Lessons Learned from Use of Social Network Strategy in HIV Testing Programs Targeting African American Men Who Have Sex with Men.

Article (PDF Available)inAmerican Journal of Public Health 103(10) · August 2013with130 Reads
DOI: 10.2105/AJPH.2013.301260 · Source: PubMed
Abstract
Objectives: We report lessons derived from implementation of the Social Network Strategy (SNS) into existing HIV counseling, testing, and referral services targeting 18- to 64-year-old Black gay, bisexual, and other men who have sex with men (MSM). Methods: The SNS procedures used in this study were adapted from a Centers for Disease Control and Prevention-funded, 2-year demonstration project involving 9 community-based organizations (CBOs) in 7 cities. Under the SNS, HIV-positive and HIV-negative men at high risk for HIV (recruiters) were enlisted to identify and recruit persons from their social, sexual, or drug-using networks (network associates) for HIV testing. Sites maintained records of modified study protocols for ascertaining lessons learned. The study was conducted between April 2008 and May 2010 at CBOs in Washington, DC, and New York, New York, and at a health department in Baltimore, Maryland. Results: Several common lessons regarding development of the plan, staffing, training, and use of incentives were identified across the sites. Collectively, these lessons indicate use of SNS is resource-intensive, requiring a detailed plan, dedicated staff, and continual input from clients and staff for successful implementation. Conclusions: SNS may provide a strategy for identifying and targeting clusters of high-risk Black MSM for HIV testing. Given the resources needed to implement the strategy, additional studies using an experimental design are needed to determine the cost-effectiveness of SNS compared with other testing strategies.
Lessons Learned From Use of Social Network Strategy in
HIV Testing Programs Targeting African American Men
Who Have Sex With Men
Donna H. McCree, PhD, MPH, RPh, Gregorio Millett, MPH, Chanza Baytop, DrPH, MPH, Scott Royal, PhD, Jonathan Ellen, MD, MS, Perry N. Halkitis, PhD,
MS, Sandra A. Kupprat, MS, and Sara Gillen, MPH
Approximately 1.1 million people are living
with HIV in the United States and about
50 000 new infections occur each year.
1
Gay,
bisexual, and other men who have sex with
men (MSM) remain the most affected subpop-
ulation. Although constituting approximately
2% of the US population,
2
MSM accounted for
63% of all new infections in 2010,
3
61% of
HIV diagnoses among men in 2010,
4
and
represent approximately 48% of people living
with HIV.
4
Among MSM, Black MSM are dispropor-
tionately affected. Young (aged 13---24 years)
Black MSM accounted for 55% of new in-
fections among young MSM in 2010.
3
There
are more new HIV infections among 13- to 24-
year-old Black MSM than among any other
subgroup by race/ethnicity, age, and gender in
the United States.
3
The available literature suggests that myriad
individual, social, and contextual factors con-
tribute to the HIV rates among young, Black
MSM.
5---13
These factors include a higher back-
ground prevalence of HIV in the community
leading to a greater chance of exposure to an
infected partner despite less risky behavior
5---8
;
a higher prevalence of other sexually trans-
mitted infections, like syphilis and gonorrhea,
that might facilitate the acquisition and trans-
mission of HIV
5---8
; limited access to treatment
and health care
6
; stigma, homophobia, dis-
crimination
12
; partner characteristics and risk
behaviors
5,9---11
; and lack of awareness of in-
dividual or partners HIV status.
5,11
Awareness of HIV status is a critical step in
addressing the HIV epidemic among young,
Black MSM. Centers for Disease Control and
Prevention (CDC) estimates that approximately
18% of the people living with HIV have not
been diagnosed.
14
Furthermore, of those living
with HIV in 2009, 66% are linked to care,
37% retained in care, and 25% have
a suppressed viral load.
14
Individuals with
consistently suppressed viral load experience
reduced HIV-related morbidity and mortality
and have a lower probability of transmitting
the virus to others.
14
Although Blacks are more
likely to have ever been tested for HIV than
other racial/ethnic groups in the United States,
2 in 5 have never been tested.
15
Additionally,
many test too late in the course of their in-
fection to receive maximum benets from
treatment.
