Identifying Why and How Non-IDU Black MSM Maintain HIV Seronegativity

Jagadisa-devasriDacus, LMSW, Principal Investigator

Specific Aims

Preliminary data from the HIV-testing component of the National HIV Behavioral Surveillance System (CDC, 2006), indicated that of the MSM surveyed 25% were infected with HIV. Of that group, 48% were unaware of their HIV status, and of the MSM who tested positive for HIV, seropositive prevalence was highest among Blacks at an alarming 46% (CDC, 2006). Subsequently, in 2006, groups of Black gay male HIV/AIDS health and human service providers and of HIV behavioral and social scientists mobilized to draw more attention to the large numbers of those infected.

Although considerable research has focused on the risk factors for HIV infection among Black MSM, the remaining 54% of Black MSM who tested seronegative have not received much attention. Since the aim of primary HIV prevention is to keep seronegatives negative, this group of Black MSM warrants attention.As the first step of a long-term research agenda, this one-year New York City-based study[1] will inform the development and evaluation of culturally- and gender-appropriate HIV primary prevention interventions for non-IDU seronegative Black MSM. The proposed study will identify, examine,and analyze the behaviors, circumstances, or other factors non-IDU seronegative Black MSM aged 21 and over report that enable them to remain negative.

The study will focus on three age cohorts (21-29, 30-39 and 40 and over) and one mixed-age cohort, to control for different age group experiences with the HIV epidemic, and to capture socially influenced responses in groups. Specifically, the study will:

a)In Phase One, complete a literature review and collectqualitative data from key informants (members or non-members of Black MSM communities who know the communities well and who can share their broad and specific perspectives about non-IDU seronegative Black MSM)and social service providers in order to inform topic guides and surveys about the strategies and tactics New York City non-IDU seronegative Black MSM implement to remain seronegative. Data includes:

  1. four individual interviews with key informants (who will offer their perspectives to inform further investigation with their peers) who are seronegative non-IDU Black MSM,
  2. two facilitated roundtable discussions at national HIV prevention conferences (US Conference on AIDS and HIV Prevention Leadership Conference) to elicit social service providers’ knowledge and perceptions of, and assumptions about,the protective factors that help their non-IDU Black MSM clients/consumers maintain seronegativity, and
  3. one focus group of six social service providers in New York Cityand one focus group of six to ten social service providers at the National AIDS Education and Services for Minorities (NAESM) Black MSM Conference.

b)In Phase Two, using topic guides and online surveys based on findings from Phase One, conduct:

  1. four 9-person focus groups of seronegative Black MSMin three age cohorts (21-29, 30-39 and 40 and over) and one mixed-age cohort to control for different age group experiences with the HIV epidemic, and to capture socially-influenced responses in groups, and
  2. 50 online surveysto capturefactors affecting those who access social networks

This pilot work will contribute to the development of new, culturally- and gender-appropriate interventions to maintain seronegativity among Black MSM in a planned series of funded projects.

Background and Significance

The Need. Disproportionate seroprevalence. Among Black men living with HIV, the primary mode of transmission is high-risk sexual contact with other men, followed by injection drug use (CDC, 2006)[2]. However, studies suggest that Black MSM are not engaging in higher risk behaviors than non-Black MSM (NASTAD, 2006, 2007). The connection between higher rates of HIV acquisition and transmission among Black MSM remains unclear, although researchers suggest that the composition of Black MSM social and sexual networks, and not sexual behaviors, may explain their greater seroprevalence compared to non-Black MSM (Bohl, Raymond, Arnold & McFarland, 2009; Millet, Flores & Peterson, 2007; Peterson & Jones, 2009). The phenomenon, described as “less risk, more effect,” is used to explain how Black MSM were twice as likely as White MSM to be diagnosed with a sexually transmitted disease (STD),even though Black MSM report fewer lifetime male sex partners, lower rates of substance abuse, and less drug use associated with HIV infectionthan White MSM (Millet, Flores, Peterson & Bakeman, 2007).

The last US Census (2000) found that Blacks represented approximately 13% of the total US population; yet in terms of race, Blacks are the racial group most affected by HIV in the US. In 37 states and 5 US dependent areas with long-term, confidential name-based HIV infection reporting, Blacks accounted for nearly half (46%) of people living with an HIV diagnosis at the end of 2007 (CDC, 2009). The Centers for Disease Control and Prevention (CDC) estimates that among Blacks, one in 16 men and one in 30 women will receive a HIV diagnosis during their lifetimes (CDC, 2010).

Seroincidence in Black men. According to the CDC (2005, 2008, 2010), among Blacks, men represent the majority (65%) of all new infections. This is six times greater than White men and three times greater than Latino men. It is also two times greater than that of Black women (CDC, 2008). Among all groups classified by behavioral risk, HIV infection rates are highest for men who have sex with men (MSM).

