Adapting an EvidenceBased HIV Prevention Intervention for Young Black MSM

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Adapting an Evidence-Based HIV Prevention
Intervention for Young Black MSM

• Susan M. Kegeles, CAPS/UCSF
• Gregory Rebchook, CAPS/UCSF
• Elder Claude Bowen,
• Minority AIDS Project, Unity Fellowship Church
• Roosevelt Mosby, Jr.,
• Sexual Minority Alliance of Alameda County
• Phill Wilson, Black AIDS Institute

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Young Black MSM are at Very High Risk for
HIV/AIDS

• AIDS is the leading cause of death in 35-44 year
  old men, 3rd leading cause among 25-34 year olds
• 94 - 97 17 of men aged 15-22 were HIV
• Estimated that in any given year, 4 of young
  Black MSM become infected with HIV

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Appropriate HIV prevention interventions for
YBMSM are necessary

• Only 1 intervention for Black MSM men has been
  developed and rigorously tested (Peterson 1996)
• New community-level interventions that address
  multiple issues through a variety of channels and
  activities are needed
• MP has not reached YBMSM before clearly needs to
  be translated to meet their needs

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The Mpowerment Project (MP)

• Demonstrated effectiveness
• Listed in CDC Compendium of HIV prevention
  interventions with evidence of effectiveness
• Scientifically tested in several communities
• Communities were primarily white and
  Latino/Hispanic
• Community-level intervention with multiple
  components
• Creates healthy community
• Promotes supportive friendship networks
• Disseminates a norm of safer sex throughout the
  community

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We are adapting and pilot-testing MP with young
Black MSM

• Community collaborative research is necessary
• 3 African American CBOs and CAPS are partnering

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Goals of Translation Project

• Determine how to modify the Mpowerment Project
  for YBMSM, ages 18-29 (Phase I)
• Implement the modified Project (Phase II) for 12
  months
• Evaluate success of the translation process
• Identify organizational, setting, researcher, and
  population characteristics that impede or
  facilitate implementation

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Phase I Formative Research to Modify MP

• Boards of Cultural Experts (BOCEs)
• N21, older men, all MSM, identities varied
  (gay, SGL, het)
• 1 Board each in LA Oakland area
• 10-11 members each
• Knowledgeable and thoughtful about the target
  population
• Received 500 for participation
• One 2-day training and 8 Board meetings (4 in
  Oakland, 4 in LA)
• Focus Groups with YBMSM (18-29 year olds)
• N34
• 6 groups of 8-10 men (4 in LA, 2 in Oakland,
  additional groups will be held in Oakland)
• Participants received 50
• Analyzed themes that arose in various groups

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Dual identity/Internalized Oppression
Issues that emerged
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Other key issues that emerged
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Internalized Oppression

• YBMSM are an oppressed minority within a
  stigmatized minority
• Many YBMSM internalize homophobic messages from
  the black community and internalize racist
  messages from the larger society
• Negative consequences result in how regard care
  for self partners
• How to modify MP
• Emphasize pride in being African American pride
  in same sex attractions
• Adapt existing small group component to focus on
  these issues and/or develop new group

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Emphasize Whole-man

• YBMSM do not want to be reduced to their sexual
  activities, sexual desires
• Recognize that their identity includes family,
  spirituality, community, history
• They face difficult issues
• Discrimination
• Biased criminal justice and socioeconomic systems
• Institutional and overt acts of racism
• Fatalism, hopelessness, and loss of control
• An unwelcoming and unsupportive mainstream gay
  community
• How to modify MP
• address multiple facets of becoming a fully
  functioning adult man
• Wellness, exercise, connection to spirituality
• Job and life-skills training, resume writing,
  interviewing, finances, banking, housing, literacy

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Diverse Sexual Identities

• YBMSM have a variety of sexual identities many
  are reluctant to join a gay project
• Many YBMSM have sex with women
• However, many black MSM do have a strong gay
  identity and are at risk for HIV
• How to modify MP
• Keep project as welcoming as possible for
  gay/SGL-identified men and men who dont
  self-label based on their sexual activities
• Avoid the term gay
• Primarily design the project for men with some
  sense of identity around their same-sex desire or
  attraction
• Use more subtle language and be more ambiguous in
  visual imagines and words than previous projects
• Modify publicity of project, activities, groups

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Lack of Adult Male Role Models

