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

1. 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

2. 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

3. 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

4. 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

5. We are adapting and pilot-testing MP with young Black MSM • Community collaborative research is necessary • 3 African American CBOs and CAPS are partnering

6. 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

7. Phase I: Formative Research to Modify MP • Boards of Cultural Experts (BOCEs) • N=21, 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) • N=34 • 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

8. Whole-man approach Privacy Concerns Diverse sexual identities Cultural appropriateness of M-groups HIV testing Bisexuality Lack of role models More HIV+ men Fatalism Dual identity/Internalized Oppression Issues that emerged

9. Creating young black gay/SGL community HIV is just one of many issues Violence Class distinctions Treatment optimism Sexual abuse Racism in gay community Stigma Inter-generational sex Drug use Black institutions and expectations Masculinity/Femininity Church/religiosity Other key issues that emerged

10. 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

11. 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

12. 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 don’t 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

13. Lack of Adult Male Role Models • Many YBMSM have not had adult men in their lives • No vision about what an older BMSM’s 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

14. 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

15. 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

16. 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

17. 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)

18. 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 Translation Research Challenges

19. 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 Challenges Continued…

20. Challenges Continued… • Therefore, modifying the intervention is not just a matter of adjusting the project for a “slight cultural nuance” - not a “quick fix” - can’t 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”)

21. Translation Research • Easy to say “we’ll 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 we’ll 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?

22. 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)

23. 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