Internet ads used by MSM to find sexual partners explicitly emphasize race/ethnicity as a criterion for sexual partner selection. Racial prejudices and stereotypes gain reinforcement in this sexual marketplace, and have particular meanings with respect to one’s “value” as a sexual partner and sexual stereotypes. These constructions raise concerns about self-perceptions of MSM of color, power dynamics within individual “hook-ups” and sexual behavior choices.
Boosting the Quality of Gay/Bi Men’s Online Communication to Promote Healthy Community
Curotto, A1; Rebchook, G1; Levine, D2
BACKGROUND/OBJECTIVES: The Internet has changed the context of MSM’s sexual risk behavior by increasing opportunities to develop social/sexual networks. CBOs and public-health agencies have responded to the challenge by using the Internet in HIV-prevention programs, mainly individual-level and health-promotion interventions. Few attempts have been made to address the link between sexual risk-taking and the Internet environment with community-building interventions, even though this type of interventions has been shown to reduce risk behaviors. In our prior research with gay/bi men who use the Internet for social/sexual networking, participants indicated that the focus of online communication on finding sex partners hinders community formation. They also identified the top-down nature of online HIV-prevention efforts as a motive for avoiding these programs and expressed the need for more community-driven approaches to online prevention. We proposed to test the viability of improving the quality of online communication among gay/bi men to promote community involvement as a step to support healthy norms.
METHODS: We created 2 multi-component websites (one for California and one for Massachusetts) to foster genuine communication among gay/bi men in an online venue where sexual-health management resources are likewise readily accessible. An interactive feature (blogs) was developed to provide a forum for conversation, self-reflection, and critical thinking. Eight community members were recruited to write blogs in which they would share their personal experiences and views, especially concerning issues that affect gay/bisexual men, including the role of the Internet in their lives. As the intervention was rolled out, each blogger has been autonomously selecting his own topics. All website visitors can interact with the bloggers and one other by posting public comments. We treat the texts of the blogs and readers’ exchanges as qualitative data, which we regularly import into ATLAS.ti to facilitate analysis and identify emergent themes and patterns. We use this analysis to test some of our working hypotheses. (The proposed presentation will include screenshots of the relevant Web pages to illustrate how the blogs attempt to generate a dialogue within an online community.)
RESULTS: So far, the 8 bloggers have posted 194 entries. These have elicited 213 exchanges in the readers’ comments. Themes that have emerged from an initial coding of these data include: aging, mentoring, and intergenerational relationships; alcohol/drug use; being HIV+; coping; couple agreements; diversity, homophobia, and racism; friendship; gay-community norms; HIV testing; online norms around sex/dating/socialization; peer pressure; quality of life; self-esteem and self-assertiveness; serostatus disclosure; and stress. These themes cover many questions reported as significant by participants in our formative research.
CONCLUSIONS/IMPLICATIONS: While not sexually-oriented, the websites we created are supportive of both sex-positive attitudes and healthy norms, and provide a culturally appropriate environment where men can communicate in honest and genuine fashion. The blogs have generated topics of interest to the target population and have begun to elicit community participation in an online dialogue. The themes emerging in these exchanges among gay/bi men touch on recognized HIV-risk factors and may therefore indicate that new approaches to HIV prevention can stem from a dialogue within the community.
Alcohol and drug use are associated with risk of transmitting HIV among patients seen in clinical care settings
C Dawson Rose, J Myers, K Koester, A Maiorana, S Shade, S Morin
Background/Objectives: The Health Resources and Services Administration “Prevention with HIV Positives in Clinical Settings Initiative” is a four-year project examining the effectiveness of HIV prevention interventions with HIV-infected individuals seen in clinical settings. This analysis describes drug and alcohol use among HIV patients in care.
Methods: We interviewed 4087 HIV infected patients in 26 HIV primary care clinics. Participants answered questions about current drug and alcohol use in the preceding 3 months using audio computer-assisted self –interviewing. Drug use was categorized into injection and non-injection drug use. Alcohol use was categorized into weekly alcohol use and binge drinking which was defined as more than 5 drinks in one day. In addition to frequencies, we examined associations by US region, gender, age, race, sexual orientation, HIV transmission risk behavior (report of unprotected sex with an HIV negative or unknown status person or sharing injection materials) and HIV medical visits.
Results: Thirty-one percent of the sample reported drinking five or more drinks per day at least once a week. Thirty-two percent reported non-injection drug use in the last 3 months. Of those who reported non injection drug use, drugs used included: marijuana (62%), crack (28%), cocaine (27%), and methamphetamines (23%). Only 4% reported injection drug use in the prior 3 months. Non-injection drug use was associated with sexual risk behavior (p. <001) and injection risk (p. <.01). Binge drinking exhibited similar associations between sexual risk behavior (p. <001) and injection risk (p.< .01). Weekly alcohol use on the other hand was associated with US region: Southern (p.<.008) and being female (p.<.001). The sample was primarily male (72%), and represented a range of race and ethnicity (African American 47%, Caucasian 34%, Latino 14%, Asian/Pacific Islander 1% and American Indian/Alaskan Native 1%. Mean age was 42 years (+8 sd). Ninety-percent of the sample reported more than one HIV medical visit in the preceding six months. By region 41% were from the eastern United States, 33% from the west and 26% from the south.
ConclusionsThis analysis provides further evidence of the association between non-injection drug use and binge drinking with HIV risk behavior. These findings help underscore the need to incorporate drug and alcohol screening into HIV prevention and care efforts in the clinic setting. This is notable given that 90% of the sample came in to their HIV clinic more than once in the preceding 6 months. Further, these findings can be useful as we fulfill the need to tailor both care and treatment clinic-based programs.
Gay Male Couples: agreement quality, relationship satisfaction, HIV-status and risk
Hoff, Chaklavarty, Darbes and Neilands
Background: Recent studies have reported high HIV incidence among gay couples. However, little is known about the relationship dynamics associated with sexual risk within or outside the relationship. Agreements couples make about whether to have sex outside the relationship is an important relationship factor. We measured the quality of these agreements to determine whether agreement quality and other relationship variables are associated with sexual risk for HIV.
Methods: The present study identifies important relationship correlates of unprotected anal intercourse (UAI) with non-main partners. From June 2005 through January 2007, we recruited 569 gay male couples throughout the San Francisco Bay Area to complete a computerized survey that examines relationship dynamics, sexual behaviors and agreements with main partner regarding sex with non-main partners. Data were clustered by couple and analyzed using univariate and multivariate logistic regression to identify relationship factors explaining with UAI with non-main partners.
Results: Couples were ethnically diverse – almost half (48%) reported being in a “mixed race” relationship. HIV-negative couples comprised 55% of the sample, 23% were serodiscordant and 22% were HIV-positive. Most couples (96%) had some kind of agreement about whether sex with non-main partners was permitted. Thirty-five percent reported they were monogamous, 25% reported their agreement allowed sex with non-main partners with some restrictions, 4% agreed to sex with non-main partners with no restrictions and 33% reported an agreement that was different from what their partner reported. Regression analysis revealed that couples who valued their agreement more and who were more satisfied with their relationship were less likely to engage in UAI with a serodiscordant or unknown status non-main partner. Discordant couples and HIV-positive couples were significantly more likely than HIV-negative couples to engage in UAI with discordant or unknown status non-main partner.
Predictors of UAI with discordant or HIV-status unknown non-main partners
|Agreement quality||.990||(.985, .995)||<.0001|
|Relationship satisfaction||.942||(.890, .997)||.038|
|Couple serostatus: discordant*||2.10||(1.28, 3.45)||.004|
|Couple serostatus: HIV-positive*||1.74||(1.04, 2.90)||.034|
* Reference Group: Couple serostatus: HIV-negative
A second model included UAI with non-main partners who had the same HIV status. In this analysis HIV-positive couples were 4 times as likely and discordant couples and one and one-half times as likely as HIV-negative couples to have UAI with a seroconcordant non-main partner. HIV-negative couples were least likely to engage in UAI with non-main partners and also more likely to have concordant non-main partners.
Implications/conclusions: Gay male couples who rate their agreement quality and relationship satisfaction higher engage in less UAI with serodiscordant and unknown status non-main partners. Couple serostatus is an important factor since HIV-positive and discordant couples were significantly more likely than HIV-negative couples to engage in sexual risk with non-main partners. When looking at seroconcordant non-main partners (results not shown), HIV-positive couples may be seeking HIV-positive partners (e.g.,“serosorting” as a prevention strategy). Future prevention efforts must be tailored to address the unique needs of couples of the different serostatus and address relationship satisfaction and relationship quality issues.