6
In 2008, more than one third of
Blacks who were diagnosed with HIV were also
diagnosed with AIDS within 1 year.
15
These data underscore the need for strate-
gies to identify undiagnosed HIV positive,
young, Black MSM. This paper presents results
from a multisite study designed to evaluate the
relative effectiveness of 3 strategiesalternate
venue testing (AVT), the Social Network Strat-
egy (SNS), and partner counseling and referral
services (PCRS; now known as Partner Ser-
vices)for reaching and motivating previously
undiagnosed, 18- to 64-year-old Black MSM
to be tested for HIV and linked to medical
care and prevention services. Applicants
were required to meet the following eligibility
criteria for funding: (1) conduct the study in
a city with an Black population of at least
100 000 based on 2000 US Census data; (2)
have an HIV counseling and testing program
(CTR) that had been in existence for at least
3 years (prior to 2006) and that historically
and currently provided services to Black men,
including MSM; and (3) conduct PCRS or have
Objectives. We report lessons derived from implementation of the Social
Network Strategy (SNS) into existing HIV counseling, testing, and referral
services targeting 18- to 64-year-old Black gay, bisexual, and other men who
have sex with men (MSM).
Methods. The SNS procedures used in this study were adapted from a Centers
for Disease Control and Prevention–funded, 2-year demonstration project in-
volving 9 community-based organizations (CBOs) in 7 cities. Under the SNS,
HIV-positive and HIV-negative men at high risk for HIV (recruiters) were enlisted
to identify and recruit persons from their social, sexual, or drug-using networks
(network associates) for HIV testing. Sites maintained records of modified study
protocols for ascertaining lessons learned. The study was conducted between
April 2008 and May 2010 at CBOs in Washington, DC, and New York, New York,
and at a health department in Baltimore, Maryland.
Results. Several common lessons regarding development of the plan, staffing,
training, and use of incentives were identified across the sites. Collectively, these
lessons indicate use of SNS is resource-intensive, requiring a detailed plan,
dedicated staff, and continual input from clients and staff for successful
implementation.
Conclusions. SNS may provide a strategy for identifying and targeting clusters
of high-risk Black MSM for HIV testing. Given the resources needed to implement
the strategy, additional studies using an experimental design are needed to
determine the cost-effectiveness of SNS compared with other testing strategies.
(Am J Public Health. Published online ahead of print August 15, 2013: e1–e6. doi:
10.2105/AJPH.2013.301260)
RESEARCH AND PRACTICE
Published online ahead of print August 15, 2013 | American Journal of Public Health McCree et al. | Peer Reviewed | Research and Practice | e1
a written agreement with the local health
department to obtain aggregate PCRS data for
Black MSM. Each of the funded sites had
existing AVT programs that were expanded for
this study to focus on Black MSM. All of the
sites received SNS training and implemented
this strategy into their existing CTR programs.
The purpose of this article is to report common,
cross-site lessons learned from implementation
of SNS into existing HIV CTR services in
New York City, New York; Baltimore,
Maryland; and Washington, DC.
THE SOCIAL NETWORK STRATEGY
For purposes of this study, SNS was based
on the concept that individuals are linked
together to form large social networks, where
high-risk sex and drug-using behaviors are
highly prevalent,
16,17
and was patterned after
the SNS used in a CDC-funded, 2-year dem-
onstration project involving 9 community-
based organizations (CBOs) in 7 cities.
18
Under
this strategy, HIV-positive and high risk HIV-
negative persons (recruiters) are enlisted to
identify and recruit persons from their social,
sexual, or drug-using networks (network asso-
ciates) for testing. As such, SNS involves work-
ing with those who test positive and negative
to identify network associates who might be at
high risk and unaware of their HIV status, as
well as social contacts in the identied networks
of these HIV-positive or negative recruiters.
Findings from the literature support the
benets of using SNS in HIV counseling, testing,
and referral programs. Results from the 2-year
CDC-funded demonstration project found an
approximate 6% prevalence of HIV infection
among network associates.
18
This rate is ap-
proximately 5 times the average prevalence
reported by publically funded CTR sites. Addi-
tionally, results from a community-based pilot
study conducted in Massachusetts on the po-
tential utility of SNS suggests that the use of
social networks can play a strong role in in-
creasing the volume of testing and targeting of
at-risk, heterosexually active populations with
undiagnosed HIV infection.
