HIV Prevention among Men Who Have Sex with Men: Health Department Response; Behavioral Interventions
Bob Wood, Matt Golden and Erick Seelbach discuss how the local health department and community in Seattle-King County responded to local data on STDs and HIV among MSM; Rob Janssen briefly summarizes the five evidence-based behavioral interventions that CDC currently offers for HIV prevention among MSM; and viewers hear from community organizations and researcher Susan Kegeles regarding specific interventions. Created: 5/17/2007 by The National Center for HIV, STD, and TB Prevention (NCHSTP).
Date Released: 10/19/2007. Series Name: CDC Featured Podcasts.
[Announcer] This podcast is presented by the Centers for Disease Control and Prevention. CDC - safer, healthier people.
[Announcer] After the airing of this Satellite Broadcast in May 2007, CDC issued a revised 2005 HIV/AIDS Surveillance Report (June 2007). Some of the data sited in this broadcast have been updated. The revised report can be found at www.cdc.gov/HIV/datarevision.htm.
[Moderator/Dr. Rob Janssen] Collaboration between health departments and community-based organizations is critical to HIV prevention efforts. From the public health staff of Seattle-King County, Washington, we hear now from doctors Matt Golden and Bob Wood, who discuss how the health department and community responded to local data on STDs and HIV among MSM. And Erick Seelbach, a prevention education manager, with a Seattle organization called Lifelong AIDS Alliance, shares his insight into the community's response.
[Dr. Matt Golden] Since the late 1990s we observed dramatic increases in the rates of sexually transmitted diseases among men who have sex with men in King County. These have been greatest in men with Syphilis. So, we've gone from having no cases of Syphilis in 1996 among gay men, to having over 150 cases per year in each of the last two years. We've also seen very large increases in Gonorrhea and Chlamydia on infection rates, though not quite as big as the changes we've seen with Syphilis and the reason we're concerned about this, are among the reasons we’ve been concerned about this, is that these concurrent sexually transmitted infections can increase HIV transmission. Now I point out, we actually have not observed big increases in the number of new cases of HIV in King County, so our worst fears have not yet at least been realized. We've recently observed four cases of multi-drug resistant HIV in Men who have Sex with Men with newly acquired HIV. For a number of years we’ve been monitoring drug resistance in people with new infections and a little over 10% of men who have sex with men have had resistance to at least one anti-retroviral. What’s new is that we’re observing men now who have resistance against all three major classes of anti-retroviral drugs. Now we don't really know what the clinical implications of these resistance mutations will be and whether it really will be much more difficult to treat these men, but certainly it's a concern and I think its one more reason for us to encourage people to be cautious and to use condoms. Serosorting refers to the practice of choosing one's sex partners or changing one's sexual behavior depending on the HIV status of your partners. We know that men who have sex with men have been serosorting since at least the late 1990s and probably before. And we don't really know whether the practice is increasing or not. I think serosorting does provide some protection against HIV. Men who report only having unprotected sex with negative partners have a lower risk of acquiring HIV than men who have unprotected partners who are positive or of an unknown status. That said, the protection is only partial. So, between 15% and 30% of men who have sex with men with newly acquired HIV report that their highest risk sexual behavior is unprotected anal sex with a man who is HIV negative. And we know that men who have more negative partners are at higher risk, as well. So, I think it's an imperfect strategy and it's hard to know how we can incorporate serosorting into our prevention messages. Whether this is a good idea or not, really depends on what behaviors it's replacing.
[Dr. Bob Wood] King County Health Department has three central roles in addressing the epidemic among men who have sex with men. One is assessment, recognizing where the epidemic is moving within various segments of the population. And in order to better address it. Second is policy development and program development, not necessarily developing all the programs within public health, but finding an array of programs that complement programs that may exist out in the community. And the third is assurance, making sure that everyone has access to prevention programs. With regard to policy development and program development, we're particularly interested in primary prevention, which is preventing infection amongst men who have sex with men and secondary prevention which is preventing the consequences of infection. King County has learned two very important lessons. One is the importance of HIV testing. We've worked to eliminate barriers to testing, one of which is the extensive counseling requirements that were called for early on. Secondly, is the separate requirement for specific consent for HIV testing. Third is the need to come back for a result visit, which is limited by the implementation of rapid testing. So we moved very rapidly to get rapid testing in place and discover that MSM prefer that method. And, fourthly, we've increased the use of nucleic acid test to identify people in the window between infection and the time they develop the antibodies. That’s increased our case finding by about 13%. The other important lesson is that community partners are very important for us to work with to identify messages to address increasing risk behavior in men who have sex with men to prevent HIV and other sexually transmitted diseases.
