Evaluation

Introduction

Since the beginning of the AIDS epidemic through 1998, 18% of all diagnosed AIDS cases in the country were Latino (most of them MSM), an ethnic group that constitutes only about 9% of the population. In the San Francisco Bay Area, the proportion of AIDS cases among Latinos increased from 10% in 1990 to 16% in 1997 (Bay Area HIV/AIDS Update, May 1998). The 1997 HIV Consensus Report estimates that 3,589 Latino MSM were infected with HIV, representing 14% of all gay/bisexual men living with HIV in San Francisco. Low acculturated Spanish speaking immigrant Latino MSM frequently suffer from financial hardship, homophobia, and racism – all strong predictors of social isolation and low self-esteem (Diaz et al, 2001, American Journal of Public Health), and often face language barriers and a justified fear of being identified as undocumented immigrants. This has a substantial effect on access to health care and social services, including HIV prevention (2001 HIV Prevention Epidemiological Profile).

Hermanos de Luna y Sol (HLS), a program of Mission Neighborhood Health Center (MNHC), is an innovative HIV risk-reduction intervention that targets Spanish-speaking, mostly immigrant, Latino gay and bisexual men in San Francisco’s Mission district. Based on principles of empowerment education and psychospiritual growth work, and addressing specific sociocultural factors that undermine safer sex in the Latino gay community, HLS aims to strengthen participants’ sources of social support and promote sexual self-regulation in order to reduce the high incidence of unprotected anal intercourse in the population. The program offers services in three major modalities:

  1. Six-week week initial discussion workshops of group intervention for new participants, implementing a pre-determined but flexible HIV prevention curriculum that promotes social connectedness, critical thinking and exploration about the factors or barriers that compete with safer sex intentions
  2. A weekly discussion/support group for graduates of the six-week cycles, aimed at providing ongoing social support, exploration and communication to sustain behavior change over time
  3. Individual risk-reduction counseling services to address individual prevention needs of those participants whose vulnerability to HIV risk merits individual attention.

The program also offers skills-building sessions, sexual abuse workshops, weekend-long retreats, and social/artistic activities for program participants.

The HLS program has been in existence for six years, initially funded and developed as a component of a larger CDC grant to MNHC, and currently funded by the AIDS Office of the San Francisco Department of Public Health (SFDPH). As agreed in the funding contract with SFDPH, we report findings for the most current program evaluation. The evaluation component of the program involves an initial baseline interview and a four-month follow-up interview to determine pre-post intervention changes in participants on variables related to HIV risk.

The present evaluation report is divided into the following sections:

  1. A demographic description of HLS participants
  2. A behavioral risk assessment, based on data collected in the baseline interview
  3. Comparison for Pre-Post Intervention Changes
  4. Self-Reported Program Effects
  5. Implications or conclusions
  6. Limitations and Barriers – BRA questionnaire

This report includes data from 185 HLS participants, of whom 87 have completed four-month follow up interviews.

1. Demographic Description of HLS Participants

As intended by HLS target population and recruitment strategies, we were able to recruit a sample of mostly self-identified gay and bisexual men (95% identified as homosexual, gay or bisexual), who are immigrant (90% born abroad), low acculturated, Spanish-speaking (only 15% indicated speaking mostly or only English at home and 11% with friends) and of low socioeconomic status (35% unemployed; only 54% living in own rented apartment or home). The group is predominantly young, with 45% of participants being 30 years of age or younger, and 87% being 40 years of age or younger.

2. Behavioral Risk Assessment

The HLS Program targets Spanish-speaking, low-acculturated, Latino, MSM immigrants. Although the exact size of this population is not known, it is estimated that approximately 55% of the 110,000 Latinos living in San Francisco are immigrants (roughly 60,500 immigrants) and perhaps half of this population is male (30,000 Latino men). San Francisco has the international reputation of a gay mecca, which provides substantial reasons to be a landing pad for Latino, MSM immigrants.