17
Furthermore, re-
sults from studies on HIV prevention among
injection drug users
19---22
suggest the potential
power and utility of social networks and their
associated norms in reducing HIV risk behavior
within networks. Finally, testing results from
the New York site of the study reported in this
article showed that SNS identied more pre-
viously undiagnosed Black MSM than AVT or
PCRS.
23
Collectively, these data provide evidence
that SNS is valuable in identifying individuals
with undiagnosed HIV status; however, there
are no data on lessons learned from strategic
implementation into existing CTR programs
targeting Black MSM. This article contributes
to that extant literature.
METHODS
The study was conducted at community-
based organizations (CBOs) located in the
District of Columbia and New York, and
a health department in Baltimore City. The
CBOs were Us Helping Us (UHU), People Into
Living, Inc. under collaboration with Abt As-
sociates, and Harlem United Community AIDS
Center in collaboration with New York Uni-
versity. UHU is one of the largest gay-identied
HIV and AIDS organizations providing services
specically to the Black community in the
Washington metropolitan area. Harlem United
Community AIDS Center is a nonprot AIDS
Service Organization in New York City that
provides health care, housing and HIV pre-
vention services for clients from East Harlem to
the Bronx. The Baltimore City Health Depart-
ment (BCHD) participated as a partnership with
Johns Hopkins Medicine. BCHD is the oldest,
continuously operating health department in
the United States.
Study Population
We conducted the study between April
2008 and August 2010. Common eligibility
criteria across the sites were (1) 18 to 64 years
of age, (2) biologically male, (3) self-reported
race as being Black, and (4) self-reported oral
or anal sex with a man in the past year. Men
at the Washington, DC, site had to report oral
or anal sex with a man in the past 6 months.
The Social Network Strategy
Recruiters participated in initial coaching
sessions and boosters, led by SNS staff at each
of the sites, on how to elicit social contacts for
testing. The network associates (NAs) were
referred by recruiters to HIV counseling and
testing services at a designated site location.
NAs and recruiters were linked. Incentives
were provided to recruiters for NAs who were
tested; NAs received incentives for testing. The
amount of the incentives varied across the sites
based on usual and customary practices for
CTR programs and HIV research studies in the
areas. The incentive schedule utilized was as
follows: (1) Baltimore, $5 gift coupons to re-
cruiters for each NA that tested; (2) Washing-
ton, $20 visa gift card to recruiters and $20
visa gift card for each NA that tested; and (3)
New York, $4 Metrocard and $10 gift cards to
recruiters and $4 Metrocard and $20 gift
card to each NA that tested and completed the
intake form. Men found to be infected, or at
high risk for becoming infected based on
reported behavior, were referred to appropriate
medical care and prevention services per the
standard protocol in place at each of the sites.
Each of the sites used separate study pro-
tocols and elements of SNS were tailored to
each individual CTR program to ensure that
normal testing processes were not disrupted by
the research. Investigators from each site and
the CDC team worked in close collaboration
to develop, implement and monitor the study
protocols. Sites submitted targeted recruitment
numbers for each of the testing strategies,
including SNS, in advance of study implemen-
tation. Additionally, all sites were required to
maintain an SNS log that was completed by
designated SNS staff and included the following
information: how the client was referred, date
and time of the interview, specics on what was
done during the interview, and successes or
problems reported. These data were collected
for the initial SNS interview and all follow-up
interviews conducted with each SNS client. Site
staff input all study data into a database de-
veloped by the CDC team. The de-identied
data were transferred from the sites via a Se-
cure Data Network to the CDC team. Successes
and challenges to implementing the strategy
and recruiting participants were monitored via
the database and discussed on monthly cross-
site conference calls and during annual face-to-
face meetings. Based on these discussions, study
protocols were amended with required IRB
approvals, and recruiting numbers were modi-
ed as needed. The lessons learned discussed in
this manuscript are common from all 3 sites
identied during the study implementation and
discussed on the monthly conference calls and
RESEARCH AND PRACTICE
e2 | Research and Practice | Peer Reviewed | McCree et al. American Journal of Public Health | Published online ahead of print August 15, 2013
at face-to-face meetings. Figures 1 through 3
provides a schematic design of the SNS strategy
used at each of the sites. Additional site specic
data on the study are available elsewhere
(C. Baytop, unpublished data, 2013).