Rapid vs. Standard Voluntary Counseling and Testing (VCT) in a Bathhouse: What ’s Gained, Lost?
Huebner, DM; Woods, WJ; Dilworth, SE; Neilands, TB; Binson, D
BACKGROUND: Identifying new HIV infections is a cornerstone of U.S. domestic HIV prevention strategy. Research demonstrates that bathhouses frequented by MSM are a feasible place to recruit high risk men for standard VCT and that bathhouse-based VCT identifies new infections that might go otherwise undetected. Although the rate of return for test results typically proves disappointing with standard bathhouse VCT, evidence suggests that the program can be effective in reducing risk behaviors. While new rapid testing in these settings is expected to improve return rates, it is not known whether using rapid test technologies will attract men with comparable histories of risk or yield similar risk reduction results. This study compared the demographic and risk profiles of men who participated in rapid vs. standard VCT at the same bathhouse, and used preliminary effectiveness data to determine if rapid VCT yielded similar behavior change at 3 months post-testing, compared to a previous study of standard VCT.
METHODS: Five hundred twenty -eight MSM participated in bathhouse-based rapid VCT at a single California venue over a 13-month period. Risk and precautionary behaviors were assessed in a convenience sample of 161 of testers at two points: immediately prior to and three months after testing. Results were compared to a previously published study utilizing identical methodology, except with standard VCT offered one year earlier in the same bathhouse (N for testing population = 492, n for sample = 133).
RESULTS: 2.5% of MSM receiving rapid VCT in the bathhouse were HIV-positive, relative to 3.7% of men receiving standard VCT. Both yielded higher seroprevalence than among MSM receiving rapid or standard VCT in other local clinics (1.8% and 1.6%). 85% of men testing positive through rapid VCT received their results, compared to just 50% of men receiving standard VCT. No differences were observed in the demographic or risk profiles of men presenting for rapid vs. standard VCT. 45% of men surveyed reported unprotected anal intercourse (UAI) with one of their two most recent partners in the 3 months prior to rapid VCT (38% for standard VCT). Logistic regression analyses revealed that from pre to three-months-post rapid VCT, men were marginally less likely to engage in UAI (OR=0.7, p<.10), Print this Page for Your Records Close Window Page 1 of 4 ..
Young Black MSM’s Concerns about HIV Testing and Obtaining Treatment: The Importance of Hope, Support, and Faith
Susan M. Kegeles, Gregory Rebchook, Emily Arnold, Michael Foster, Haqumai Sharpe, Richard Hamilton
BACKGROUND: HIV rates have reached catastrophic levels among YBMSM, who test less frequently, are less likely to be aware of their HIV+ serostatus, and receive HIV treatment later than do other MSM. Our previous research showed the importance of religion and spirituality for many YBMSM, and therefore, we are studying the role that faith-based organizations can play in HIV/AIDS prevention for YBMSM, including testing and treatment for HIV+ men.
METHODS: We conducted 6 focus groups in Los Angeles with N=38 18-29 year old YBMSM, with diverse SES. Men were recruited from church-based events, a community-based organization, at HIV treatment clinics and via the Internet. Topics included church involvement, spirituality, HIV testing and treatment and HIV prevention programs. Focus groups lasted approximately 2 hours and were recorded and transcribed. Transcripts were coded and discussed at team analysis meetings. Analysis memos captured the content for each analysis session.
RESULTS: The issue of gossip among YBMSM and in the Black community regarding men’s serostatus arose across focus groups. Men described concerns about accessing testing and treatment due to potential gossip within the Black gay community and larger Black community. Men explained this also affected disclosure of positive serostatus to sex partners, because they might tell others of one’ serostatus. Stigma for being HIV+ was both positively and negatively impacted by receiving treatment. Treatment was perceived by some as a way of avoiding having the physical appearance of having HIV, because one could remain healthy-looking on medications. Others felt that one’s positive serostatus would be obvious because of severe medical side-effects after starting treatment. The need for hope and belief in medications’ effectiveness and spirituality, faith, and the belief that God had provided testing and treatment facilitated obtaining testing and treatment. However, many YBMSM felt their churches had declared them sinners who deserved to contract HIV, which impacted their sense of self-worth and interfered with getting tested and obtaining treatment. Yet, some men had found churches that accepted and supported them as gay, and in some cases as HIV+ men. Many men discussed the need to be mentally healthy in order to obtain testing and treatment, and this was related to frustration that many other more basic needs are ignored with the exclusive focus on HIV/AIDS. To encourage testing and treatment, men recommended that: YBMSM, and particularly HIV+ men, should support their friends to seek HIV-related services; there should be support groups for YBMSM; and various mass media approaches should, in YBMSM’s own words, be used to promote the importance and availability of testing and treatment, but featuring typical YBMSM rather than public figures.
CONCLUSIONS: Approaches to facilitate YBMSM getting tested and if HIV+ into treatment involve getting support from other YBMSM and support groups, possibly conducted at churches that accept them, but there were also enormous concerns about the rumors about HIV-status, and related stigma and rejection from their communities. YBMSM need hope, information, and support from the Black gay community, the larger Black community, and the church.
Factors that Influence Successful Implementation of an Evidence-Based Intervention, the Mpowerment Project, by Community Based Organizations (CBOs)
Susan M. Kegeles, Gregory Rebchook, Emily Arnold, Scott Tebbetts, David Sweeney, John Hamiga, Dave Huebner, Wayne Steward
BACKGROUND: Research into the development of HIV prevention interventions cannot affect the spread of the epidemic unless CBOs implement the programs successfully. Whereas substantial scientific effort has gone into creating interventions, little research has examined barriers and facilitators to successful implementation by CBOs. Since community-level interventions (CLI) are cost-effective and reach populations that do not seek help for changing risk behavior, they are particularly important to move into practice. “Successful implementation” means the intervention retains fidelity to the original intervention’s theoretical underpinnings and methods, while being tailored to communities’ culture and social environments. The goal of this study is to identify factors that facilitate or impede the successful implementation of an evidence-based CLI, the Mpowerment Project (MP).
METHODS: Seventy-two CBOs implementing the MP were followed longitudinally; the Project Evaluator conducted telephone interviews at baseline, 6, 12, and 24-months with CBO staff and intervention participants (N = 523 interviews). Interviews focused on how each intervention core element was being implemented, with follow-up probes regarding reasons for changing the core element. In addition, MP Technology Exchange Services, which are an integrated system of materials, on-going technical assistance (TA), training, and web-based services, were provided to CBOs. The TA providers took extensive notes during all TA sessions, and subsequently created a detailed commentary about the session. Likewise, the Evaluator took extensive notes during each interview. All notes and commentaries were entered into a database. Preliminary analyses of the data generated broad themes that served as organizing codes regarding barriers and facilitators to effective implementation. Emerging issues across CBOs that facilitated or impeded implementation were discussed in monthly analysis meetings, and summary notes later systematically compared the organizing codes. We continued to generate additional sub-codes to capture the complexity within the data. All themes (operationalized as codes) were generated from the data.
RESULTS: The following table lists the themes that function as barriers or facilitators to successful implementation. Complex contextual issues beyond the level of the individual conducting the intervention exerted tremendous influence on implementation effectiveness. These issues are both internal and external to the organization. Unexpectedly, funders also played an important role in successful implementation (in addition to their provision of resources).
|Knowledge about intervention||x||x||x|
|Planning activities are conducted before implementation||x|
|Belief in intervention’s efficacy||x||x||x|
|Desire to change agency’s existing prevention approach||x||x|
|Evaluates intervention’s on-going functioning||x|
|Expectation that agency will evaluate program’s on-going functioning||x||x|
|Agency conducts the work of the intervention||x|
|Staff held accountable for job performance||x|
|Staff appropriateness (fit) for coordinator position||x|
|Proximity to gay magnet city||x|
|Community accepts YGM||x|
|Intervention is complex/multifaceted||x|
CONCLUSIONS: Many barriers to and facilitators of successful implementation of an evidence-based intervention are beyond the direct influence of individual staff members or of the implementing agency itself. Therefore, successful translation of an evidence-based intervention into practice requires focusing on more than just the individual who implements the intervention. The organization as a whole (including front-line staff, managers, and executive directors), funders, and community members need to work together to achieve successful implementation. To facilitate this process, intervention with entire systems may be necessary. Additional research on the application of systems-level theories, organizational development, and ecological models of change may be necessary to identify best practices necessary for the scale-up of innovative HIV prevention programs in the field.