Our sample is a homosexually active group of men, with 86% reporting sex with other men in the last three months, and 59% reporting sex with more than one partner in the same time period with a mean number of partners of 4.9. About half of the sample (46%) reported insertive anal intercourse and 47% reported receptive anal intercourse for the past three months. Of those who engage in anal sex, only one half (50%) reported consistent condom use for insertive anal intercourse and about two-thirds (62%) reported consistent condom use for receptive anal intercourse. These data show that our target population is somewhat riskier than other samples of Latino gay/bisexual men, of whom about 70% report consistent condom use within a similar time period. Condom use for oral sex is extremely low, with about 71-74% of the sample reporting never using condoms for either receptive or insertive oral sex. The prevalences of sex with women (14%) and injection drug use (14%) are relatively low in this sample.

3. Pre-Post Intervention Changes

Pre – Post Changes (N=87) on Variables Targeted by HLS Program
Pre Post *Baseline Improvement
Consistent Condom Use
–anal receptive 55% 63% +15%
–anal insertive 46% 64% +39%
No Condom Use
–anal receptive 21% 10% -52%
–anal insertive 15% 8% -47%
Firm Committment(“Definitely Yes”)
to condom use for anal sex 22% 34% +55%
Internalized Homophobia
(“Homosexuals should be silent and discreet.”) 48% 65% +35%
Self Esteem
–reported as “low” or “very low” 22% 8% +64%
–reported as “high” or “very high” 37% 51% +38%
Social Networks
has more than 2 friends with whom to “go out and have fun” 62% 76% +23%
*Baseline Improvement = Post %-Pre %/Pre %

4. Self-Reported Program Effects

Quantitative look at results (this is a PDF document)

Testimonies of participants’ reactions to the program

5. Implications/Conclusions

The demographic data collected in the BRA show that the HLS program is successfully recruiting men from the intended target population. This population continues to be vulnerable with respect to HIV transmission, given the high rates of inconsistent condom use for anal intercourse within a relatively short time period. The program was highly successful in reducing by 52% the percentage of men who never use condoms for anal intercourse. Other pre-post changes observed suggest that the program is moderately effective in increasing consistent condom use and that those changes go hand in hand with an increase in gay-positive attitudes and an increase in both self esteem and social support. Even though the program increased the number of men (from 22% to 34%) who are strongly and firmly committed to condom use for anal sex, the prevalence of such firm commitment is still relatively low at posttest. It is important to discuss these findings among program staff and explore the issues around personal commitment for condom use. Closely related is the fact that many men continue to participate in situations that are difficult to practice safer sex, such as anonymous sexual encounters in public places and sex under the influence of alcohol and/or drugs. It is possible that men’s less than firm commitment to condom use reflects their awareness of the difficulties encountered in their attempts to maintain safer sex practices over time, especially in difficult circumstances. The HLS program should focus increased attention on issues related to specific difficult situations like anonymous sex and substance use, and explore ways to increase men’s strategies in those situations and increase their commitment to safer sex. Above all, the program should continue its good work in promoting self-esteem and social connection, as well as their success in increasing the rates of consistent condom use in this vulnerable population.

6. Limitations and Barriers

I. The main limitation is that data on sexual behavior are assessed for all partners combined, and thus do not distinguish between partner type, monogamy arrangements with the given partner, serostatus of sexual partner, etc. In the absence of such information about sexual partners, it is possible that levels of potential HIV transmission can be overestimated. Also, the data are based on a convenient sample, including only men who are interested in participating in a prevention program — such sampling may not include men who are at both extremes of the risk continuum, namely, consistently safe men who are socially connected and personally satisfied and see no need to participate in the HLS program, or on the other end of the continuum, consistently risky men who do not care or are afraid, embarrassed or intimidated by participation in a prevention program.

II. The BRA respondents are exactly the intended target audience for the HLS program.

III. Our BRA instrument inadvertently left out information regarding sources of primary health care. Also, the suggested response summary tables are at times confusing, because it was not clear what denominator should be used in the calculations of the respective percentages. DPH should convene a meeting with program evaluators and other personnel responsible for filling out the BRA reports in order to discuss some of these issues. Click here for the BRA questionnaire.


Preliminary report, respectfully submitted by Rafael M. Díaz, Ph.D., Program Evaluation Consultant, February 1, 1998

Hermanos de Luna y Sol is a program of the Mission Neighborhood Health Center, funded by the AIDS Office of the San Francisco Department of Health. The evaluator would like to acknowledge the work of program staff Rómulo Hernández and Erick Gwiazdon in the collection of data and the valuable help of Miguel Casuso-Rivera in the creation of the evaluation database.

Last modified: February 7, 2011