24
HIV testing procedures were conducted in
accordance with standard CTR procedures at
each of the sites. Testing at the UHU and
Harlem United sites was conducted using the
OraQuick Advance Rapid HIV-1/2 Antibody
Test for screening (OraSure Technologies, Inc.,
Bethlehem, PA) and the OraSure (OraSure
Technologies, Inc.) for conrmatory testing.
Clients who screened HIV-positive were given
an appointment to receive their conrmatory
test results. Those conrmed as HIV-positive
received appropriate counseling and follow-up
per standard procedures at the sites. Testing
at BCHD was conducted using conventional
testing, (ELISA and conrmatory Western blot,
as well as HIV RNA testing), as per BCHD
standard diagnostic algorithm.
RESULTS
A total of 24 recruiters were identied and 149
men were tested through SNS at the UHU site in
Washington, DC. Almost half (49%) were 25 to
34 years of age, about two thirds (62%) reported
at least some college education, and more than
half (52%) identied as heterosexual, but reported
sex with a male partner in the past year. Addi-
tionally, more than two thirds (68%) reported that
they had never been tested for HIV. Of the
149 men tested, 30 tested HIV-positive. Of those,
16 (11%) were newly identied as HIV-positive.
A total of 70 recruiters were identied and
109 men received HIV testing through SNS
at the Harlem United site. The mean age of the
men in the New York sample was 25 years.
About one third reported having either a high
school education or some college or Associates
degree, and all reported their sexual orienta-
tion as either gay (59%) or bisexual (41%).
Almost 6% of the recruiters reported that they
Identify UHU
CTR sta to
participate in
SNS program
Prescreen of
clients by
CTR
Group
presentation
to CTR sta
on SNS
program
Individual
meeting with
CTR sta on
SNS program
UHU CTR
sta identies
potential
recruiters
through
engagement of
high-risk
negatives/
positives
Screening
and
invitation of
potential
recruiter
Conduct
individual
or group
orientation
session
If not
appropriate for
program, refer
to ongoing risk-
reduction
counseling
Coaching
on
techniques
to approach
networks
Interview
recruiters to
solicit
information
on type of
network
Create SNS
recruitment
plan
Recruitment
of
network
associates
Testing of
network
associates
STEP 1:
STEP 2:
Ongoing coaching for
SNS recruiters as
needed
Note. CTR = counseling and training program; SNS = Social Network Strategy; UHU = Us Helping Us.
FIGURE 1—Schematic design of UHU Social Network Strategy: Washington, DC.
RESEARCH AND PRACTICE
Published online ahead of print August 15, 2013 | American Journal of Public Health McCree et al. | Peer Reviewed | Research and Practice | e3
had never been tested for HIV. Of the 109 men
tested, 21 (19%) tested HIV-positive. The
study protocol did not provide a mechanism to
reconcile whether men who tested positive had
ever received a prior HIV-positive diagnosis
with the New York City Department of Health.
For purpose of the study at the BCHD, all
Black men who tested positive for HIV for the
rst time, (according to BCHD records), from
alternate venue testing (AVT) or from BCHDs
xed testing sites and reported engaging in sex
with a man within the last 6 months were
alternately assigned to SNS or partner services
(known as partner counseling and referral
services at the time of the study) based on the
order in which they received their results. As
such, 27 pr evious H IV-positive men a nd 9
newly identied HIV-positive men (n = 36)
were assigned as SNS recruiters. Twenty-two
declined and received standard partner ser-
vices per the BCHD protocol. Fourteen men
(10 previous positives and 4 new positives)
elected to participate as SNS recruiters. A
total of 22 men were tested. Eight (36%)
tested HIV-positive and none w ere newly
identied.
DISCUSSION
We learned several common lessons re-
garding development of the plan, stafng,
training, and use of incentives.
