Running head: EVIDENCE-BASED INTERVENTIONS FOR HIV 1

Evidence-Based Interventions for HIV-Positive African American MSM in Long Beach

Best Practice Research Paper

Czarina Muyargas

HSC 435 Section 02

California State University, Long Beach

EVIDENCE-BASED INTERVENTIONS FOR HIV 2

Evidence-Based Interventions for HIV-Positive

African American MSM in Long Beach

Today, more and more people are living with HIV than ever before as they are living

longer with the disease, new infections continue to occur, and diagnoses exceed deaths each year

(CDC, 2015). The HIV epidemic in the United States remains a major public health concern

among various populations. According to CDC (2016), an estimated 1.2 million people in the

United States are currently living with HIV approximately 1 in 8 of those are not aware that

they are infected. Prevention efforts have led to significant declines in diagnoses within certain

populations, though as many as 50,000 people still become newly infected each year (CDC,

2016). HIV is also known as human immunodeficiency virus. The virus damages the bodys

immune system, particularly the T cells, which are responsible to protecting the immune system

(CDC, 2016). HIV is transmitted through certain bodily fluids from an infected person including

fluids like blood, semen, rectal fluids, and vaginal fluids (CDC, 2016). The virus is most

commonly transmitted through sexual behaviors and the exchanging of needles or syringes.

The population that I will be addressing is HIV infected African American men who have

sex with men (MSM) in Long Beach. CDC (2016) states that, African Americans are the most

disproportionately affected racial/ethnic group in the United States. They make up a very large

proportion of new HIV infections as well as those currently living with HIV (CDC, 2016).

According to CDC (2016), in 2014, 44 percent of estimated new HIV diagnoses in the United

States were among African Americans, who only comprised 12 percent of the U.S. population.

In addition, men who have sex with men (MSM) continue to remain the population also most

heavily affected by HIV (CDC, 2016). Among all African Americans infected with HIV in 2014,

approximately 57 percent (11,201) identified themselves as gay or bisexual men (CDC, 2016).
EVIDENCE-BASED INTERVENTIONS FOR HIV 3

Lastly, in 2014 Long Beach had the second highest rate of HIV among all counties in California,

with roughly 1,579 total cases (California Department of Public Health, 2014). Of that number,

69.1 percent were infected due to male-to-male contact (2014).

HIV prevalence among African American MSM is so high due to multiple factors that put

them at an increased risk. One main factor is that unprotected anal sex results in a higher risk of

transmission compared to vaginal sex (CDC, 2016). The CDC (2016) also states that

socioeconomic factors contribute to the increased risk including having low income and

educational levels, limited access to adequate health care, and high rates of unemployment.

Additionally, African American gay and bisexual men make up a small proportion of all gay and

bisexual men, and members of their sexual networks are more likely to be African American

(CDC, 2016). Finally, CDC (2016) argues that a very low percentage of this population is

unaware of their HIV status resulting in individuals not seeking HIV treatment and increasing the

possibility of transmitting the disease to others without knowing.

Five Health Promotion Programs that Address HIV-Positive MSM

The Dish Study is a group-level, social-cognitive theory based intervention that aims to

reduce sexual risk and increase social support and the use of condoms among Black men who

have sex with men (MSM) while also analyzing self-efficacy approaches and outcome

assumptions (Koblin et al., 2012). The study design is a single site, randomized comparison trial

conducted with a 3-month follow-up. Participants of the program included 283 black MSM who

reported that they had 2 or more sexual partners and engaged in unprotected anal sex with

another man in the last 3 months (Koblin et al., 2012). The participants were randomly enrolled

in 1 of 2 study arms, intervention or control. Men who were selected to be in the intervention
EVIDENCE-BASED INTERVENTIONS FOR HIV 4

group attended five 2-hour group sessions over the duration of 2 weeks focused on educating

participants on sexual risk reduction while incorporating meal preparation (Koblin et al., 2012).

Both the intervention (n=142) and control (n=141) arms completed a computer-based

behavioral assessment and received counseling regarding HIV risk reduction at baseline (Koblin

et al., 2012). Koblin et al. (2012) reported that no major statistical differences were discovered

between the 2 groups after 3 months regarding the number of male partners, number of

unprotected anal sex partners, proportion reporting unprotected sex, number of acts protected by

condoms, self-efficacy, condom attitudes, condom intentions, social isolation, and psychological

distress. Though, both groups showed a decrease from baseline to 3-months in sexual risk

behaviors, social isolation, and psychological distress. Inversely, improvements in self-efficacy,

condom attitudes, and condom intentions resulted (Koblin et al., 2012).