Modes of delivery and acceptability of Prevention with Positives interventions part of the Health Resources and Services Administration (HRSA) Special Projects of National Significance (SPNS) HIV prevention in clinical settings initiative.
Andre Maiorana, Kimberly A. Koester, Karen Vernon, Janet Myers, Carol Dawson Rose, Stephen F. Morin
Objectives: Prevention with Positives (PwP) to reduce patients’ risk of transmitting HIV to others is increasingly being implemented in primary care settings. This qualitative study presents post intervention perceptions of patients and staff to assess the acceptability and to better understand the outcomes of different models of PwP delivered either by clinicians, and/or “specialists” (health educators or social workers), and/or HIV-infected peers as part of SPNS demonstration projects in medical settings.
Methods: Post-intervention interviews with 33 interventionists (clinicians, specialists, or peers) and with 60 patients in 15 clinics. Transcripts of the taped interviews were coded and analyzed to identify convergent and divergent themes among intervention models.
Results: Patients: The different interventions provided a chance to learn or reinforce knowledge, receive counseling, and explore (often for the first time) patients’ feelings, attitudes and behaviors related to HIV prevention and safer sex. Across intervention models, messages related to HIV re-infection and STD prevention resonated with patients as strong reasons to protect themselves. They were willing to talk to clinicians about their sexual practices but HIV prevention was not a priority in the hierarchy of needs patients expected clinicians to address. Rapport or a pre-existing relationship with clinicians also influenced patients’ willingness to talk about sex. Clinicians’ recommendations about prevention were important, but some patients expressed concern about disappointing them by recounting experiences of unsafe sex. Patients liked that the intervention messages were tailored to their specific risk and needs and that they could honestly talk about their sexual practices to non-judgmental specialists and peers. Sessions with specialists and peers generated introspection and linkages to other services. Specialists were perceived as professionals, who could help with counseling or education, but patients saw peers as equals who could understand their experience, and as role models to identify with and learn from. The relationship with the peers was particularly important to address stigma, disclosure, and normalize prevention and living with HIV.
Interventionists: While protecting sex partners was emphasized, re-infection related messages were used by staff regardless of the intervention model because they were easier to bring up and better accepted by some patients, who felt staff were protecting their health. Interventions gave clinicians new tools to consistently discuss and integrate brief prevention messages into primary care visits. Risk assessments were a reminder about prevention and helped clinicians to learn information unbeknownst to them about patients’ risks and behaviors. Specialists and peers could spend more time talking about prevention and exploring issues at length. Peers perceived their role was crucial as models for living with HIV, particularly for patients who were socially isolated and fearful of disclosing their HIV status to anyone.
Conclusions: The potential success of an intervention depends on the complementary fit between the intervention model and the clinical setting. Regardless of the model and who delivers prevention, the opportunity to discuss prevention in the medical setting could motivate patients to reduce risk. Interventions tailored to the patient population and the clinic environment can increase the feasibility and acceptability of PwP.
Understanding HIV Risk in Prison among Heterosexually-Identified African American Men who have sex with Men
Myers, J, Maiorana, A, Zack, B.
Although studies have examined HIV transmission in prison, little is known about the specifics of HIV risk behavior inside. This qualitative study assessed factors influencing risk behavior among heterosexually-identified African American men in prison which will be used to tailor HIV prevention services for men returning to the community.
Semi-structured interviews were conducted with 26 men within two weeks of release from prisons in Northern and Central California. Participants were recruited at a post-release meeting mandated by the state’s department of corrections. Interview transcripts were coded and summarized for emerging themes.
Respondents were parolees and ranged in age from 20 to 62 years. Across the sample there was a mix of severity in the crimes committed and so in the “level” on which men were housed in prison. The average length of stay among the men interviewed was 13 months (with a range from 1 month to 7.5 years). Many had in common chaotic lives, and a family history of crime, drugs, violence or prostitution. Respondents noted that the scope of sex in prison is sensationalized. Most sex is consensual and occurs among men identified as “homosexuals,” “punks,” or “faggots.” Forced sex was reported to be less common but does occur as punishment, when seeking protection, or by a few inmates preying on the weak. Attitudes towards sex among men included disapproval, ridicule, indifference, or tolerance. Twenty-five participants stated that men who have sex with men are gay, regardless of self-identification. Only one respondent talked about his own sexual experience with another man, yet all men said that it happened to others. Respondents considered themselves straight and could not understand why men in prison would have sex unless they were homosexual before prison or “lifers” who could “indulge” because they have nothing to lose. HIV risk in prison was also related to illicit drugs used because of addiction or to escape reality. Most men did not use because of the expense, the risk of being caught, a chance to be clean and sober, and the potential violence (including sexual violence) associated with drugs’ effects or drug-related debts. Inmates do not generally talk about HIV, except in the context of jokes or to know who is infected. Many inmates do not test for HIV, because of concern about their sex or drug history and fear finding out their status.
Since men’s stated goal was to get out of prison, good behavior, minding their own business, and engaging with a few men they could trust were coping strategies used to avoid conflict and not to get caught in activities that could bring extra time. HIV risk behaviors seem to occur among men who are in for longer periods of time, use and need drugs, are gay (and may or may not hide their identity), and/or are victims of sexual assault. Talking about and preventing HIV risk in prison and in the community is complicated by secrecy/trust, issues of sexual and ethnic identity, definitions of sex relative to coercion, and lack of disclosure.
HIV prevention services in California are well targeted to the geography of the epidemic
Starley B. Shade, Wayne Steward, Janet Myers, Christine Dahlgren, Shanna Livermore, Valerie Eckert, Christopher Krawczyk, Steve Morin
Objective: To assess the geographic distribution of HIV prevention services relative to the epidemic in local areas.
Methods: We assessed the total number of state-funded HIV prevention service contacts in each county in California between July 1, 2004 and June 30, 2005. We also assessed the prevalence of AIDS in each county using estimates of the number of people living with AIDS and population on June 30, 2005. Provision of HIV prevention services and prevalence of AIDS was compared across all 58 counties and aggregated within seven regions in California (Northern/Sierra counties, Greater Bay Area, Sacramento Area, San Joaquin Valley, Central Coast, Los Angeles, and other Southern California counties).
Results: The provision of HIV prevention services in California is highly correlated with the proportion of the population living with AIDS in each region of the state (r=0.47; p<0.001). Although there was considerable variability in the provision of services across counties within each region of California, there was considerably less variability across regions. Across seven regions in California, the ratio of HIV prevention service contacts to the number of people living with AIDS in these seven regions ranged from 1.2 to 5.3. Despite this variability, the amount of HIV prevention services delivered was consistently related to the prevalence of AIDS in a region (see figure; r=0.97; p<0.001).
Conclusions: HIV prevention services in California are being appropriately distributed according to the geographic distribution of the epidemic. State-wide databases of HIV prevention services provide an excellent tool to inform policy and funding decisions.
Tailoring of “Prevention with Positives” interventions in clinical care settings
Starley B. Shade, Janet J. Myers, Carol Dawson Rose, Wayne Steward, Stephen F. Morin
Objective: To estimate the potential benefit of tailoring HIV prevention interventions with HIV-infected patients in clinical care settings.
Methods: We used audio computer-assisted self-interviewing to assess the number of occurrences and types of sexual behaviors associated with sexual transmission of HIV in the past six months, and the behavioral correlates associated with these sexual risk acts, among 4053 men and women in 26 US HIV primary care clinics. For each person, we created an overall estimate of his or her probability of transmitting HIV during the six-month period by combining the reported number of each sexual risk act with HIV-uninfected and unknown HIV status male and female sexual partners and the known probability of transmitting HIV for each sexual risk act (obtained from previously published studies). Next, we created hypothetical scenarios which assumed that an intervention reduced sexual transmission of HIV in accord with findings from past studies. Based on these assumptions, we then estimated the potential reduction in transmission of HIV that would occur if the intervention were directed at all HIV-infected individuals in care or if it were tailored only to individuals who reported behaviors known to correlate with sexual risk acts.
Results: Overall, we estimated that HIV-infected patients in our study transmitted HIV to 36 HIV-uninfected or unknown HIV status sexual partners in the past six months. The mean probability of transmitting HIV to an HIV-uninfected or unknown status sexual partner in the past three months was 0.9% per patient. Behavioral correlates associated with increased probability of transmitting HIV included: being a male who has sex with men (MSM), weekly use of alcohol, or any use of amphetamines (see table).