Lessons Learned
The SNS Plan. Successful implementation
and use of the SNS strategy in an HIV CTR
program requires a detailed plan that is de-
veloped with input from clients and staff and
tailored for the existing testing program. The
plan may require several modications. Regu-
larly scheduled check-in meetings between
supervisors and staff (at least monthly) to
discuss challenges and resolutions and modify
plans as needed are critical. The inclusion of
program staff in a regular review of the plan
will enable buy-in among all employees and
provide an opportunity to develop strategies
for addressing challenges and improving pro-
ductivity. This plan should include intake forms
that allow collection of data needed to link
persons to appropriate follow-up care.
SNS Program Staff. SNS staff should possess
excellent interpersonal and project manage-
ment skills and include members of the target
population. Based on experiences at the 3 sites,
the best stafng plan is to have 1 primary
counselor whose sole responsibility is to mon-
itor and manage all SNS activities. Ideally, all
counseling and testing staff should be trained
on SNS and be tasked with identifying potential
recruiters and referring those individuals to
the primary counselor that oversees SNS
activities. Th at primary counselor sho uld be
responsible for orienting and providing
coaching to recruiters, tracking NAs, and
making decisions about when to dismiss or
retire a r ecruiter. The primary counselor
should also network with and plan HIV testing
events for agencies, clubs, ch urche s, and
venues the target pop ulatio n is likely to fre-
quent. Additionally, high t urnover rates
should be anticipated among the staff. How-
ever, providing incentives (e.g., special recog-
nition awards or nancial compensa tion for
ach ievement of recruit ment goals) to staff
based on their productivity in identifying and
retaining recruiters keeps morale high and
turnover low.
Training. Based on results from this study,
all counseling and testing staff should receive
SNS training. The optimal approach is to have
staff attend trainings together to facilitate dis-
cussions and provide opportunities for staff to
interact on training scenarios. This training
should focus on the following: SNS theory;
strategies for identifying, creating rapport and
Positive test
BCHD HIV TESTING SERVICES
Fixed facility testing:
STI clinics
PLACES methodology
Alternative venue testing
Pre-test counseling using standardized
intake form
HIV testing
Negative test
Notication of results and post-
test counseling
Partners tested
Partner counseling and
referral services
Social network
interview
Social contacts oered SNI and
tested
Alternating
Identify more venues
for AVT (PLACES)
PART 1
PART 2
Community testing
partners
Negative test
Positive test
HIV+ and refuse SNI
HIV-and
refuse SNI
Accept SNI
Note. AVT = alternate venue testing; BCHD = Baltimore City Health Department; SNI = social network interview; STI = sexually
transmitted infection.
FIGURE 2—Schematic design of BCHD Social Network Strategy: Baltimore, MD.
RESEARCH AND PRACTICE
e4 | Research and Practice | Peer Reviewed | McCree et al. American Journal of Public Health | Published online ahead of print August 15, 2013
establishing partnerships with and coaching
recruiters; and processes needed to create
daily, weekly, and monthly goal setting for staff.
Additionally, booster sessions (i.e., ongoing
trainings) are needed to maintain momentum
and increase productivity. Sites in this study
included booster sessions in regular staff
meetings.
Incentives. Use of incentives for testing was
customary at UHU and Harlem United prior to
implementation of this study. For this study, the
UHU and Harlem United sites provided in-
centives to both recruiters and NAs who tested;
the BCHD site provided incentives to recruiters
only. However, the incentive amounts at UHU
and Harlem United were increased based on
feedback received from study participants. As
a result, the participation rate increased at both
sites. These results suggest that use of incen-
tives increased participation in testing. The
type and amount should be determined by
community standards (e.g. be competitive
with incentives offered in other CTR or HIV
research-related activities conducted in the
area). Results also suggest that use of incentives
may result in a higher number of previous
HIV-positive persons testing through the pro-
gram. As such, it is critical to collaborate with
health departments in SNS testing initiatives
to verify true undiagnosed HIV-positives.
Testing History. It is important that sites have
mechanisms in place (e.g., relationships with
local health departments) to determine the
testing history of men tested via SNS. There are
multiple reasons why network associates may
report not being HIV positive at the time of
testing, particularly when incentives are provided
for testing. Mechanisms to verify testing history
that do not rely solely on self-report will allow
sites to more accurately determine the number
of new diagnoses identied by the strategy.