[Erik Seelback/KING COUNTY CBO] There's been a long history of community response to HIV and STDs in the gay community in Seattle. The original organizations dealing with HIV and AIDS were organized by community members to respond and then there's the history of community folks being dissatisfied with those services and forming their own organizations. So, the community organizations have been responsive to community members. We are in constant dialogue trying to make sure that our programs are as effective as possible and that we're talking about what the community members are talking, that the strategies that they're using are being incorporated into the work that we do. There's also a lot of organizing via community members still around the issues that are important to them. There was recently a community forum on serosorting that was organized from a community of grass roots level. We have groups of guys who are in recovery from crystal who are organizing among themselves to help each other through those issues. So the community has been responding across this all of these years. There’s a very strong partnership here in Seattle between local community and community organizations and public health. They continually prioritize working with the community in order to be as effective as possible in the fight against HIV. So, we as an organization have had a long history of working with the health department on various projects. The most recent or current hallmark of that is bath house Testing. They provide the HIV/STD testing in the bath houses, at the same time we provide peer outreach workers so that people have somebody who looks like them and talks like them to encourage them to go in and actually get tested. The Health Department has a long history of supporting various projects from various health summits and provider gatherings to the Gay Men's Task Force which works on unifying providers around responses. So, public health has an ongoing dialogue with community organizations to make sure that they're doing the best that they possibly can and we look to them for capacity building to make sure we're doing the best that we possibly can.
[Moderator/Dr. Rob Janssen] Evidence-based behavioral interventions for persons at risk for HIV, and people living with HIV, are essential components of CDC's response to the HIV epidemic. Researchers, Health Departments, and community-based organizations now have years of experience developing, evaluating, and adapting behavioral interventions for various populations. For example, CDC now offers five evidence-based HIV interventions designed for MSM. The first of these interventions for MSM is called Many Men, Many Voices, a group intervention for gay men of color and MSM who do not identify themselves as gay or bisexual. The second intervention is Mpowerment, which comprises HIV prevention, safer sex, and risk-reduction messages in a community-building format. The third intervention, Popular Opinion Leader, involves identifying, enlisting and training key opinion leaders to encourage safer sex as the norm in the social networks of MSM. The fourth intervention is healthy relationships, which helps develop skills and self-efficacy of MSM and other people living with HIV/AIDS. The last intervention is called Promise, it stands for Peers Reaching Out and Modeling Intervention Strategies. Peer advocates distribute role model stories that help others adopt practices to reduce or eliminate their risk for HIV infection. In addition to these interventions and other interventions, such as Street Smart, have been adapted for use with MSM. For today's broadcast, we spoke with CDC researchers and visited several organizations to discuss some of these interventions in more detail.
[Kenneth Jones/CDC] In response to a 2003 investigation of increasing HIV rates of HIV infection among black college students in North Carolina, the CDC funded the North Carolina Divisions of Public Health to implement and evaluate a version of The Popular Opinion Leader Intervention developed by Jeff Kelly that we essentially adapted for black MSMs in the state. Now, this was important to the CDC because this was an opportunity to learn whether an intervention that had been proven successful for one population could be effective for black MSM's and reducing their HIV risk.