Given a hypothetical intervention that reduces sexual transmission of HIV by 20%, intervening with all patients in HIV-care would eliminate transmission of HIV to 7 HIV-uninfected or unknown HIV-status sexual partners. However, it would be necessary to intervene with a large number of patients to observe this reduction in transmission (need to intervene with 555 individuals to avert 1 infection). In contrast, tailoring interventions with HIV-infected patients who were MSM or reported weekly alcohol use or reported any amphetamine use would eliminate fewer HIV infections, but would require intervention with fewer individuals per transmission averted. Interventions tailored to MSM or amphetamine users would be more efficient compared to those targeted to weekly alcohol use.
|Patients in intervention||Percent of patients||Mean probability of transmission||Transmissions averted with 20% effective intervention||NNT
(number needed to avert 1 infection)
|Weekly alcohol users||28%||1.4%||3.1||365|
|One or more behaviors||63%||1.1%||5.7||447|
|Two or more behaviors||22%||2.2%||4.0||223|
|All three behaviors||2%||5.7%||1.1||88|
Conclusions: Tailoring of “Prevention with Positives” in HIV care settings to MSM and heterosexual amphetamine users may improve the effectiveness of these interventions. Clinicians and policy makers must weigh the goal of eliminating all HIV transmission against the reality of resource limitations.
A Move Toward Serosorting Following Acute HIV Diagnosis: Part 1 of 4 on Findings from the NIMH Multi-Site Acute HIV Infection Study
Steward, WT; Remien, RH; Truong, HM; Brooks, RA; Correale, J; Dubrow, R; Ehrhardt, AE; Kerndt, PR; Pinkerton, SD; Sikkema, KJ; Young, C; Morin, SF
BACKGROUND: People with Acute HIV Infection (AHI) are at high risk of transmitting the virus when engaging in sexual risk behaviors because they have a very high viral load. Directing prevention services to this group may significantly reduce incident infections. As part of an NIMH-funded multi-site research collaborative, we identified cases of AHI and examined changes in sexual behavior in the months following notification of HIV infection. Understanding the impact of HIV diagnosis on risk behavior is important for informing the development of effective interventions for people with AHI.
METHODS: Six university-based sites across the United States (Brown, Columbia, UCLA, UCSD, UCSF, and Yale) established collaborations with HIV testing programs and clinical investigators in order to identify cases of AHI. Each person was assessed within four weeks of HIV diagnosis and again eight weeks later. Assessments included an interview in which they discussed their understanding of AHI and the events surrounding infection and diagnosis, and a structured survey that assessed the recent HIV sexual risk behaviors with seropositive, seronegative, and serounknown partners. Thus far, fifteen individuals with recent HIV infections have been identified, enrolled into the study, and completed both waves of data collection. Most were men who had sex with other men (n=13; 87%).
RESULTS: As seen in Table 1, participants reported a significant change in the proportion of unprotected anal and vaginal sex acts that occurred with HIV-seropositive partners. In the two months before diagnosis, 23% of unprotected acts were with positive partners. By contrast, in the two months after diagnosis, 97% of unprotected sex acts were with infected partners (?2 = 228.9, p<.0001). Consistent with this finding, men expressed a strong preference during the open-ended interviews for having sex partners who are also HIV-seropositive. Overall, there was a decline in the number of unprotected acts following diagnosis. Participants reported a total of 264 unprotected sex acts before diagnosis (average acts per participant = 17.6) and a total of 170 unprotected acts after learning that they have HIV (average per participant = 11.3).
CONCLUSIONS: Diagnosis with AHI can have dramatic effects on the type of partners with whom people have unprotected sex. In particular, men who have sex with men quickly adopt serosorting behaviors, limiting most of their sex without condoms to interactions with men whom they know to be HIV-seropositive. Interventions to address risk behaviors during AHI should be designed with an awareness of these informal risk reduction strategies.
Table 1. Total Number of Reported Unprotected Anal and Vaginal Sex Acts
|Time Period||HIV-Positive Partners||HIV-Negative Partners||HIV-Unknown Partners|
|Two Months Before Diagnosis||60||83||121|
|Two Months After Diagnosis||165||3||2|
HIV Prevention Fatalism is Associated with Less Frequent Delivery of Prevention with Positives Counseling Among Providers in Publicly-Funded Clinics
Steward, WT; Myers, JJ; Shade, SB; Koester, KA; Maiorana, A; Dawson Rose, C; Morin, SF
BACKGROUND: Delivering prevention counseling to HIV-infected patients in clinical care settings (Prevention with Positives, or PwP) is an important goal in the United States. However, our prior research has found that providers of such counseling sometimes experience HIV prevention fatalism, a belief that HIV-infected individuals are not able or willing to change their transmission-risk behaviors. In this study, we examined how fatalism affected the delivery of prevention counseling in publicly-funded clinics that were in the process of developing PwP interventions.
METHODS: Three hundred sixteen providers at 26 Ryan White CARE Act-funded clinics completed surveys between April, 2004, and March, 2006. All surveys were conducted prior to the start of any training for the clinics’ PwP interventions. Participants indicated the percentage of new and returning HIV-infected patients with whom they discussed PwP topics, and their attitudes and beliefs about PwP services. HIV prevention fatalism was assessed as the degree to which a provider believed that his or her patients would continue to infect other people regardless of the amount of counseling they received.
RESULTS: Overall, providers stated that they held PwP discussions with 67% of their new HIV-infected clients and 53% of their returning HIV-infected clients. However, providers who reported the most HIV prevention fatalism conducted PwP counseling 10% less often with new clients and 11% less often with returning clients than providers who reported the least fatalism. Importantly, fatalism affected the relationship between PwP counseling and other provider beliefs. As seen in Table 1, other beliefs had more pronounced associations with counseling among the most fatalistic, as opposed to the least fatalistic, providers. For example, providers who were the least fatalistic were 8% less likely to offer prevention counseling if they did not feel comfortable talking about injection drug use. By contrast, the most fatalistic providers were 53% less likely to deliver counseling when uncomfortable with conversations about injection drugs (interaction term: ?2= 5.23, p < .03).
CONCLUSIONS: HIV prevention fatalism affects PwP service delivery in publicly-funded settings. It is associated directly with less prevention counseling and also enhances the degree to which other provider beliefs influence delivery of the service. Research is needed to understand the origins of prevention fatalism and to develop support services to help providers feel efficacious about the prevention counseling that they conduct.
Table 1. Change in Percent of Patients Counseled if Providers Endorse Other Beliefs
|Belief Endorsed by Provider||Least Fatalistic Providers||Most Fatalistic Providers|
|Not responsible for PwP||-31.19%*||-69.85%**|
|Not comfortable with PwP||-20.89%||-36.74%**|
|Not comfortable talking about IDU||-8.85%*||-53.04%**|
|Do not know how to discuss PwP||-14.68%||-34.49%**|
|Not enough time for PwP||6.75%||-12.29%|
|Explain reinfection to patients||52.56%**||41.49%**|
|Have received adequate training for PwP||51.27%**||35.60%**|
|Footnote: Significance level indicated by superscripts||*p<.05||**p<.01|
HIV/STI Testing Programs in Bathhouses: Canada and U.S. Comparison
Woods, WJ; Binson, D; Euren, J; Pollack, LM
BACKGROUND/OBJECTIVES: Public policy is an important influence on public health practice. In HIV prevention, policies that encourage testing in specific venues can contribute to early detection and intervention. Bathhouses catering to MSM are one such venue. We compared HIV testing programs in two countries with similar venues, but different policy orientations, to understand how public policy influences the delivery of services. Comparing on-site testing programs may broaden and deepen an understanding of health policies in both countries.
METHODS: A cross sectional telephone survey of bathhouse managers identified 112 venues (Canada 35, U.S. 77; refusals: Canada 8, U.S. 23) using the Damron Men’s Travel Guide 2003 and www.cruisingforsex.com as the sample frame. Letters of introduction were sent to the general manager at each club. Managers reported on club testing programs. Managers from 27 of the 35 identified Canadian clubs (77.1%) and 54 of 77 identified U.S. clubs (70.1%) agreed to participate in the survey. Results are Fisher Exact Test or X2.