• Many YBMSM have not had adult men in their lives
• No vision about what an older BMSMs life is like
• BOCEs and focus groups raised mentoring as an
  important issue
• How to modify MP
• Change CAB - members as mentors
• Train mentors in work
• Create safe venues for mentors to socialize with
  YBMSM
• Seminars, panel discussions and other forums for
  YBMSM to learn from the mentors

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HIV Testing Treatment Issues

• High seroprevalence rates
• Increased emphasis on getting HIV men to know
  serostatus obtain treatment
• How to modify MP
• Not focused on previously in MP
• Develop messages that YBMSM can use to encourage
  each other to get tested feel okay about
  treatments
• Important to destigmatize HIV men (see Arnold et
  al.)
• Enhance referrals to HIV testing sites where
  YBMSM will feel welcome

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Changing small group component

• Issues in current M-groups are relevant
  important to YBMSM - but insufficient
• Address whole-man empowerment, internalized
  racism homophobia
• Trust rapport - concern about spreading my
  business
• Change format of teaching (pedagogy)
• More culturally relevant appropriate exercises
  (eg, music, affirmations, spoken word)
• Create safety so sharing can be less superficial
• Increase variety to allow more role-playing with
  different kind of sexual partners
• Expand beyond 1 session - yet balance with how
  many sessions young men are willing to attend

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Church/Religiosity/Spirituality

• Frequently mentioned
• Mentioned by those who feel alienated from the
  church and those who still participate in it
• A need exists for YBMSM to discuss how religion
  affects them
• How to modify MP
• Help men identify options for spirituality
  faith
• Help men find peace with their spirituality and
  sexuality
• Panels, discussion groups, etc.
• Possibly connect with an opening affirming
  church

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Phase II Implement Project for YBMSM

• Each CBO is running the intervention currently
• 12 months of implementation
• 2 programs in LA operated jointly 1 program in
  Oakland
• Researchers provide on-going support
• Materials (training manuals, videos, facilitator
  guides)
• Trainings (initial 3-day on-site follow up)
• On-going technical assistance (via phone, e-mail)
  with constant feedback about evaluation results
• On-line services (website, online materials,
  Listserv, chat room)

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Translation Research Challenges

• When asked community about how to change the
  intervention - to deconstruct the intervention
  --
• Found that the basic ideas of the intervention
  (guiding principles, core elements) were relevant
• Yet scope depth of issues required to address
  in order to change the intervention were
  substantial

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Challenges Continued

• Risk behavior among YBMSM occurs in a very
  different cultural, economic, social context
  from the original communities. E.g.
• Homosexuality is organized very differently than
  in white community
• How Black men cope with racism is critical -
  through the use of community structures (family,
  church, community) - which affect HIV prevention
  efforts
• Much higher proportion of Black men live in
  disenfranchised, marginalized communities, in
  poverty, than whites - adds tremendous complexity
  to life issues to address
• HUGE class issues in Black community

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Challenges Continued

• Therefore, modifying the intervention is not just
  a matter of adjusting the project for a slight
  cultural nuance - not a quick fix - cant
  simply use culturally appropriate music and
  colors for materials
• Re-designing the intervention requires developing
  new components considerable re-framing of
  current components
• Developing the adapted intervention is
  time-consuming and requires pilot-testing,
  careful evaluation, trial and error,
  re-designing, and re-implementing (far more than
  anticipated) but difficult to get funded! (its
  only translation research)

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Translation Research

• Easy to say well translate this so it is
  culturally appropriate for X population
• Beware of ethnocentricism inherent in assumptions
  about translation research
• We developed it for white people and now well
  translate it to others - uses whites as the
  standard, the norm - and suggests little
  critical reassessment
• Would whites be comfortable if an intervention
  was first developed for Blacks and then
  translated for whites?

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When is a new efficacy study required?

• When new core elements are required, when
  existing core elements are substantially
  modified, when intervention is conducted in
  very different context
• Hope to do this in randomized, controlled trial
  eventually
• First goal is to learn if the modified Project is
  acceptable to the new target population (this
  study)

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Acknowledgements

• Funding from
• State of California Office of AIDS
• Universitywide AIDS Research Program
• and great project officers
• Roger Myrick, PhD and Anthony Lemelle, PhD
• For their realization about the need to conduct
  translation research in order to have an impact
  on the epidemic