Conclusions
The focus of this article is to present
common, cross-site lessons learned from
implementation of the SNS into existing CTR
programs in New York, Baltimore, and Wash-
ington, DC. Our intent is to provide information
for HIV counseling and testing program sites
that may be interested in implementing SNS
into their programs that target Black MSM.
Based on the results, use of the SNS in HIV
counseling and testing programs may provide
a strategy for identifying and targeting clusters
of high-risk, previously undiagnosed, Black
MSM for HIV testing. Successful implementa-
tion of the strategy, however, is resource in-
tensive and requires a detailed plan, training,
a dedicated staff, support from the testing
agency, input from the target population, use
of appropriate incentives, and collaborations
with health departments. Future studies should
use an experimental design and common pro-
tocol to determine the effectiveness and cost
of implementing SNS into testing programs and
to identify the best combination of testing
strategies for identifying, reaching and moti-
vating previously undiagnosed HIV-positive
Black MSM to be tested for HIV and linked
to care and prevention services.
j
About the Authors
Donna H. McCree is with the Division of HIV/AIDS
Prevention, National Center for HIV, Viral Hepatitis, STD
and TB Prevention, Centers for Disease Control and Pre-
vention, Atlanta, Georgia. Gregorio Millett is with Centers
for Disease Control and Prevention, Washington, DC.
Chanza Baytop and Scott Royal are with Abt Associates,
Bethesda, MD. Jonathan Ellen is with the Department of
Pediatrics, Johns Hopkins University School of Medicine,
Baltimore, MD. Perry N. Halkitis and Sandra A. Kupprat
are with the Center for Health, Identity, Behavior and
Prevention Studies, Steinhardt School of Culture and
Human Development, New York University, New York, NY.
Sara Gillen is with Community Health Services, Harlem
United, New York, NY.
Correspondence should be sent to Donna Hubbard
McCree, PhD, MPH, RPh, Associate Director for Health
Equity, Division of HIV/AIDS Prevention, National
Center for HIV, Viral Hepatitis, STD and TB Prevention,
Centers for Disease Control and Prevention, 1600 Clifton
Road NE MS D-21, Atlanta, Georgia 30333 (e-mail:
zyr1@cdc.gov). Reprints can be ordered at http://www.
ajph.org by clicking the Reprints link.
This article was accepted January 21, 2013.
FIGURE 3—Schematic design of Harlem United Social Network Strategy: New York, NY.
RESEARCH AND PRACTICE
Published online ahead of print August 15, 2013 | American Journal of Public Health McCree et al. | Peer Reviewed | Research and Practice | e5
Contributors
D. H. McCree provided scientic and administrative
oversight to the entire project, participated in the design
of the study, wrote the rst draft of the article, and
participated in revising all drafts of the article. G. Millett
assisted in leading the scientic and administrative
oversight of the entire project, participated in the design
of the study, and participated in revisions of the drafts.
C. Baytop, S. Royal, J. Ellen, P. N. Halkitis, and S. Gillen
served as principal investigator or coprincipal investiga-
tor at their individual sites, participated in the design of
the study, participated in recruitment and data collection,
and participated in revising all drafts of the article. S. A.
Kupprat served as project coordinator at the New York
site, participated in the design of the study, participated
in recruitment and data collection, and participated in
revising all drafts of the article.
Acknowledgments
This work was funded by Cooperative Agreements to Abt
Associates (1 UR6 PS000330), the Baltimore City Health
Department (5UR6PS000329), and Harlem United
Center for AIDS Research (5UR6PS000368) from the
US Centers for Disease Control and Prevention (CDC).
The authors wish to acknowledge the counseling and
testing staff at each of the participating sites and other
members of the CDC Study Team, Kenneth Jones, Holly
Fisher, and Sekhar Thadiparthi for their outstanding
contributions to this study. We also thank the study
participants for making this effort possible.
Note. The contents of this article are solely the
responsibility of the authors and do not necessarily
represent the views of CDC.
Human Participant Protectio n
All study protocols were approved by the CDC Human
Subjects Review Board and the institutional review
boards at each of the participating sites. All participants
provided informed consent for partici pation in the Social
Network Strategy.