RESULTS: Canadian clubs (55.6%) were less likely than (U.S. 75.5%) to have a testing program (p=.080). We identified 82 separate testing programs operating in the 55 clubs that reported having programs. Data that follow describe the testing programs, not the clubs, as some clubs had more than one program. There were significant differences (X2=13.1, df 2; p<.01) in whether the initiation for a specific program came from health officials (Canada 52.9%; U.S. 10.6%), the bathhouse management itself (Canada 23.5%; U.S. 48.9%) or community-based providers (Canada 23.5%; U.S. 40.4%). There was a trend that a testing program was offered more frequently by health officials in Canada (42.1%; U.S. 27.0%) and less likely by community providers (Canada 57.9%; U.S. 73.0%), but it was not significant (p=.259). There was no significant difference in who paid for staff and testing materials (i.e., those who ran the program usually assumed costs). The table shows types of infections for which testing was available. None of the Canadian HIV testing programs reported using rapid testing technologies, while 41.8% of U.S. programs did (p<.001). Similarly, Canadian bathhouses were less likely than U.S. bathhouses to provide HIV results at the bathhouse (Canada 11.8%; U.S. 62.7%; p<.001).
CONCLUSIONS: U.S. bathhouses are more likely than Canadian bathhouses to have on-site HIV testing, but Canadian programs were more likely to test for a variety of STDs. Canadian managers explained anecdotally that universal health care made it less important for outside agencies to provide testing in their clubs. Still, when testing was offered in their clubs, they apparently thought it important to test for HIV as well as other STIs. The historical tension between U.S. public health and bathhouses may explain why U.S. health officials were less likely than Canadian officials to initiate testing programs in clubs. Rapid testing appears to be finding a footing in these outreach programs and have reduced bathhouse managers’ traditional concerns about providing test results inside the club.
Table: Types of testing on offer through programs in Canada and U.S.
|Programs Test for:||Canada||U.S.|
|Hepatitis (A, B or C)||83.3%||33.3%*|
Partner-provided social support influences choice of risk reduction strategies in gay male couples
Darbes, L.A., Chakravarty, D., Hoff, C.C., & Neilands, T.
BACKGROUND: Intimate relationships bring an additional dimension to the investigation of HIV risk behavior among gay men. Primary partners may influence an individual’s sexual behavior both within their relationship and with outside partners. We examined whether social support provided by a primary partner that specifically focused on safer sex (HIV-specific social support, (HIV-SS)) was associated with sexual risk for HIV, defined as unprotected anal intercourse (UAI) with outside partners.
METHODS: We recruited a sample of 569 gay male couples from the San Francisco Bay Area. Each partner completed a computer-administered survey that encompassed psychosocial factors and relationship dynamics. The outcomes measured were UAI with outside partners of either discordant or unknown status (OUT-DIS) and UAI with sero-concordant outside partners (OUT-CON). Data were clustered by couple and analyzed using univariate and multivariate logistic regression to identify whether HIV-specific social support from one’s primary partner was significantly associated with UAI with outside partners.
RESULTS: The sample was ethnically diverse. Fifty-five percent of the couples were HIV-negative, 23% were discordant, and 22% were HIV-positive. Monogamy was reported by 35% of the couples. All results described below are significant with p < .03 or lower. All adjusted odds ratios (AOR) are reported per standard deviation of continuous predictors. All analyses controlled for general social support provided by the primary partner. Across sero-status groups, higher levels of HIV-SS were a significant predictor of less UAI with OUT-DIS (AOR = 0.43). When examining results for specific sero-status groups, the finding was similar for concordant negative couples (AOR = 0.41), whereas for discordant couples, the association between increased HIV-SS and UAI with OUT-DIS exhibited a 69% reduction in the odds of engaging in UAI. We also examined the association between HIV-SS and OUT-CON. For this outcome, across sero-status groups, greater levels of HIV-SS were associated with a significant decrease in OUT-CON (AOR = 0.46). When examining sero-status groups individually, increased HIV-SS remained significantly associated with less OUT-CON for men across sero-status groups: sero-discordant (AOR = 0.50), concordant negative (AOR = 0.57), and concordant positive (AOR = 0.40). However, increased levels of general social support provided by primary partners were significantly associated with increased levels of UAI with OUT-CON across sero-status groups (AOR = 1.23) (controlling for HIV-SS). Results for specific sero-status groups suggest that the overall result could be partially driven by the results for concordant positive couples.
CONCLUSIONS: Increased social support provided by a primary partner that specifically focused on safer sex was associated with significant reductions in UAI with both outside partners who were of discordant or unknown sero-status and with outside concordant partners. Increased general social support provided by a primary partner, however, was a significant predictor of increased UAI with outside concordant partners (sero-sorting) across sero-status groups. Findings from both outcomes suggest that partners may be influencing men’s decisions to engage in conscious risk reduction strategies. Tailoring particular types of partner support (e.g., general vs. regarding safer sex) could be important components of interventions and prevention programs targeted towards gay men in relationships.
Promoting regular testing: Reactions to information on acute HIV infection among an urban high risk population.
Arnold, EA, Koester, KA, Morin, SF, and Steward, WT.
Background: Acute HIV infection (AHI) plays a critical role in the spread of the disease. Individuals who are in the first ten weeks of HIV infection are up to 11 times more likely to transmit the virus to their sexual partners than individuals who have been infected for longer. A major challenge in developing interventions for individuals with AHI is finding ways to promote HIV testing immediately after potential HIV risk exposures so that cases are diagnosed in the acute phase. In this study, we explored ways of enhancing testing in a low-income, urban community at high risk for HIV.
Methods: We conducted in-depth interviews with 18 people from a high-risk, predominantly homeless, drug using, urban population who were receiving HIV testing at a community-based organization. Interview topics included last testing experience, patterns of previous testing experiences, facilitators and barriers to seeking testing, and the acceptability of changing testing and risk-reduction behaviors in light of information on AHI. We specifically asked about two testing-related strategies: being screened for HIV as frequently as every two months and being screened for HIV whenever one perceives oneself as potentially having AHI.
Results: The majority of the participants found the information about AHI and its implications on transmissibility of the virus to be very important. In general, participants were receptive to testing more frequently than to testing in response to perceived AHI. Approximately half of the participants already were testing regularly because of their own high-risk behaviors and because their physical and social environments were laden with reminders of HIV—e.g., having acquaintances who are known to be HIV positive; and witnessing HIV-related risk behaviors occurring in public settings. Those individuals who were engaging in high risk activities felt that increasing the frequency of regular testing to every two months would be acceptable if it were convenient, whereas those who were engaging in fewer high-risk behaviors believed that testing every two months would be too burdensome. By contrast, seeking testing in response to perceptions of AHI was almost universally viewed as more problematic because the flu-like symptoms associated with AHI are similar to the symptoms associated with heroin withdrawal or with having Hepatitis C, both very common conditions in this population. Since HIV testing was perceived as routine, as was disclosing one’s HIV status to sexual and drug using partners, our participants were willing to commit to regular HIV testing, especially when testing was bundled into other services they were utilizing, such as shelters, snacks, and mental health counseling, making testing both convenient and relatively free of stigma.
Conclusions: AHI is a compelling and interesting topic for people living in low-income, urban areas. Those individuals who perceive themselves to be at high-risk of infection thought it would be acceptable to be tested as frequently as every two months in order to diagnose new cases of HIV as quickly as possible.
Acculturation and Cultural Adaptability among African American, Asian/ Pacific Islander (API), and Latino Men Who Have Sex with Men (MSM) Living in Los Angeles
George Ayala, PsyD, Jay P. Paul, & PhD Kyung-Hee Choi, PhD, MPH
Background: Acculturation, as a social factor, has been shown to have predictive value in health outcomes research. The conceptual utility of acculturation as conventionally defined is somewhat challenged by examining the experiences of MSM of color who are managing their identities, participation in, and sense of belonging to multiple communities (e.g., ethnic communities, mainstream gay community, mainstream L.A. life, and specific social networks of other MSM of color).
Methods: From July 2005 to July 2006, we conducted 6 focus group discussions and 35 in-depth interviews with 29 African American, 28 API, and 28 Latino MSM (aged 18+) in Los Angeles. Study participants were asked about their experiences of being African American, Latino, API and gay or bisexual in Los Angeles. Transcribed interviews were coded and analyzed for themes.
Results: Respondents discussed the challenges and rewards of being gay in communities of color and being African American, API or Latino in the gay community. These discussions included descriptions of social norms and cultural expectations that impact them in the different communities in which they are a member. Respondents showed considerable variation in their capacity to maneuver through and participate in these different communities. Specifically, many respondents expressed frustration over trying to fit into the mainstream gay and people of color communities, while others proudly shared the comfort and ease with which they moved between multiple social worlds. This adaptability to various social venues seemed based on a number of factors, including respondents’ comfort level with “different-ness” as well as their shared identity, sense of social and cultural connectedness, and level of interaction with others within a given community.