[Omar Whiteside/NC CBO] Here at Metrolina AIDS Project in Charlotte, we’re conducting an intervention that targets African-American MSM. It’s based on The Popular Opinion Leader Model by Jeff Kelly and encourages individuals to talk to their friends about safer sex. We basically took Kelly's model and we tried to make it more culturally competent. There were components of it that we felt like didn't relate to the African-American MSM experience. So, we tried to specifically change those aspects. There are certain parts of the curriculum that include conversations that folks have, so we wanted to include relevant topics for African-American MSM. Staff were initially apprehensive, this is an intervention that has never been done for African-American MSM, because of that, they were afraid. I mean, it helped in our situation that we had three other cities, including ourselves that were doing the intervention. It was done here in Charlotte, in Greensboro and in Raleigh. So, because of that we had the support from other folks who were going through the same thing, who had situations that were somewhat similar, even though we realized that because we're in different parts of the state, there’re literally different climates. Here in Charlotte it’s a lot more business-like, a lot more professional. So we were able to work with one another to figure out some of the details about the implementation. We learned that HIV prevention targeting African-American MSM works. We learned that it's important to have community partners that champion your cause. Here in Charlotte we had a club owner that was more than happy to come on board and to give us free run of her space. We also learned that it's important to have support. We had support on the state level from the North Carolina Department of Health and Human Services. We also had support from other community- based organizations that were doing the same intervention. So, we were able to rely on each other just to give us the added boost when it came to those late nights when we were really considering whether or not we were doing the right thing.
[Devin/Same CBO] When I first got involved with the intervention, my role was just a POL member and as I went to, progressed through, the rest of the training process, I got a little bit more hands on involved when I became the administrative assistant, when I started going to the clubs and bars and talking to people about the program, about safer sex practices and actually building community among African-American MSM population in Charlotte. So, that was a lot more important to make sure that the social norm that we had, the consent of the community, for that social norm can be changed or adjusted.
[Evelyn Foust/NC State AIDS Director] It's incredibly important that community-based organizations take ownership of the data to drive their interventions. One of the things that state health departments should do, can do, is to share that data that we collect. Health departments are very good at collecting data and analyzing data. That’s a strength for us. What we have to work at, I think, is to share it in ways that’s easy and accessible. So, for example, in North Carolina, we take our EPI profile that we update annually and it is an extensive EPI profile, you can get by state trends, you can get county trends and we put it on our web. The other thing that we do is often encourage community-based organizations to link with their local health departments who often have epidemiologists who are willing and quite capable of helping to analyze some local trends. One of the things that we can do is share the data and make it accessible and look at it frequently. If you did an EPI profile last year, work with it all year long and make sure it's fresh. Health departments play a huge role in delivering interventions, but we deliver them in partnership with our community-based organizations. Interventions at times look scary, they’re sometimes process-driven, however the interventions we have today, we're getting results. If you get results, that's what it is all about. Twenty-five years into this epidemic, we should be doing whatever it takes to end the spread of HIV and AIDS.
[Kenneth Jones/CDC] Prior to the implementation of the intervention, 42% of the men in our study reported unprotected anal sex. After implementing the intervention, over the course of one year, in three North Carolina cities unprotected anal sex was reduced by 45%. In addition, the average number of partners for unprotected anal sex was also decreased. So, this is one of the first studies to show that adapting an intervention that has been shown effective for another population, can also be effective and reduce Black MSMs risky behaviors.
[El Paso CBO] Here at Linburn Center of El Paso, we are conducting two HIV interventions for MSM. They are based on Jeff Kelly's Popular Opinion Leader Model and we have found out that by changing the marketing to include POL graduates in posters which are then placed at the bars and the other venues that the community attends. We have received a great response from both the venue owners and the community at large and we have also found out that the POLs themselves found their status being enhanced by these posters. This way if they decide to have sex once they find themselves at the bars, they can always be reminded by the posters to stop by the bar and pick up a free condom. Some of the things that we have learned is that you don't need a whole lot of money. By taking some feedback from the community members that you are serving, and taking their input, we have actually been able to establish very good rapport with the venue owners and what we have found out is that it has had an incredibly good response. We are very honored to find out that some other organizations in the United States have replicated our materials and are now using them themselves. And that makes us very happy.
[Another person from CBO] Here in El Paso one of the interventions for MSM is Man Hunter, which is the Popular Opinion Leader. What we do is we try to diffuse a positive sex message throughout the community and our friends. Instead of calling it Popular Opinion Leader, we’ve change it to Man Hunters so people can identify us and they can come up to us and ask us questions about the program. Therefore diffusing a positive message to the whole community.
