A Peer-to-Peer Collaborative Learning Approach for the Implementation of Evidence-Informed Interventions to Improve HIV-Related Health Outcomes

The nationwide scale-up of evidence-based and evidence-informed interventions has been widely recognized as a crucial step in ending the HIV epidemic. Although the successful delivery of interventions may involve intensive expert training, technical assistance (TA), and dedicated funding, most organizations attempt to replicate interventions without access to focused expert guidance. Thus, there is a grave need for initiatives that meaningfully address HIV health disparities while addressing these inherent limitations. Here, the Health Resources and Services Administration HIV/AIDS Bureau (HRSA HAB) initiative Using Evidence-Informed Interventions to Improve HIV Health Outcomes among People Living with HIV (E2i) piloted an alternative approach to implementation that de-emphasized expert training to naturalistically simulate the experience of future HIV service organizations with limited access to TA. The E2i approach combined the HAB-adapted Institute for Healthcare Improvement's Breakthrough Series Collaborative Learning Model with HRSA HAB's Implementation Science Framework, to create an innovative multi-tiered system of peer-to-peer learning that was piloted across 11 evidence-informed interventions at 25 Ryan White HIV/AIDS Program sites. Four key types of peer-to-peer learning exchanges (i.e., intervention, site, staff role, and organization specific) took place at biannual peer learning sessions, while quarterly intervention cohort calls and E2i monthly calls with site staff occurred during the action periods between learning sessions. Peer-to-peer learning fostered both experiential learning and community building and allowed site staff to formulate robust site-specific action plans for rapid cycle testing between learning sessions. Strategies that increase the effectiveness of interventions while decreasing TA could provide a blueprint for the rapid uptake and integration of HIV interventions nationwide.

An evaluation of nine culturally tailored interventions designed to enhance engagement in HIV care among transgender women of colour in the United States

INTRODUCTION

Transgender women (TW) worldwide have a high prevalence of HIV, and TW with HIV encounter numerous healthcare barriers. It is critical to develop evidence-informed interventions to improve their engagement in healthcare to achieve durable viral suppression (VS). We evaluated whether participation in one of nine interventions designed specifically for TW was associated with improved engagement in HIV care among transgender women of colour (TWC).

METHODS

Between 2013 and 2017, nine US organizations implemented nine distinct and innovative HIV care engagement interventions with diverse strategies, including: individual and group sessions, case management and navigation, outreach, drop-in spaces, peer support and/or incentives to engage TWC with HIV in care. The organizations enrolled 858 TWC, conducted surveys, captured intervention exposure data and extracted medical record data. Our evaluation of the interventions employed a pre-post design and examined four outcomes-any HIV care visit, antiretroviral therapy (ART) prescription, retention in HIV care and VS (both overall and among those with a clinic visit and viral load test), at baseline and every 6 months for 24 months. We employed logistic generalized estimating equations to assess the relative odds of each outcome at 12 and 24 months compared to baseline.

RESULTS

Overall, 79% of participants were exposed to at least one intervention activity. Over 24 months of follow-up, participants received services for a median of over 6 hours (range: 3-69 hours/participant). Compared to baseline, significantly (p<0.05) greater odds were demonstrated at both 12 and 24 months for three outcomes: prescription of ART (ORs: 1.42 at 12 months, 1.49 at 24 months), VS among all participants (ORs: 1.49, 1.54) and VS among those with a clinic visit and viral load test (ORs: 1.53, 1.98). The outcomes of any HIV care visit and retention in HIV care had significantly greater odds (ORs: 1.38 and 1.58, respectively) only at 12 months compared to baseline.

CONCLUSIONS

These evaluation results illustrate promising approaches to improve engagement in HIV care and VS among TWC with HIV. Continued development, adaptation and scale-up of culturally tailored HIV care interventions for this key population are necessary to meet the UNAIDS 95-95-95 goals.