Conclusions: Findings from the qualitative data collected support the use of more complex, multi-directional, and multi-dimensional definitions of acculturation. In this sense, acculturation has the potential for being a useful conceptual lens with which to better understand the experiences of African American, API, and Latino MSM who navigate issues of identity, community affiliation, and adaptability across multiple communities on a day-to-day basis. More research is needed to determine whether social adaptability has a protective effect against negative health outcomes including the risk for HIV infection.
Race/Ethnicity and Erotic Advantages/Disadvantages: MSM of Color, Sexual Stereotyping and Hierarchies of Desire
JP Paul, PhD; G Ayala, PsyD; K-H Choi, PhD, MPH
BACKGROUND: In the general community, partner selection has long been noted as being shaped by race/ ethnicity. The degree to which race/ethnicity determines erotic appeal and sexual partner selection among MSM is not understood as well, despite its importance in defining sexual mixing and sexual networks.
METHODS: Between July 2005 and July 2006, we conducted 6 focus group discussions and 35 individual qualitative interviews, with 28 Latino, 28 API, and 29 African American MSM in Los Angeles. They were asked about their experiences as MSM of color in Los Angeles, including those related to sexual partner formation. Audiotapes were transcribed and coded for themes.
RESULTS: Many of the respondents spontaneously spoke about an implicit hierarchy of sexual desirability, based upon race/ethnicity. Their descriptions were consistent with respect to where different groups fit in that hierarchy: white MSM were generally viewed as most desirable, then Latino MSM, then African American MSM, and finally API MSM (who were typically viewed in a desexualized fashion). Attributions about one’s characteristics/capacities as a sexual partner based upon race/ethnicity were identified by study participants, but were viewed as relatively benign and sometimes used to one’s benefit with respect to sexual “hook-ups”. Many men reported having their own racial/ethnic preferences for sexual partnerships. However, such attributions were only of benefit in defining one’s suitability as a casual sexual partner, and not as a romantic partner. Race/ethnicity was also reported by men as a source of fetishistic attraction by other (principally white) MSM. Most felt demeaned by the racial stereotypes underlying these attractions, which were similarly described within each racial/ethnic subgroup of MSM. The power of race/ethnicity to shape sexual relationships extended to the labels used in the gay community to describe white MSM who preferred MSM of color; such language was seen as having its derogatory or dismissive aspect.
CONCLUSIONS/IMPLICATIONS: Race/ethnicity is a powerful determinant of sexual marketability in the gay male community. This factor can constrict the field of available and desirable sexual partner choices for MSM of color. Sexual encounters can draw upon potent stereotypes of race/ethnicity to construct power dynamics within a given dyad.
Making sure research is used: Community-generated recommendations for disseminating research
Daniel Bao, José Ramón Fernández-Peña, Hank Wilson, Tim Berthold, Teresa Betancourt, William Bland, Beth Freedman, Katie Kramer, Lisa Moore, Stephan Oxendine, Patricia Perkins, Brenda Storey, Dan Wohlfeiler, Ellen Goldstein, Pamela DeCarlo
Issue: HIV research, no matter how innovative, will never make a difference in the epidemic unless it is disseminated in an appropriate and timely manner to the people and organizations providing HIV services. Yet many researchers are not trained, rewarded or supported to disseminate research findings beyond academic journals.
Setting: The Community Advisory Board (CAB) of the Center for AIDS Prevention Studies (CAPS), University of California San Francisco, has encouraged and guided CAPS researchers in expanding their dissemination efforts to better reach CBOs, policymakers and community stakeholders.
Project: The CAPS CAB drew from their own experiences and interviewed researchers and CBOs to develop “Recommendations for Research Dissemination” (Recommendations). The CAB found several barriers to successful dissemination such as: lack of time and money, little consideration of non-traditional dissemination during faculty promotions, government funders’ restrictions on publishing, and lack of knowledge regarding dissemination to CBOs. While acknowledging these concerns, the CAPS CAB agreed that researchers should adhere to some minimum requirements for dissemination. (caps.ucsf.edu/uploads/projects/collaboration/dissemination.php)
Results: The Recommendations provide guidelines on the audience, content and methods for disseminating HIV prevention research. To support researchers, the Recommendations also provide sample grant language, proposed timelines and examples of effective dissemination. Recommendations include:
- Overall: Include a plan for dissemination in the original research study grant to ensure that it is funded and accomplished.
- Audience: Report back to study participants and the CBOs who helped with recruitment.
- Content: Disseminate data before the end of a study, including: basic descriptions of studies, recruitment, demographics, baseline data, instruments and interesting findings. Also, report on positive, negative and null findings. CBOs and other researchers can learn from research “failures.”
- Methods: Disseminate through websites, conferences, CBO in-services, newsletters, community forums, press releases, mail and e-mail.
Lessons Learned: These Recommendations are unique in that they come from a community perspective and encourage researchers to go beyond traditional academic dissemination methods. Using CABs and other community resources can help researchers ensure their findings are delivered to the most useful audiences. The CAPS CAB is in the process of disseminating these Recommendations to CBOs, researchers, university training programs and funders.
Internalized Homophobia is Associated with HIV Transmission Risk among HIV-Positive Gay-Identified Men.
M. Johnson, A. Carrico, S. Morin, E. Charlebois, and M. Chesney
Background/Objectives: We explored whether internalized homophobia (IH) is associated with regular stimulant use, HIV transmission risk, psychological wellbeing, and anti-retroviral (ART) medication adherence in gay-identified, HIV+ men.
Methods: Men in San Francisco who were screened for inclusion in the Healthy Living Project prevention trial were interviewed using audio computerized-assisted self-interviewing (ACASI) and computer-assisted personal interviewing (CAPI) assessments of IH, substance use, sexual behaviors, mood, and medication adherence. The sample of 465 gay-identified men was largely Caucasian (62%), but a substantial portion of participants were African American (18%) and Hispanic/Latino (10%). Mean age was 41.5 years (SD=8.3) and 76% attended at least some college. We validated a 4-item (e.g., I wish I were heterosexual) measure of IH using both exploratory and confirmatory factor analyses. The IH factor appeared to be a good fit for the data and items demonstrated adequate internal consistency (Cronbach’s Alpha = .77).
Results: Elevated IH was associated with a 55% greater likelihood of reporting stimulant use 2-3 times per week or more (OR = 1.55, p <.01; 95% CI: 1.15-2.08) and a 41% greater likelihood of reporting unprotected receptive (but not insertive) anal intercourse with a HIV-negative or unknown serostatus partner (OR = 1.41, p <.05; 95% CI: 1.02-1.96). Higher IH was also associated with increased affective symptoms of depression (r = .40, p < .001) and decreased positive states of mind (r = -.29, p < .001). Among participants on ART (n = 328), those who were higher in IH were 31% more likely to report taking less than 90% of medication doses in the past 3 days (OR = 1.31, p < .05; 95% CI: 1.04-1.64).
Conclusions/Implications: Internalized homophobia may be an important factor in understanding personal and public risk behaviors among gay-identified, HIV-positive men. Future investigations examining the inter-relationships among IH, substance use, psychological wellbeing, and risk behaviors are warranted.
“Coming to this group really made me see how much I had to learn”: Peer-Delivered Interventions in U.S. Clinical Settings Address the Prevention Needs of People Living with HIV/AIDS
Kimberly A. Koester, Andre Maiorana, Karen Vernon, Janet Myers, Carol Dawson Rose, Stephen F. Morin
Background: In the U.S., HIV prevention increasingly includes behavioral interventions designed to reach people living with HIV in clinical settings where they seek care. These interventions include some delivered by individuals with similar characteristics to patients (“peer-based interventions”), which have been used successfully to change other health behaviors. Nevertheless, interventions for people living with HIV delivered by HIV-infected peers have been understudied. In this qualitative study, we evaluated the acceptability to patients participating in peer-based interventions in clinical settings.
Methods: We designed a comprehensive evaluation of fifteen demonstration projects funded under the Health Resources and Services Administration’s (HRSA) Special Projects of National Significance (SPNS) Initiative on Prevention with HIV Infected Persons Seen in Primary Care Settings. The objectives of the qualitative evaluation component were to assess clinic staff members’ and patients’ perceptions of feasibility and acceptability of the interventions in order to understand intervention outcomes. For this analysis, we focused exclusively on interview data collected from patients enrolled in peer-delivered interventions. Recorded interviews were transcribed and coded to identify converging and diverging themes.
