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HIV prevalence and incidence rates have reached catastrophic levels among Young black Men who have sex with Men (YBMSM), ages 18-29. The goal of this project is to determine the efficacy of a Multilevel, theory- based Intervention, calld United Black Element (UBE), in reducing YBMSM's sexual risk behavior and increasing the frequency of HIV testing. Although based on the Mpowerment Project, a cost-effective HIV Prevention Intervention that has been shown to be efficacious in reducing the rate of unprotected sex among Young MSM, UBE has been extensively adapted to the socioeconomic, cultural, and social context of YBMSM's lives. Through the Development of an empowered, mobilized YBMSM community, UBE creates positive social norms around HIV Prevention that are diffused throughout diverse social networks. We began work to launch and begin testing the efficacy of UBE in Dallas and Houston, TX with CDC funding; Dallas was randomized to the Intervention condition. Large cities were chosen since that is where the majority of YBMSM reside, and testing a community mobilization approach in such a setting is critical in considering how to translate it to practice. It took longer than anticipated to fully implement UBE because of community capacity issues, but UBE is now fully implemented and is reaching into diverse social networks of Dallas YBMSM. The CDC funding that supported the Intervention and baseline assessments has ended, and the Texas State Health Department is now funding UBE at a local organization with which we are collaborating. In the proposed mixed methods project, we have an extraordinary opportunity to study the impact of this Intervention without having to start up or cover the costs of the Intervention. Thus, the aims of this mixed methods project are to: 1) Analyze public health data and conduct 3 additional annual cross-sectional Surveys of YBMSM in Dallas and Houston using venue-based sampling to determine the efficacy of UBE in: (a) reducing unprotected anal sex; (b) increasing recent HIV testing; (c) modifying psychosocial mediating variables that may be causally related to HIV risk reduction; and (d) changing psychosocial factors related to positive mental health and wellbeing; 2) Determine how community changes occur during implementation of UBE by examining when changes in the psychosocial mediating variables, sexual risk behavior and HIV testing take place and if changes in sexual risk behavior and testing continue to improve, remain the same, or decrease over time; 3) Explore how UBE penetrates diverse YBMSM subcommunities in Dallas, and how this Multilevel Intervention impacts individual, interpersonal, and social level factors related t risk behavior and testing. Using ethnography, we will follow a longitudinal cohort while the Intervention is being fully implemented. 4) Examine the potential integration of biomedical HIV Prevention methods into UBE through administering and analyzing quantitative data from the survey and qualitative data from the interviews.

In California and locally in Alameda County, HIV disproportionately impacts African American and Latino men who have sex with men (MSM). This study will develop and test an innovative strategy to identify MSM who are unaware of their status, have them test for HIV and for those that are positive, link them to HIV care and services. The proposed intervention will have MSM, called “seeds,” reach out to their social networks and recruit their peers to take an HIV test using a self-test kit. Seeds will be trained to deliver prevention messages that encourage their friends and peers who are at risk for HIV to take the HIV self-test. The seeds provide support through the testing process and if the peer is found to be positive, they will assist in linking the peer to HIV care and services. The use of the self-test kit has the potential to overcome many of the structural barriers to testing, such as stigma, discrimination, homophobia, privacy concerns, lack of access to care, mistrust of medical providers and wait times in clinical settings. This intervention strategy also has the potential to reach young MSM who don’t normally test, by accessing this hard-to-reach population in a place where testing can occur immediately and the men are in control of the process. The study aims to examine how well the proposed intervention identifies MSM who had been undiagnosed and how well the intervention links HIV positive MSM to care.

As HIV research and prevention efforts increasingly target gay men in relationships, situational factors such as couple serostatus and agreements about sex become central to examinations of risk. Discordant gay couples are of particular interest because the risk of HIV infection is seemingly near-at-hand. Yet, little is known about their sexual behaviors, agreements about sex, and safer sex efforts. The present study utilized longitudinal semi-structured, qualitative interviews to explore these issues among 12 discordant couples. Findings show that nearly every couple had agreements about reducing the likelihood of HIV transmission from one partner to the other. Negotiating these agreements involved establishing a level of acceptable risk, determining condom use, and employing other risk-reduction techniques, such as seropositioning and withdrawal. For half of the couples, these agreements did not involve using condoms; only two couples reported consistent condom use. Despite forgoing condoms, however, none reported seroconversion over the course of data collection. Additional issues are raised where long-term HIV prevention is concerned. Future prevention efforts with discordant couples should work with, rather than fight against, the couple’s decision to use condoms and endeavor to complement and accentuate their other safer sex efforts.