Prevalence and Correlates of Sexual Violence Experienced by Young Adult Black Men Who Have Sex with Men

Men who have sex with men (MSM) experience high prevalence of sexual violence (SV), and SV has well-documented effects on health. Research gaps are especially evident for young Black MSM (YBMSM), who experience significant HIV disparities and syndemics, including multiple forms of violence victimization. We examined lifetime prevalence of SV (having been forced or frightened into sexual activity) in a cross-sectional sample of YBMSM (N = 1732), and tested associations of demographic, psychosocial, and structural factors using multivariable regression. YBMSM were recruited between 2013 and 2015 using modified venue-based time-location sampling (e.g., at bars and clubs) in Dallas and Houston, Texas. Approximately 17% of YBMSM experienced any SV in their lifetimes. SV was associated with high school non-completion (OR 1.78; 95% CI 1.15-2.77), lower psychological resilience (OR 0.84; 95% CI 0.71-0.98), lifetime history of homelessness (OR 5.52; 95% CI 3.80-8.02), recent financial hardship (OR 2.16; 95% CI 1.48-3.14), and recent transactional sex (OR 3.87; 95% CI 2.43-6.15). We also examined differences by age of SV onset (childhood versus adulthood). YBMSM with adolescent/emerging adult-onset SV may have been more ambivalent in reporting lifetime SV experience, compared to men with childhood-onset SV, and correlates differed by age of onset. Childhood-onset SV was associated with high school non-completion, lower levels of psychological resilience, history of homelessness, recent financial hardship, and recent transactional sex. Adolescent/emerging adult-onset SV was associated with greater depressive symptoms, history of homelessness, and recent financial hardship. There is a need for multi-level approaches to SV prevention and treatment, including services and supports that are culturally-relevant and responsive to the needs of YBMSM.

Resilience and Depression in Young Black Men Who Have Sex with Men: A Social-Ecological Model

Although the health of young Black men who have sex with men (YBMSM) is typically discussed in terms of HIV, they are significantly affected by depression. The present study explored protective and risk pathways to depressive symptoms among YBMSM within a social-ecological framework. A cross-sectional sample of 1,817 YBMSM in two large, southern cities in the United States completed a survey of sociodemographic characteristics as well as individual (e.g., resilience, internalized heterosexism) and contextual (e.g., peer social support, experiences of racism) factors. In cross-sectional analyses, structural equation modeling was used to examine whether there were indirect associations between contextual factors and depressive symptomology that were mediated by individual factors. Higher peer social support was associated with lower depressive symptoms via greater resilience; there was no direct association between peer social support and depressive symptoms when controlling for this indirect association. Additionally, there were indirect associations between several contextual risk factors and higher depressive symptoms via perceived HIV-related stigma and internalized heterosexism; some direct associations between contextual risk factors and higher depressive symptoms were significant when controlling for these indirect associations. Despite a number of risk factors for depression for YBMSM, resilience is a key protective factor that may play a critical role in the beneficial effects of peer social support. Broadly, findings suggest that public health efforts must continue to build upon and leverage YBMSM's community-based strengths in the service of improving their mental health and, indirectly, their physical health.

Sources of Resilience as Mediators of the Effect of Minority Stress on Stimulant Use and Sexual Risk Behavior Among Young Black Men who have Sex with Men

The greatest proportion of new HIV infections among men who have sex with men (MSM) is occurring among young Black MSM (YBMSM) ages 13-24. Consequently, research is needed to understand the psychosocial pathways that influence HIV risk and resilience in YBMSM. Minority Stress Theory proposes that the stigma, prejudice, and discrimination facing sexual and racial minorities are chronic stressors that lead to increased engagement in risk behaviors. The present study examined whether minority stress is associated with stimulant use and sexual risk behaviors by depleting psychosocial resilience. We recruited 1817 YBMSM, ages 18-29, from multiple venues in two major cities in Texas for participation in a brief survey. Results from structural equation modeling indicated that decreased resilience partially mediated the association of minority stress with sexual risk behavior. Resilience was also negatively associated with stimulant use. Interventions focused on cultivating psychosocial resilience could mitigate the deleterious consequences of minority stress and reduce stimulant use in YBMSM.