Seroprevalence in MSM. MSM is the term the CDC surveillance system uses to indicate the behaviors that transmit HIV infection; it is not a descriptor of sexual identity or sexual orientation. Whereas MSM were 2% of the US population, they accounted for 53% of all people living with HIV infection in 2006. Together with AIDS diagnoses and AIDS-related deaths, MSM have been the most affected group since the beginning of the HIV/AIDS epidemic in the US.

Incidence among Black MSM. Black MSM represent 63% of new infections among all Black men and 35% of new infectionsamong all MSM (CDC, 2008; 2010). What is even more troubling is that for Black MSM aged 13 to 29, HIV incidence is higher compared to their age and racial peers; they are 1.6 and 2.3 times greater than that of White and Latino men respectively (CDC, 2008, 2010; NASTAD 2009). According to Peterson and Jones (2009) “Black MSM in the United States now experience rates of HIV infection that rival those among the general population in the developing world.” Data collected from 2005 to 2008 indicated that the percentage of diagnoses of HIV infection among Black MSM increased from 36% to 40%, while decreasing from 41% to 37% among White MSM. Additionally, by 2008, data showed that HIV infection (both incidence and prevalence) among Black MSM surpassed and exceeded that of Whites (CDC, 2010).

Addressing the epidemic among Black MSM. To date, there are only two CDC's Diffusion of Effective Interventions project (DEBIs)interventions that use scientific research to address HIV acquisition and transmission among Black MSM. One intervention, d-up! Defend Yourself, is only a “cultural adaptation” of another community-level intervention that was not originally intended or developed for Black MSM (Jones et al., 2008). The scientific evidence behind d-up! aims to change social norms regarding condom use via influential opinion leaders trusted by their peers through friendship and social networks. The other intervention, Many Men, Many Voices (3MV), aims to prevent HIV and STD transmission among gay and non-gay identified Black MSM. The evidence behind this intervention deals with influencing factors such as cultural, social, and religious norms, HIV and STDs, sexual relationship dynamics, racism and homophobia (Wilton et al., 2009). In addition, both d-up! and 3MV have at least one or more of the following strategies as a focus: addressing barriers to HIV counseling and testing, treatment and care; demonstrating cultural competency; intervening in social networks; empowering and mobilizing Black MSM communities; and providing comprehensive health and wellness services.

These evidence-based interventions (EBIs) have been proven effective with Black MSM at high- and at greatest risk for HIV acquisition and transmission (Effective Interventions, 2010). A limitation of the EBIs is that they are not designed for Black MSM who are at low risk and already engaging in protective behaviors. Unfortunately, there are no EBIs designed to support or reinforce the protective behaviors, social norms, and other factors that contribute to seronegativity among non-IDU Black MSM. This lack is consistent with the scientific research that has focused only on the transmission-related behaviors of Black MSM.Hopefully, this study will prompt a reexamination and reassessmentof the current primary HIV prevention portfolio for seronegative Black MSM with the aim of retooling and/or developing new tools and measures to support HIV-uninfected Black MSM to maintain seronegativity.

The Setting. New York City will provide an ideal backdrop against which to research the strategies and tactics of non-IDU seronegative Black MSM because New York State ranks the highest in the country with regard to HIV infection rates among Blacks and highestamong Black MSM, 44 % and 29% respectively (Kaiser Family Foundation, 2011). Additionally, New York City has numerous community based social service agencies and organizations (includingAIDS service organizations)that provide health and human services to Black MSM.Thus, service providers here have experience with clients and perspective as their clients have adapted to different phases of the epidemic.

Preliminary Studies

Mr. Jagadisa-devasriDacus, PI, is a New York State (NYS) licensed social worker who received his Masters of Social Work from the Columbia University School of Social Work. Mr. Dacushas worked with Black MSM for over a decade, largely as a clinician and trainer on, and facilitator of, HIV prevention interventions and strategies, including the Centers for Disease Control and Prevention (CDC) Demonstration of Evidence-Based Interventions. As the former Senior Director of Training & Capacity Building Programs at the Harm Reduction Coalition(HRC),Mr. Dacus oversaw the provision of technical assistance, information and technology transfer, and skills-building activities to over 5,000 social service providers and over 800 HIV/AIDS prevention organizations and health departments (HDs) which comprised HRC’s clientele.

With over seven years of experience as a CDC-funded capacity building assistance provider for CBOs and health departments targeting African American communities, he has extensive experience serving Black MSM populations in numerous social services settings, i.e., The New York State Black Gay Network, the New York City Lesbian, Gay, Bisexual and Transgender (LGBT) Community Services Center, Bronx AIDS Services, and Gay Men’s Health Crisis. Additionally, Mr. Dacus has a history of working for and with CBOs and HDs engaged in the implementation of HIV prevention interventions for other high-risk racial and ethnic populations, youth and young adults, and LGBT communities. He has served on the New York City HIV Prevention Planning Group as the Chair of the MSM Workgroup, is an Institute for HIV Prevention Leadership scholar, and is a lead and master trainer on 12 evidence-based HIV prevention interventions (many of which have been developed with, adapted for, and implemented with Black MSM) which form part of the CDC's DEBI Project.