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RESEARCH AND PRACTICE
e6 | Research and Practice | Peer Reviewed | McCree et al. American Journal of Public Health | Published online ahead of print August 15, 2013
    • "Currently, research is limited in that area. However, among the few studies focused solely on BMSM, studies related to HIV testing issues and behaviors specifically for BMSM have focused on geographic setting as an influence on HIV testing [22], strategies for identifying and targeting clusters of high-risk BMSM for testing [21], and HIV-related stigma (Morris et al., 2014; Sayles, Wong, Kinsler, Martins, & Cunningham, 2009; Smit et al., 2012) and homophobia232425. In a review of HIV stigma-related studies, Smit et al. [24] found some MSM avoid HIV testing due to fears of stigma and discrimination. "
    [Show abstract] [Hide abstract] ABSTRACT: Background: HIV testing continues to be a major priority for addressing the epidemic among young Black men who have sex with men (BMSM). Methods: This study explored barriers to HIV testing uptake, and recommendations for motivating HIV testing uptake among Black men who have sex with men (BMSM) aged 18 to 30. BMSM (N = 36) were recruited through flyers and social media for six focus groups. Results: From the perspectives and experiences of young BMSM, participants recommended that information be included in HIV testing messages that would help young BMSM do self HIV-risk appraisals. Particularly, participants recommended that more knowledge about Pre-Exposure Prophylaxis (PrEP) and the role of PrEP in safer-sex practices be provided. This information is important to help those untested, or who infrequently test, better understand their risk and need for testing. Likewise, participants recommended that more information about a person being undetectable and the risk of condomless sex with an HIV negative sex partner; this information will be helpful for both the HIV negative and HIV positive sex partner for making safer sex decisions. Participants also recommended that interventions should focus on more than drug use as risk; the risk posed by the use of alcohol before and during sex deserves attention among young BMSM. Conclusions: These findings may inform new HIV testing interventions being tailored for young BMSM. The interventions should also consider revisiting street-based peer-outreach approaches for those young BMSM with limited access to social media campaigns due to limited access or infrequent use of social media.
    Full-text · Article · Oct 2015
  • [Show abstract] [Hide abstract] ABSTRACT: Worldwide, men who have sex with men (MSM) remain one of the most HIV-vulnerable community populations. A global public health priority is developing new methods of reaching MSM, understanding HIV transmission patterns, and intervening to reduce their risk. Increased attention is being given to the role that MSM networks play in HIV epidemiology. This review of MSM network research studies demonstrates that: (1) Members of the same social network often share similar norms, attitudes, and HIV risk behavior levels; (2) Network interventions are feasible and powerful for reducing unprotected sex and potentially for increasing HIV testing uptake; (3) HIV vulnerability among African American MSM increases when an individual enters a high-risk sexual network characterized by high density and racial homogeneity; and (4) Networks are primary sources of social support for MSM, particularly for those living with HIV, with greater support predicting higher care uptake and adherence.
    Article · Jan 2014
  • [Show abstract] [Hide abstract] ABSTRACT: We investigated the structural characteristics of a multiplex HIV transmission risk network of drug-using male sex workers and their associates. Using a sample of 387 drug-using male sex workers and their male and female associates in Houston, Texas, we estimated an exponential random graph model to examine the venue-mediated relationships between individuals, the structural characteristics of relationships not linked to social venues, and homophily. We collected data in 2003 to 2004. The network comprised social, sexual, and drug-using relationships and affiliations with social venues. Individuals affiliated with the same social venues, bars, or street intersections were more likely to have nonreciprocated (weak) ties with others. Sex workers were less likely than were other associates to have reciprocated (strong) ties to other sex workers with the same venues. Individuals tended to have reciprocated ties not linked to venues. Partner choice tended to be predicated on homophily. Social venues may provide a milieu for forming weak ties in HIV transmission risk networks centered on male sex workers, which may foster the efficient diffusion of prevention messages as diverse information is obtained and information redundancy is avoided. (Am J Public Health. Published online ahead of print April 16, 2015: e1-e8. doi:10.2105/AJPH.2014.302474).
    Full-text · Article · Apr 2015
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