A Person-Centered Approach to HIV-Related Protective and Risk Factors for Young Black Men Who Have Sex with Men: Implications for Pre-exposure Prophylaxis and HIV Treatment as Prevention

Although young Black men who have sex with men (YBMSM) are disproportionately affected by HIV, they may be more heterogeneous as a group than is typically appreciated. Thus, the present study used a person-centered data-analytic approach to determine profiles of HIV-related risk among YBMSM and whether these profiles could be distinguished by age, HIV status, and socioeconomic risk (i.e., socioeconomic distress). YBMSM (N = 1808) aged 18 to 29 years completed a survey of sociodemographic characteristics, HIV status, and HIV-related behavioral and attitudinal factors (i.e., safer-sex self-efficacy, negative condom attitudes, being in difficult sexual situations, being in difficult sexual relationships, HIV treatment optimism, perceived HIV stigma). Latent profile analysis was used to identify HIV risk profiles and whether age, HIV status, and socioeconomic distress were associated with these profiles. Four profiles emerged: low-, medium-, and high-risk profiles, respectively, and a mixed profile characterized by a tendency to be in difficult sexual situations and relationships while also reporting high safer-sex self-efficacy and low negative attitudes toward condom use. Difficult sexual situations emerged as the key defining indicator of whether a profile reflected higher or lower risk. Younger age, being HIV-positive, and socioeconomic distress were associated with having a higher-risk profile. Given that unique risk profiles emerged that were differentially predicted by sociodemographic characteristics and HIV status, these findings have implications for tailoring interventions to the needs of different subgroups of YBMSM. Also, disempowering or risky sexual situations and relationships among YBMSM must be addressed.

Effect of a Community-Level HIV Prevention Intervention on Psychosocial Determinants of HIV Risk Behaviors among Young Black Men Who Have Sex with Men (YBMSM)

In contrast to intervention studies that assess psychosocial factors only as mediators or moderators of HIV risk, the present study assessed the effects of an Mpowerment-based community-level intervention on psychosocial determinants (e.g., depressive symptoms, sexual stigma) of HIV risk behavior among young black MSM. Approximately 330 respondents were surveyed annually for 4 years in each of two sites. General linear models examined change across time between the intervention and comparison communities, and participation effects in the intervention site. Social diffusion (spreading information within networks) of safer sex messages (p < 0.01) and comfort with being gay (p < 0.05) increased with time in intervention versus control. Cross-sectionally, intervention participants responded more favorably (p < 0.05) on social diffusion and depressive symptoms, but less favorably (p < 0.01) on sex in difficult situations and attitudes toward condom use. Findings suggest a need to address broader health issues of MSM as well as sexual risk.

HIV risk and multiple sources of heterosexism among young Black men who have sex with men

OBJECTIVE

This study examined whether the association between social support and condom self-efficacy would be moderated by (a) internalized heterosexism among and (b) enacted heterosexism experienced by young Black men who have sex with men (YBMSM), who contend with high HIV incidence, heterosexism, and low uptake of preexposure prophylaxis.

METHOD

Participants were 1,210 YBMSM (ages 18-29) who completed measures of social support, internalized and enacted heterosexism, and condom self-efficacy in 2 large cities in the southern United States as part of a community-level HIV-prevention study.

RESULTS

A significant 3-way interaction between social support and both hypothesized moderators, internalized and enacted heterosexism, showed that social support was positively associated with condom self-efficacy when both internalized and enacted heterosexism were high (1 SD above the mean; b = .177, 95% confidence interval [CI: .088, .266]). However, social support was not associated with condom self-efficacy when scores were low (1 SD below the mean) on both internalized and enacted heterosexism (b = .024, 95% CI [-.054, .101]), low on internalized and high on enacted heterosexism (b = .058, 95% CI [-.061, .117]), or high on internalized and low on enacted heterosexism (b = .039, 95% CI [-.083, .161]).

CONCLUSIONS

YBMSM who are high in both internalized and enacted heterosexism may see greater benefits from social support on condom self-efficacy than would YBMSM who grapple with less heterosexism. In addition to promoting social support, interventions should aim to assess and reduce multiple forms of stigma. (PsycINFO Database Record

Spirituality/religiosity, substance use, and HIV testing among young black men who have sex with men

BACKGROUND

Spirituality and religiosity may serve as both a resource and a barrier to HIV prevention with young black men who have sex with men (YBMSM). We examined indices of spirituality/religiosity as correlates of binge drinking, stimulant use, and recent HIV testing in a sample of YBMSM.