Mr. Dacus possesses 18 year’s worth of experience and practice in public health as a social worker, with specific training and expertise in key research areas for this application. As a doctoral candidate at the Hunter College School of Social Work, he will continue to develop his skill set and refine his expertise in the areas of formative and survey research and primary and secondary data analysis on issues related to HIV/AIDS. Mr. Dacus has: Developed and implemented evaluation processes in the nonprofit sector; conducted formative evaluation related to evidence-based HIV prevention interventions(e. g., Safety Counts[3]); taken research and evaluation courses and workshops; designed focus group guides; conducted focus groups; and trained health and human service providers on how to conduct focus groups

The research team will consist of:

  • Principal Investigator – Jagadisa-devasri Dacus, LMSW, Ph.D. Candidate
  • Co-Investigator – Beatrice Krauss, PhD
  • Research Assistant – TBH

Mr. Dacus will be joined on this project by a Master’s level research assistant, trained in the social, health, or behavioral sciences with at least two years of experience in designing and conducting surveys and focus groups with the target populations. Beatrice Krauss, Ph.D., Professor of Public Health, will assist in designing analyses and lend her expertise on elicitation research designed to inform intervention design (see Krauss et al., in Pequegnat and Szapocznik, 2000).

Research Design and Methods

Overview. The research will be conducted in two phases: Phase one) Mr.Dacus will conduct a comprehensive and comparative review of the literature on risk-promoting and risk-reducing factors among non-IDU Black MSM populations, both locally and nationally, and will interview or lead discussions of key informants and service providers, in order to author appropriate on-linesurveys and focus group guides; Phase two)will consist of (a) focus groups of seronegative Black MSM in three age cohorts (21-29, 30-39 and 40 and over) and one mixed-age cohort, and (b) online surveying (using SurveyMonkey.com, encrypted version) to capture factors affecting those non-IDU seronegative Black MSMS who access online social networking sites.

In all phases, sampling will be designed to capture the diversity of Black seronegative MSM in order to facilitate saturation of the strategies used by those in different age, socio-economic, and social networks. Relationship pattern (e.g., concurrency, serial monogamy) is assumed to be a protective or risk strategy, hence sampling is not directed by relationship pattern.

Phase One Literature Review: Sampling and Analysis

Mr. Dacus will work with health research librarian, John Carey, at the Hunter College Brookdale Health Professions Library, to conduct the literature review on risk-promoting and risk-reducing factors among non-IDU Black MSM populations. They will utilize pertinent City University of New York databases (e.g., EBSCO, MEDLINE, Psychinfo, Pubmed, Social Sciences) to acquire all pertinent literaturesince 2000as well as examining core concepts in Substance Abuse and Mental Health Services Administration (SAMSHA) and CDC evidence-based HIV risk reduction interventions for Black males/MSM.

Standard literature review quality control procedures will be used: 1) selection and review of key search terms by logical analysis and by reference to key articles and the keywords included in those articles, 2) independent search by two team members, 3) checking that references cited in key articles have been obtained, 4) development of data quality inclusion criteria (e.g., clinical or service experience, research design quality) and 5) hand-search of selected years of key journals to ensure there have not been omissions in the electronic search. The literature will be summarized by narrative meta-analytic techniques, that is a table of empirically-supported or clinically-observed strategies and their relationship (+,0,-) to protective, neutral or risk-enhancing outcomes.

Analysis of core elements of existing evidence-based interventions will be conducted by thematic content analyses of intervention descriptions by two team members with conflicts resolved by the third.

Phase One Key Informant and Service Provider Interviews

Inclusion Criteria for Phase One. Qualitative data will be collected via individual interviews, roundtable discussions, and focus groups with people who meet the following categorical criteria:

  1. Individual interviewees – key informants who are seronegative non-IDU Black MSM
  2. Roundtable discussants – with social service providers at two national HIV prevention conferences (US Conference on AIDS and HIV Prevention Leadership Conference) with expert knowledge, professional perceptions of, and assumptions about, the protective factors that help their non-IDU Black MSM clients/consumers maintain seronegativity
  3. Focus group participants (two groups) – (group #1) New York City-based social service providers and (group #2) social service providers recruited at the NAESM Black MSM Conference

Recruitment Phase One.

Key Informants. The research team will endeavor to have a diverse sampling of four non-IDU seronegative MSM representing different socioeconomic statuses, age groups (21-29, 30-39 and 40 and over), educational experience, and styles of socializing, who are central in large Black MSM networks.