Another intervention for MSM in El Paso is called Life Guard. We adapted the original POL conversations and now we're concentrating on having conversations with men that are HIV positive. We emphasize the importance of using condoms and we also talk about the dangers of getting re-infected. One thing that was a success in our city, were our t-shirts that say Life Guards. It was a conversation piece and started off the conversations. We were able to have many conversations because of the t-shirts.
[Dr Susan Kegeles/San Francisco] Here at The Center for AIDS Prevention Studies, we're working with many community-based organizations that are implementing and adapting the Mpowerment Project. The Mpowerment Project is a community level HIV prevention intervention for young MSM to reach all young MSM in a community through activities to build a stronger, safer community of young men who support each other in many ways, including about having safer sex. It's also based on empowering young men. The program is run by men for men to address the issues important to them including HIV prevention. The project has five components that work together – and without any one of them it doesn't work well. The first component is Outreach. Men conduct outreach to their peers at venues where they can find young MSM and the intervention hosts social activities to attract men to the program and where safer sex promotion can then be conducted. The second component is a small group called M Groups, to address personal risk behavior. In addition, through this group we address the third component, called Informal Outreach. Mobilizing men to support their friends about safer sex and then they can become part of the supportive community. The fourth component is the Publicity Campaign so that all MSM in the community hear about the intervention. And the fifth component is having a safe space to hold the activities where men are comfortable being themselves in a kind of community center. The interventions can be adapted to different groups by keeping the guiding principals of this program and incorporating cultural issues. For example, one guiding principal is pride in who you are as an MSM. When adapting this to black MSM it's important to weave in pride in being a black man. And so, we talk about the impact of internalized racism and how you feel about yourself and how you behave sexually. This is added to the guiding principal about pride in who you are as an MSM and becoming aware of the impact of internalized homophobia in your life and in your sexual activities. In addition, for young black MSM spirituality issues are important and should be woven into the program. The components still continue but how they're implemented are changed somewhat. We're now conducting a randomized controlled trial of the effectiveness of a black Mpowerment project. The context of young black MSM lives can be quite different from the men's lives in the initial trial. It's hard being a young black man in this society that’s often quite racist and it’s also hard being a MSM in the black community that does not always support its MSM brothers. So it's important to test the program's effectiveness among black MSM. So, the thing to remember about the Mpowerment Project is that it mobilizes young MSM to shape a healthy community for themselves, build positive social connections and support their friends to have safer sex and it focuses on the entire community of young MSM, instead of on individuals or small groups.
[Asian and Pacific Islander Coalition on AIDS/New York City] In New York City, at Asian and Pacific Islander Coalition on HIV and AIDS we have two interventions that deal with the Men Who Have Sex with Men community, that is Street Smarts and there are many components to that such as our street outreach where we have safer sex kits that contain condoms and lube and how to use them. Also, information on our programs and how to get tested. Our other components to Street Smarts is our group level intervention where we have eight young people meet and they learn different things from basic HIV information to coping skills and that's something which I really liked about that intervention. Our other intervention is Healthy Relationships where we have folks who have been identified as HIV positive, learn different issues on how to disclose their status to their families, their friends, also to their sex partners and needle-sharing partners and also how to reduce the risk in those situations. We’ve realize that it's very important to adapt our material to a community. For instance, in Street Smarts, we’ve taken our role plays and have specific Asian and Pacific Islander information and also adapted the language where our young people can relate to. For our Healthy Relationships we've taken the video, which is a very important part in the intervention, and put Asian faces in there such as from Happy Together and the Wedding Banquet and, also, we outreach in neighborhoods that have a lot of folks who are Asian Pacific Islanders such as Flushing and China Town. The lessens that we've learned with young MSMs is to keep it interactive and fast-paced. Since it is the MTV generation, and that the staff have to feel comfortable with the curriculum and activities so they won't have to rely on the manual and people have to remember that Asian and Pacific Islanders they're very diverse although South Asia is very different from Hawaii or Tahiti.
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