METHODS

From 2011-2013, annual venue-based surveys of sexually active YBMSM ages 18-29 were conducted in Dallas and Houston, Texas. Binge drinking and stimulant use were assessed in the past two months. Participants recently tested for HIV (i.e., within the past six months) were compared to those without recent HIV testing (i.e., never tested or tested more than six months ago).

RESULTS

Among the 1565 HIV-negative or HIV-unknown YBMSM enrolled, more engagement in spiritual and religious activities was associated with greater odds of reporting stimulant use (Adjusted Odds Ratio [AOR]=1.20; 95% CI=1.04-1.40) while higher spiritual coping was associated with lower odds of reporting stimulant use (AOR=0.66; 95% CI=0.56-0.78). Binge drinking was independently associated with 29% lower odds of recent HIV testing (AOR=0.71; 95% CI=0.55-0.92), but lower odds of binge drinking did not mediate the association of engagement in spiritual and religious activities with 27% greater odds of recent HIV testing (AOR=1.27; 95% CI=1.11-1.46).

CONCLUSIONS

Among YBMSM, culturally tailored approaches addressing spirituality/religiosity could support prevention of stimulant use and increase HIV testing. In particular, expanded efforts are needed to promote HIV testing in binge drinkers.

'Triply cursed': racism, homophobia and HIV-related stigma are barriers to regular HIV testing, treatment adherence and disclosure among young Black gay men

In the USA, young Black gay men are disproportionately impacted upon by HIV. In this qualitative study consisting of in-depth interviews with 31 young Black gay men and nine service providers, where we used thematic analysis to guide our interpretations, we found that HIV-related stigma and homophobia, within the larger societal context of racism, were related to sexual risk behaviour, reluctance to obtain HIV testing or care, lower adherence to treatment medication, and non-disclosure of a positive HIV status to sexual partners. Participants experienced homophobia and HIV-related stigma from churches and families within the Black community and from friends within the Black gay community, which otherwise provide support in the face of racism. Vulnerability to HIV was related to strategies that young Black gay men enacted to avoid being stigmatised or as a way of coping with alienation and rejection.

Peer social support is associated with recent HIV testing among young black men who have sex with men

Resiliency factors such as social support have been associated with more frequent HIV testing among MSM. We examined the association between social support and delayed HIV testing in the context of structural discrimination and individual factors among young Black MSM. We combined two independent cross-sectional samples recruited 1 year apart from a venue-based, modified time-location sampling study of young Black MSM aged 18-29 years in the US South. Our subsample (N = 813) was men who self-reported not being HIV positive and who indicated they had one or more male sex partners in the past 2 months. Using a social epidemiology framework we estimated associations of structural (racism and homophobia), social (social support from other Black MSM friends) and individual factors with delayed HIV testing (>6 months ago) using logistic regression. Bivariate analyses demonstrated that individual level variables as well as experiences of racism (OR 1.20, 95% CI 1.02-1.41) and homophobia (OR 1.49, 95 % CI 1.02-2.17) were associated with higher risk of delayed HIV testing. Receiving social support from other Black MSM friends was associated with lower risk of delayed HIV testing (OR 0.80, 95 % CI 0.67-0.95). In multivariable models, social support remained significantly associated with lower risk of delayed HIV testing after inclusion of structural and individual level variables. Social support has a positive and robust association with HIV testing among young Black MSM. Whether community building and development of resiliency factors can overcome structural, social, and individual-level barriers to HIV prevention and care for young Black MSM warrants further study.

Sorting through chickens and eggs: a longitudinal examination of the associations between attitudes, norms, and sexual risk behavior

OBJECTIVE

Health behavior theories posit that health-relevant attitudes, beliefs, and behavioral skills drive subsequent actions people take to protect themselves from health threats. Within the realm of HIV-related sexual risk behavior, much of the research in support of this notion is cross-sectional, rather than longitudinal, particularly in studies of gay and bisexual men. Other psychological theories (e.g., self-perception or cognitive dissonance theories) suggest that the opposite could be true--that health-relevant attitudes and beliefs might change as a function of previous risk or precautionary behavior. Appreciating the complex nature of these associations is essential for modifying theory and developing appropriate interventions.