HIV in Lebanon and the Middle East is predominantly among men who have sex with men (MSM), and rates of HIV and sexual risk behavior are on the rise among young MSM (YMSM), driven in part by increased freedom of expression, social tolerance in areas such as Beirut, an influx of migration attributed to MSM refugees coming from war torn Iraq and Syria, and a flourishing sex tourism industry. At a time of political and societa upheaval across MENA, with no substantial HIV prevention programs for MSM anywhere in the region, Lebanon and MENA may be at risk for a critical surge in HIV infection in this vulnerable population. This context presents a great opportunity for an intervention like Mpowerment (MP) to make a critical impact. MP is an evidence-based community-level, structural, social and behavioral HIV prevention intervention developed for YMSM. It combines strategies for individual and community empowerment and mobilization, self-affirmation, sexual self-knowledge, and the creation of supportive social environments for YMSM. It has been widely disseminated in the U.S., but it has never been used in a Muslim-dominant setting;hence, the need for formative research to help us understand how to best tailor MP for this much understudied cultural setting that is not well understood. The gay community in Beirut has grown significantly in recent years with regard to organization, development and advocacy, making it ready to take on and be successful with a community driven intervention like MP. This 5-year project will culturally adapt and pilot MP for YMSM (age 18-29) in Beirut. Phase 1 will involve extensive formative research including innovative peer ethnography and focus groups to better understand the social networks of YMSM and how they communicate about HIV and sexual health with each other, and elicit feedback on how to culturally adapt the MP program for Beirut. In Phase 2 we will pilot specific MP components and adapt the intervention manual. Phase 3 will consist of a 2-year pilot implementation and controlled evaluation of MP to assess intervention effects on community levels of sexual risk behavior and HIV testing. Cohorts of 200 YMSM in each of Beirut and the comparison community of Jounieh will be used to evaluate intervention effects. This study is innovative in being the first implementation and evaluation of any psychosocial sexual health intervention for MSM in all of MENA, and the first study of the social network-driven MP program that will use social network (SN) methodology for evaluating and adapting the intervention. It will have impact by providing pioneering data to broaden the field's understanding of the cultural underpinnings of HIV risk behavior and how to intervene to promote HIV prevention among a highrisk group (YMSM) in a cultural setting in which very little prior work has been done. The goal of this research is to establish an evidence-based model for HIV prevention and sexual health promotion with YMSM in the Middle East and other Muslim-dominant countries.

Project Director/Lead Investigator: Ma Somsouk, MD (UCSF PI); Uri Ladabaum (Stanford Co-PI); Eric Vittinghoff (Co-I); Ellen Chen (Co-I);  Marguerita Lightfoot, PhD (UCSF PRC PI)

Research Findings Summary

This study enrolled more than 9,500 patients - men and women ages 50-75 - from six clinics in the San Francisco Health Network. About half of them received routine care, while the other half were mailed a stool sample test kit called (FIT). The FIT kit is a non-invasive colon cancer screening that checks for blood in the stool as a possible sign of colon cancer. Results show that mailing the FIT kits increased the number of patients who completed the screening from 21% to 49%. Participants who did not speak English, or who had done a FIT test before, were more likely to complete the test. Common barriers to participants returning the FIT kits were forgetting, not understanding, not wanting to test, or other health problems, which may be addressed during follow-up calls. Specific Aim 1: To determine if centralized panel management with mailed fecal immunochemical tests (FIT) outreach improves uptake of CRC screening compared with usual care. In collaboration with primary care providers, we will leverage the EHR system to identify asymptomatic patients not up-to-date with CRC screening. Patients will be randomized 1:1, stratified by clinic and race to mailed FIT outreach versus usual care. The primary outcome will be the difference between groups in completion rates of FIT tests at one-year from randomization. Secondary outcomes include the FIT completion rate 28 days after mailing, reasons for incomplete tests, FIT test positivity, colonoscopy completion rates and pathology findings, and the programmatic efficacy of the delivery model over time on proportion of patients up-to-date with CRC screening. Other outcomes include the CRC-specific mortality, incidence, and stage in those receiving usual care versus mailed FIT. Specific Aim 2: To determine if the mailed outreach program can be used to improve other health maintenance practices. We hypothesize that a centralized panel model program supporting CRC screening could also be used to improve other health maintenance efforts. Among patients appropriate for screening, patients will be randomized to receive information about age-appropriate health maintenance measures (e.g., mammogram, vaccinations). Specific Aim 3: To describe and compare the cost and effectiveness of the centralized panel management for mailed FIT versus usual care. We hypothesize that the administrative cost and utilization of FIT kits will drive cost up, but will be balanced by increased uptake of CRC screening. Adapting previously developed decision analytic models with Markov processes12-18, the cost and effectiveness of mailed FIT outreach versus usual care will be examined. Outcomes reported include implementation and operational cost of the outreach program (e.g., personnel, capital expenditure, and colonoscopy utilization), cost per clinical outcome (e.g., patient screened, cancer diagnosed, quality-adjusted life year), and performance incentives needed to break even.