Results: Patients reported feeling connected to the peers providing intervention services and an appreciation for the knowledge they gained during participation. Patients felt that peers shared similar life experiences and perceptions; they described their participation as “life-enhancing” and shared that the interventions facilitated “soul searching,” which helped to alleviate the isolation experienced by many of the patients.. Patients reported that the intervention made them feel more comfortable disclosing their serostatus to sex partners and to family members. Some patients were more comfortable talking to a peer while others found it “easier” to learn from someone that has gone through and experienced issues related to HIV. Patients described a sense of surprise concerning new information learned during the intervention, particularly around condoms. For many, the opportunity to participate in or observe a condom demonstration and to learn about the various options available e.g., female condoms, flavored condoms, was a novel and useful experience.
Conclusions: Peer-based HIV prevention interventions in clinical settings can be “powerful,” educational opportunities to discuss topics that matter for patients’ day to day lives as well as providing a time and place for contemplation and reflection. People living with HIV/AIDS have a clear role as advocates for prevention and are an asset in delivering prevention services in clinical settings.
Audio Computer-Assisted Risk Assessment is Associated with Higher Self-reported Risk among HIV-Infected Latinos
Myers JJ, Shade SB, Koester K, Morin SF.
Background: HIV prevention studies face challenges to assessing HIV risk behavior. Most studies show that audio computer-assisted self interviewing (ACASI) methods yield more accurate data because they reduce discomfort and social desirability bias among participants. Few studies have examined differences among Latinos in risk report by the type of interview method. This is important because Latinos are disproportionately infected with HIV and accurate risk data will contribute to better prevention programs.
Methods: Using data from 26 HIV primary care clinics across the US, we assessed differences in reported HIV-risk behavior among Latino HIV patients (n=550) completing risk assessment by ACASI (n=386) and in face-to-face interviews (n=164). We compared reported proportions of unprotected vaginal or anal intercourse with HIV-uninfected and status-unknown partners (transmission risk behavior or TRB) in sites using ACASI and interviewer-administered methods. We also used qualitative interview data to examine issues of acceptability of both types of interview methods by participating patients.
Results: Latino patients were significantly less likely to report transmission risk behavior when the sexual risk assessment was administered face-to-face by an interviewer (12% reported TRB) than when the risk assessment was completed by patients via ACASI (20% reported TRB; p=0.007). This difference held true for both men and women, for patients of all ages and sexual orientations, for patients of all educational backgrounds and regardless of clinical status (assessed by most recent CD4 t-cell count). No differences in reported risk were found for White HIV patients. In qualitative interviews, both Latino and White patients reported few problems using ACASI, and it was well accepted as a method for collecting sensitive behavioral data. Patients expressed negative feelings about the questions asked as part of the sexual risk assessment because of their complexity and length; however, this was true regardless of the interview method.
Conclusions/implications: ACASI methods may be more effective for yielding accurate self-reports of HIV risk among Latinos. Response burden should be considered in the design of sexual risk assessment instruments.
“It’s appalling how, online, we stopped having conversations.” Focus group data guided the development of a Web-based HIV prevention program to meet the needs of gay/bisexual men who use the Internet
Background/Objectives: MSM who use the Internet to meet sex partners report high rates of unprotected sex and STDs. Most online HIV prevention efforts have been individually-oriented, and while effective, in-person community-level interventions exist, there has been little research into developing similar Internet-based programs.
Our previous online research with MSM indicated that Internet-based prevention programs that involve the community and are appropriate to online culture may be well-received. This project incorporated these lessons and sought additional input from community members to develop and pilot a website designed to positively affect online social norms around safer sex and HIV prevention.
Methods: We recruited 38 men from online venues to participate in 1 of 4 focus groups conducted throughout California. We asked participants to discuss their (1) experiences in online MSM venues; (2) suggestions about a new website designed for MSM in California; (3) reactions to some proposed features for the site; and (4) perceptions about online HIV prevention. Fifty-eight percent of participants were white, 21% Latino, 11% Black/African-American, 5% Pacific Islander, 3% Asian, and 3% Native American. Their mean age was 35 (range 22-66). Two researchers moderated the group, and one took detailed notes. The notes were analyzed by the entire team to identify emergent themes, in addition to summarizing the feedback to our direct questions. The results were then used to design the intervention website.
Results: Each group consistently stated frustration about the lack of open, honest, and meaningful communication in existing online MSM venues. Participants commonly expressed a desire to communicate online with other men about shared interests and concerns, in ways not limited by the user-profile or chat formats available on most MSM websites. Participants supported several of the features we proposed and provided ideas for improvement. They expressed some interest in information about sexual health but recommended that this be not the site’s primary focus. Participants hoped for an alternative to sexually-oriented sites while maintaining a strong recognition that “sex sells.” They suggested a site that would represent all men in the community, including HIV-positive men discussing their experiences, and men of different ages sharing knowledge and experiences across generations in non-sexual, supportive ways.
Implications: We used these formative data to design a site, CaliforniaMen.net, that would address many of the needs identified by participants. The site features: (1) blogs authored by California MSM, providing a discussion forum; (2) a “Little Black Book” application to (a) organize information about one’s sexual encounters, (b) define one’s comfort level with risk-taking and determine when it may have been surpassed; and (c) receive STD/HIV testing reminders based on potential exposures as reported in the Little Black Book; (3) user reviews of the popular “hook-up” websites to allow men to become active commentators about their environment; (4) a Q&A feature with a prominent physician; and (5) referrals and links to online resources. Evaluation efforts are currently in progress. These include qualitative interviews with site users, as well as quantitative analysis of website traffic which, so far, has been less than anticipated.
An intervention to help CBOs achieve greater fidelity to an evidence-based HIV prevention model
Background: The CDC and other funders are encouraging CBOs to adopt evidence-based HIV prevention interventions, including the Mpowerment Project (MP), a community-level program for young gay/bisexual men ages 18-29. The MP is included in CDC’s Diffusion of Effective Behavioral Interventions Project. While some funding exists to implement these programs, there has been scant research regarding what approaches can help organizations implement them with fidelity to the original models. This presentation describes how the original MP researchers intervened with CBOs to help them effectively replicate its implementation.
Methods: In order to study how an intervention directed at an organization can affect program fidelity, we are conducting a longitudinal study of MP’s implementation with 72 CBOs. This project will determine if there is a relationship between fidelity and use of the Mpowerment Project Technology Exchange System (MPTES) which includes: technical assistance (TA), training, and replication materials. We conducted semi-structured interviews with 1-5 people from each agency at four time points (baseline-before TA was provided, 6, 12, and 24 month follow-up). We have conducted 532 interviews with 329 individuals from agencies implementing MP. During the interviews, agencies reported their fidelity to each of the MP’s core elements, and these data were used to compute a self-reported fidelity score. Additionally, we created externally-rated fidelity scores by having 3 research team members review TA notes and qualitative data from the interviews to independently rate each agency’s overall program fidelity on a 10-point scale. To determine the reliability of these externally-rated fidelity scores, we randomly selected 26 rating periods and found that the 3 raters were within 1 point of each other 73% of the time, and within 2 points of each other 100% of the time.
Results: Utilization of the MPTES was assessed by reviewing our records and asking respondents how many times they used each MPTES component. These variables were subjected to a factor analysis, which yielded two strong uncorrelated factors: the Materials Utilization Scale (including the use of all replication materials) and the Interactive TA Scale (including all TA activities). We computed Pearson correlations to assess the relationship between these scales and both externally-rated fidelity and self-reported fidelity. As indicated in the table below, Materials Utilization and Interactive TA were related to both fidelity scores at different times in the study. The 24 month follow-up is close to completion.
Table 1. Correlation between MPTES activities and fidelity
|BASELINE||6 MONTH FOLLOW UP||12 MONTH FOLLOW UP|
|Fidelity-self report||Fidelity-external rating||Fidelity-self||Fidelity-external||Fidelity-self||Fidelity-external|
Conclusions: These findings indicate that there is a relationship between utilization of technology exchange services and program fidelity. It appears that during initial program implementation, materials help CBOs implement MP with fidelity, but then after agencies have learned “the basics” from the materials, the interactive TA becomes more important. Our findings suggest that materials alone are insufficient to help agencies maintain fidelity over time, and that interactive TA is necessary to help agencies retain fidelity to the original intervention’s theoretical underpinnings and methods, while tailoring it to each community’s unique characteristics.