Treatment Advocacy Program is an individual-level intervention that is based on primary-

care counseling. The theoretical basis the invention uses include basic coping and self-regulation

framework (Mckirnan et al., 2010). The goal of the intervention is to reduce HIV transmission

risk in clinic patients who are HIV-infected men who have sex with men (MSM) (Mckirnan et

al., 2010). The intervention involves 3 modules that are conducted by peer advocates in four 60-

90-minute counseling sessions over a period of 8 weeks. Participants included 313 HIV-positive

MSM who were randomly assigned to TAP (n=166) or standard care comparison (n=155)

(Mckirnan et al., 2010). Participants in the comparison group were placed on a 12-month

waitlist before receiving regular HIV primary care. HIV transmission risk was evaluated at

baseline, 6 months, and 12 months.

Mckirnan et al. (2010) reported that after completion of the study, a greater transmission

risk reduction was reported by the TAP participants compared to the comparison participants. A
EVIDENCE-BASED INTERVENTIONS FOR HIV 5

decline from 34 percent at baseline to almost 20 percent at 6 and 12 months was reported

regarding transmission risk among intervention participants (Mckirnan et al., 2010). Mckirnan et

al. (2012) also found that transmission risk was almost 25 percent for control participants.

Although results are very meek, TAP resulted in the decrease of transmission risk among HIV-

infect MSM.

STYLE is an evidence-based linkage-to-care program aimed at improving retention in

HIV care. The intervention uses an on-going social marketing campaign to promote engagement

and retention of HIV testing and primary care for HIV-positive African American young men

who have sex with men (YMSM) (Hightow-Weidman et al., 2011). Recruitment strategies

include HIV outreach and referrals by health departments in the community and AIDS based

organizations. After being selected to participate in the intervention, men were scheduled an

appointment with a physician to receive HIV testing and care. Participants were also provided

additional support services that included support group meetings, by phone or in person

individual counseling, and appointment scheduling assistance (Hightow-Weidman et al., 2011).

Hightow-Weidman et al. (2011) reported that after a 3-year period, 81 men who were

STYLE participants were either recently diagnosed or reengaged in HIV care. Overall, 63

percent of participants attended at least 1 medical visit every 4 months (Hightow-Weidman et al.,

2011). Hightow-Weidman et al. (2011) indicated that STYLE participants (80%) went to a

considerably greater percentage of scheduled HIV appointments compare to the pre-STYLE

participants (67%). STYLE was considered an effective prevention intervention that improved

HIV diagnoses.

MAALES is a group-level, HIV sexual risk reduction intervention aimed at reducing

sexual risk behaviors and discussing sociocultural concerns among African American men who
EVIDENCE-BASED INTERVENTIONS FOR HIV 6

have with men and women (MSMW). The program includes 6 small-group sessions and 2

booster sessions. Over a period of 4 years, 437 African American MSMW were enrolled and

randomly assigned to 1 of 2 study arms; MAALES (n=198) or HIV-education counseling

comparison (n=188) (Harawa et al., 2013). The comparison group received a single HIV risk

reduction counseling session, while intervention participants engaged in group discussions that

discussed cultural patterns and influences in society to promote improved health behaviors. At

baseline, 3 months, and 6 months after the intervention, participants completed surveys (Harawa

et al., 2013). Harawa et al. (2013) indicated that the program results show 73 percent of

intervention participants retained 1.5 months after completing program, while the percentage of

the comparison group was only 41.

Think Twice is an individual-level, single session intervention program that uses the

Conflict Theory of Decision Making to inform participants about knowledgeable decision-

making regarding partner selection and HIV risk reduction among at-risk (MSM). The

intervention focuses on educating participants to make safe decisions when engaging in sexual

risk behaviors. A group of 149 high-risk MSM were recruited and randomly enrolled in an

intervention condition (n=149) that focused on serosorting or standard HIV risk reduction

counseling condition (n=74) (Eaton et al., 2011). A peer counselor conducted the intervention

and addressed misunderstandings when selecting a sexual partner and encouraged participants to

identity accurate beliefs of serosorting risks. Eaton et al. (2011), stated the results indicated that

3 months after the intervention, intervention participants reported considerably fewer male sex

partners than control participants. In addition, participant retention of those who received the

intervention was 81 percent, while the those who did not receive the intervention was 77 percent

(Eaton et al., 2011).

EVIDENCE-BASED INTERVENTIONS FOR HIV 7

Intervention Proposal

Group-level HIV behavioral interventions address and promote individual behavior

change (CDC, 2016). Brothers Unite is a HIV prevention intervention that utilizes the

Transtheoretical Model of Behavior Change to reduce unprotected anal sex and increase the use

of condoms during anal sex among Black MSM in Long Beach. In addition, the key intervention

effects include increasing protective sexual behaviors, getting tested more frequently for HIV,

and reducing the number of sex partners. The program is a group-level intervention that aims to

shape behavioral and social factors that contribute to the HIV transmission and risk among

African American MSM in Long Beach.