DESIGN

Using longitudinal data from gay and bisexual men (n = 1465), we used structural equation modeling to examine three possibilities--that perceived norms and attitudes about sexual risk would be (a) related to unprotected anal intercourse cross-sectionally, (b) related to unprotected anal intercourse at a subsequent time point, and/or (c) predicted from previous instances of unprotected anal intercourse.

RESULTS

Safe-sex norms and attitudes were related to unprotected anal intercourse cross-sectionally, but did not predict unprotected sex longitudinally. Rather, perceived norms and attitudes changed as a function of previous risk behavior.

CONCLUSIONS

These results raise the possibility that modified theoretical models might be necessary to adequately describe sexual risk behavior among gay and bisexual men.

Translating research into practice: the dissemination and initial implementation of an evidence-based HIV prevention program

Substantial effort has gone into scientifically developing and evaluating HIV prevention interventions. These programs make only minor contributions to HIV prevention efforts until they are widely put into practice; however, little research has been conducted to study how evidence-based, community-level HIV prevention interventions diffuse from research into practice. This article explores how one such evidence-based intervention for young MSM, the Mpowerment Project (MP), is scaling up in the US. The goals of this article are threefold: (a) to describe our longitudinal study, currently underway, concerning issues regarding translating research to practice; (b) present detailed data from 69 CBOs that are implementing the MP regarding characteristics of their communities, agencies, and target populations; and (c) to present baseline data on how these agencies are attempting to implement the MP, focusing on which intervention components CBOs decided to implement, modify, or delete and the implications of these modifications.

Challenges and facilitators to building program evaluation capacity among community-based organizations

We have been collaborating with many community-based organizations (CBOs) to increase their capacity to implement our evidence-based HIV prevention intervention. A frequent issue in these collaborations is how CBOs can evaluate their implementation of the intervention using feasible and sound methods. This study sought to provide the foundation for evaluation recommendations, tools, training, and technical assistance to help CBOs build their evaluation capacity. We conducted a qualitative study of 21 CBOs, 12 funders, and 11 technical assistance providers regarding beliefs and attitudes about evaluation, preferences and requirements for evaluation, evaluation methods that are currently being used at CBOs, and recommendations regarding feasible and effective evaluation that CBOs can use. The themes that arose in the telephone interviews are organized around three major topics: facilitators and barriers to conducting evaluation, evaluation methods that CBOs use, and how to increase CBOs' capacity to conduct evaluations.

A Longitudinal Study of the Association Between Treatment Optimism and Sexual Risk Behavior in Young Adult Gay and Bisexual Men

To determine whether optimism about highly active antiretroviral therapy is associated with sexual risk behavior among young adult HIV-negative gay and bisexual men, and to test 2 alternative explanations for this association: that treatment optimism leads to increased sexual risk or that treatment optimism is the result of previous sexual risk. Data on sexual risk behavior, treatment optimism, and perceived susceptibility to HIV infection were obtained from a sample of 538 HIV-negative or untested gay and bisexual men (ages 18-30) who were not in monogamous relationships. Follow-up data were collected 18 months later. In the cross-sectional data, treatment optimism was associated with the 2-month cumulative incidence of unprotected anal intercourse (UAI) with nonprimary partners; however, this effect was observed only among men who felt highly susceptible to HIV infection. Longitudinal analyses revealed that treatment optimism did not predict subsequent UAI, but UAI did predict later treatment optimism. Treatment optimism is associated with sexual risk behavior among young adult gay and bisexual men. However, these data suggest that optimism may result from, rather than precede, sexual risk.

Experiences of harassment, discrimination, and physical violence among young gay and bisexual men

OBJECTIVES

We examined the 6-month cumulative incidence of anti-gay harassment, discrimination, and violence among young gay/bisexual men and documented their associations with mental health.

METHODS

Gay/bisexual men from 3 cities in the southwestern United States completed self-administered questionnaires.

RESULTS

Thirty-seven percent of men reported experiencing anti-gay verbal harassment in the previous 6 months; 11.2% reported discrimination, and 4.8% reported physical violence. Men were more likely to report these experiences if they were younger, were more open in disclosing their sexual orientation to others, and were HIV positive. Reports of mistreatment were associated with lower self-esteem and increased suicidal ideation.

CONCLUSIONS

Absent policies preventing anti-gay mistreatment, empowerment and community-building programs are needed for young gay/bisexual men to both create safe social settings and help them cope with the psychological effects of these events.