Translating Research into Practice: Real world adaptations of an evidence based community level HIV prevention intervention for young MSM (YMSM).
Scott Tebbetts, Susan M. Kegeles, Greg Rebchook
BACKGROUND: Considerable effort has been made to encourage community-based organizations (CBOs) to adopt evidence based HIV prevention interventions. Because the Mpowerment Project (MP) is one in a small group of evidence based interventions targeting MSM and the only program specifically developed for YMSM, an increasing number of agencies are adopting the intervention to target MSM in their communities. In a longitudinal, collaborative study with 72 CBOs implementing the MP, we have been examining how the agencies have tailored and adapted the intervention’s core elements.
METHODS: Semi-structured telephone interviews lasting 40-120 minutes were conducted with 1-5 people from each CBO at baseline, 6, 12, and 24 months. We have conducted 532 interviews with 329 individuals from agencies implementing MP. We asked participants open-ended questions about how each core element was being implemented and they were prompted to describe in detail any adaptation of a core element and why it was modified. All responses were typed up, near verbatim as much as possible, and then were entered into a database. The adaptations have been discussed at monthly data analysis meetings, and adaptations to core elements have been summarized.
RESULTS: The MP was developed for 18-29 year old YMSM and was meant to reach men of all ethnicities together. It is now being used on youth and men who have sex with men, who may or may not identify as gay or bisexual, ranging from 13 – 60 years of age, of specific ethnic groups (Black, Latino, Asian/Pacific Islander, Native American) and from rural to very urban locales. CBOs are actively adapting the MP’s core elements to address the needs of their target populations, their organizational resources, and their geographic location. This presentation will describe common adaptations to each core element and the rationale for the changes. The following table shows examples of how core elements have been tailored and adapted.
|Core Element||Example of Adaptation||Rationale for Adaptation|
|Core Group||Reduce meeting frequency to once/month instead of once/week||Rural locale makes meetings difficult to attend|
|Project Space||Meetings take place in private homes/apartments instead of in a designated project space||Lack of funding for stand-alone space and/or lack of safe, private alternatives|
|Project Events||Emphasize HIV testing during project events instead of emphasizing a social focus in order to recruit men to events||Funding requirement and/or agency priority on testing|
|Formal Outreach||Outreach team conducts outreach without a theme instead of employing an eye-catching approach||Coordinators report that the outreach team refuses to conduct thematic outreach|
|Coordinators||Coordinator staffing levels of less than the recommended 1.5 FTE||Lack of funding|
|M-groups||Adding new role plays; curriculum expanded into 4 sessions and conducted consecutively over 4 weeks instead of one 3-hour session||Allows the project to focus on issues associated with maintaining safer sexual behaviors in greater depth|
|Publicity||Solely use web-based outlets such as MySpace.com, Manhunt.com rather than also distributing materials at community spaces||Increased use of the Internet by target population to communicate and find potential sex partners|
|Informal Outreach||Use a visual “tick board” in project space to track number of informal outreach occasions rather than solely using encouragement to support men to speak with peers||Establishes a visual reminder of the need to support each other in having safer sex|
|Use the agency Board of Directors as the project CAB instead of convening one specific to the intervention||Eliminates the need to coordinate a separate group|
CONCLUSIONS: Some adaptations to the MP adhere to the model’s guiding principles and theoretical framework and are within the MP’s fidelity parameters. Such adaptations may increase the MP’s effectiveness for certain target populations, such as introducing role plays for the M-groups that closely mirror men’s experiences, thus making the M-groups more personally relevant. Other adaptations, however, are more drastic and may work against efforts to implement the MP with fidelity and may “mutate” the model into a different intervention. For example, some coordinators conduct all publicity regarding the intervention via Internet rather than going to bars, cafes and STI/HIV testing sites, thus possibly reducing the likelihood of reaching all segments of the young MSM community. With this in mind, training approaches, replication materials, and technical assistance should include more examples of how the MP can be successfully tailored and adapted in ways that retain fidelity to the intervention, while making it culturally and geographically appropriate, acknowledging the use of fewer resources than in the original intervention. Additional outcome monitoring and evaluation may be necessary to assess the effectiveness of adaptations that fall beyond the parameters of the original model.
Rapid HIV Testing Training and Education for Healthcare Professionals: What Are the Results?
To, KX, Bernstein, M, Reyes, EM, Myers, JJ, Morin, SF
BACKGROUND: The Pacific AIDS Education and Training Center (PAETC) held its second annual Rapid Testing Forum in spring 2006. It examined ways for PAETC staff and faculty to support expansion of rapid HIV testing in diverse care settings and to motivate healthcare professionals to help implement rapid testing through their work. Changes in knowledge among forum participants and post-forum application of knowledge and skills in their work were evaluated.
METHODS: A pre- and post-forum self-assessment evaluation questionnaire was used by 35 participants to rate their knowledge of rapid HIV testing implementation issues. A four month follow-up questionnaire was completed by 19 respondents asking whether they applied knowledge and skills from the forum to their jobs, which activities they applied, and the resulting impact of those activities. For the self-assessment ratings of knowledge and skill level, matched and paired samples t-tests were run. Mean scores for the group were calculated at pre-forum and post-forum. The follow-up data was analyzed qualitatively and categories created.
RESULTS: The mean score at pre-forum for overall combined items for the entire group of respondents in the assessment was 2.69 (“medium” level of knowledge) out of 5.00. The mean score at post-forum was 4.29 (“high”). Knowledge of rapid HIV testing implementation issues in emergency departments showed the largest improvement in rating, from “medium” (2.50) to “high” (4.25). Twenty-seven percent of participants considered themselves to be at a high and very high level of knowledge in this topic before the forum, whereas 84% of them rated themselves at high and very high levels after the forum ( p<0.05). To develop or plan trainings on rapid HIV testing was the forum objective that respondents said that they applied the most during the four months after attending forum. Forty-two percent of the respondents (8 of 19) said they fulfilled this objective, primarily by developing and planning trainings for staff in labor and delivery and pediatric/prenatal departments of clinics or hospitals. Most of the other training objectives were not applied at all or very small numbers of respondents applied them. Respondents primarily utilized training as the activity to carry out two of the objectives, to develop or plan trainings on rapid testing and to conduct trainings on rapid HIV testing.
CONCLUSIONS: Training by itself is insufficient for implementing rapid testing in clinical settings. Structural and policy barriers in clinical settings need to be addressed in conjunction with application of training. Implementation of forum objectives was minimal due to organizational barriers and the current lack of resources, such as unprepared lab field services; clinical lack of information on rapid testing technologies, policies, procedures, protocols and forms; and lack of clinical staff training, which prevented PAETC healthcare professionals from supporting care settings in expanding rapid testing services.
Greg Rebchook will moderate Session A16: Impact of Sexual Relationships on HIV Risk Among MSM.He was suggested by Track A co-chairs (Drs. John Peterson and Jacques Norman) a This session is scheduled for Tuesday, December 4th from 3:30 – 5:00 PM.
Session A16: Impact of Sexual Relationships on HIV Risk Among MSM
– Return To Sexual Abstinence Among Young Men Who Have Sex With Men
– Relationship Dynamics Associated with Sexual Risk for HIV Among Gay Male Couples
– Patterns of Sexual Risk Behaviors and Partner-Types as Predictors for HIV Among MSM
More AIDS cases are reported among men who have sex with men (MSM) than in any other group. Young MSM report riskier sexual behaviors than older men, and young MSM of color are among the most severely impacted by this disease. The session describes a study of sexually experienced, young MSM who halt sexual activity to reduce their risk for HIV and other diseases. Findings suggest that these men are more connected to ethnic communities (and to the importance of their ethnic identity than sexually active, young MSM) and that research should gather information about ethnic/gay identity to develop interventions to reduce sexual activity through enhancing community connections and sense of self. The session also describes an examination of the agreements that MSM couples make about sex outside the relationship to determine the relationship variables that are associated with sexual HIV risk. Findings indicate couples that rate their agreement quality and relationship satisfaction higher engage in less unprotected anal intercourse with sero-discordant and unknown status external partners. The session also describes an examination of the relationship between HIV acquisition and sexual acts with various partner types among MSM. Findings indicate that unprotected receptive positioning — and engaging in sex with multiple HIV-status partner types in either position — are most hazardous for HIV acquisition, an important component of prevention counseling efforts directed at MSM.
Last modified: November 2, 2012