Recruitment methods include outreach programs at various public pro-gay events in the

community, flyers and advertisement postings at different locations where African Americans

MSM often convene, and referrals from peers of current participants. Eligibility criteria will be

confirmed by screening individuals in two ways, first an online questionnaire followed by an in-

person interview screening. Men will be eligible if they are HIV-negative or HIV-unknown and

identifies as Black MSM. They must be 18 years or older, reside in Long Beach, and open to

participate in a group-setting discussion that addresses sexual behavior between males.

All eligible participants will complete an electronic baseline assessment prior to the

beginning of the intervention. Each participant will then be randomly assigned to one of two

groups, the intervention group or the wait list control group. The participants who are assigned

to the intervention group are required to attend three 2-hour sessions conducted by 2 trained

African American MSM counselors at a local community center. Each session will address a

variety of topics including behavior change options for HIV prevention, factors contributing to

transmission and risk factors, and methods to reduce HIV transmission risk. Those who are in
EVIDENCE-BASED INTERVENTIONS FOR HIV 8

the control group are scheduled to receive the intervention 3 months after they have completed

their baseline assessment. The evaluation plan for this program includes interview style data

collection from all participants in the Brothers Unite intervention group at baseline, 3 months,

and 6 months after the intervention program. As for the comparison group, data will be collected

at 3 months and 6 months after completion of baseline assessment. Some barriers of this

proposed HIV intervention include lack of easily accessible HIV testing for Black MSM due to

socioeconomic status as well as the stigma of HIV that is still evident in certain communities. A

limitation of the intervention arrangement is the ability for participants to not attend and

complete the full 3 sessions due to attendance being self-decided. Another limitation includes the

use of the wait list control condition to evaluate the intervention program. Although the time

difference in length of intervention received offers better results for change, having a wait list

control group that doesnt receive the program may lead to bias.

When applying the Transtheoretical Model to Black MSM perspective on condom use,

each stage is defined as followed: Precontemplation: He has no intention of using condoms

regularly within the next six months, Contemplation: He is seriously taking into consideration

about using condoms regularly in the following six months but has not made any commitments,

Preparation: He is intending to use condoms within the next month, Action: He is finally able to

successfully use condoms every time he has intercourse and has been doing so for up to six

months, and Maintenance: Condoms have been used at every act of intercourse for more than 6

months.

Conclusion

Based on the risk factors and statistics alone, it is evident that HIV has become a

substantial health challenge facing this particular population. In order to reduce the number of
EVIDENCE-BASED INTERVENTIONS FOR HIV 9

new HIV infections among African American MSM in Long Beach, interventions that produce

behavior changes regarding linkage and retention in HIV care, medication adherence, and risk

reduction must be implemented. If current HIV infection rates continue, about 1 in 2 black men

who have sex with men in the U.S. will be infected with HIV during their lifetime (CDC, 2016).

Recent efforts have greatly reduced the number of new HIV infections as well as decreased

transmission risk, but we must continue to make these efforts in order to reach the Health People

2020 goal.
EVIDENCE-BASED INTERVENTIONS FOR HIV 10

References

Centers for Disease Control and Prevention. (2016, October 27). HIV Transmission | HIV Basics

| HIV/AIDS | CDC. Retrieved from http://www.cdc.gov/hiv/basics/transmission.html

Centers for Disease Control and Prevention. (2016, October 27). About HIV/AIDS | HIV Basics |

HIV/AIDS | CDC. Retrieved from https://www.cdc.gov/hiv/basics/whatishiv.html

Centers for Disease Control and Prevention. (2016, September 26). African American | Gay and

Bisexual Men | HIV by Group | HIV/AIDS | CDC. Retrieved from

http://www.cdc.gov/hiv/group/msm/bmsm.html

Centers for Disease Control and Prevention. (2016, August). Today's HIV/AIDS Epidemic.

Retrieved from https://www.cdc.gov/nchhstp/newsroom/docs/factsheets/todaysepidemic-

508.pdf

Department of Public Health. (2014, June 30). HIV/AIDS Surveillance in California. Retrieved

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Eaton, L. A., Cherry, C., Cain, D., & Pope, H. (2011). A Novel Approach to Prevention for At-

Risk HIV-Negative Men Who Have Sex With Men: Creating a Teachable Moment to

Promote Informed Sexual Decision-Making. American Journal of Public Health, 101(3),

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Harawa, N. T., Williams, J. K., McCuller, W., Ramamurthi, H. C., Lee, M., Shapiro, M. F.,

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