The Mpowerment Project: community-building with young gay and bisexual men to prevent HIV1

The Mpowerment Project is a community-level HIV prevention intervention for young gay and bisexual men ages 18-27. The program seeks to build a strong, supportive young gay and bisexual men's community where young gay and bisexual men nurture and protect each other, particularly with regard to HIV prevention. The program's theoretical framework draws from the areas of diffusion of innovations, community organizing, peer influence, and personal empowerment. The Mpowerment Project promotes a norm for safer sex through a variety of social, outreach and small group activities. The project is run by a "Core Group" of 12-15 young gay and bisexual men who, with volunteers, design and carry out all project activities. Implemented in 4 communities (Eugene, OR; Santa Barbara, CA; Albuquerque, NM; Austin, TX), the Mpowerment Project has proven to be effective in reducing high risk sex. This paper discusses the development and implementation of the program and various challenges encountered.

The role of technical assistance in the replication of effective HIV interventions

This article examines the role of technical assistance (TA) in supporting the replication of proven HIV interventions. A case study of the replication of the VOICES/VOCES intervention elucidates the level and types of TA provided to support new users through the adoption process. TA included help in garnering administrative support, identifying target audiences, recruiting groups for sessions, maintaining fidelity to the intervention's core elements, tailoring the intervention to meet clients' needs, strengthening staff members' facilitation skills, troubleshooting challenges, and devising strategies to sustain the intervention. Two to four hours per month of TA were provided to each agency adopting the intervention, at an estimated monthly cost of $206 to $412. Findings illustrate how TA supports replication by establishing a conversation between the researcher TA providers experienced with the intervention and new users. This communication helps preserve key program elements and contributes to ongoing refinement of the intervention.

Orientation and training: preparing agency administrators and staff to replicate an HIV prevention intervention

Effective orientation and training are fundamental to the successful implementation of any intervention because they communicate the critical first impressions of the intervention and the skills needed to conduct it. When research-based HIV prevention interventions are translated into practice, issues arise that require adaptation and expansion of the basic functions of orientation and training. This article identifies some of these issues by drawing on the experience of researchers in the Replicating Effective Programs (REP) project. The purpose, structure, and instructional approach of the orientation and training for administrators, staff, and volunteers are described in depth for one project, with comparisons and additional examples from others. Based on these descriptions, critical issues for orientation and training for replication are presented. These include extending orientation and training to a broad audience within the adopting agency, allocating sufficient time to ensure understanding of the intervention, and planning for staff turnover.

From science to application: the development of an intervention package

Many community-based organizations and health departments want to implement HIV prevention interventions with scientifically demonstrated effectiveness. The Replicating Effective Programs (REP) project supported researchers in developing intervention packages designed to help prevention partners replicate effective programs in their settings. Intervention packages convey the intervention's foundation, components, and methods and are one part of a larger system needed to transfer research-based HIV prevention technology to service providers. Implementation packages were developed using a multistage process. The original researchers drafted the materials, advisory groups reviewed the packages, and adopting agencies used the materials in trial runs. The advisory groups and adopting agencies recommended extensive use of examples, thorough explanations about the rationale for each intervention component, explicit representation of people of color in the materials, clear statements about the intended audience(s), and an easy-to-use and visually appealing format. Packages were revised based on these recommendations and the outcomes of the trial runs.

Bridging research and practice: community-researcher partnerships for replicating effective interventions

Long-term collaborations among researchers, staff and volunteers in community-based agencies, staff in institutional settings, and health advocates present challenges. Each group has different missions, procedures, attributes, and rewards. This article reviews areas of potential conflict and suggests strategies for coping with these challenges. During the replication of five effective HIV prevention interventions, strategies for maintaining mutually beneficial collaborations included selecting agencies with infrastructures that could support research-based interventions; obtaining letters of understanding that clarified roles, responsibilities, and time frames; and setting training schedules with opportunities for observing, practicing, becoming invested in, and repeatedly implementing the intervention. The process of implementing interventions highlighted educating funders of research and public health services about (a) the costs of disseminating interventions, (b) the need for innovation to new modalities and theories for delivering effective interventions, and (c) adopting strategies of marketing research and quality engineering when designing interventions.