Outreach,Care,and Prevention to Engage HIV Seropositive Young Men of Color Who Have Sex with Men: A Special Project of National Significance Program Initiative

T imely entry into HIV care post-diagnosis has a number of benefits, including decreased morbidity, mortality, and infectiousness, ¹ as well as exposure to secondary prevention through clinical interventions. ² In 2000, analyses of data from the HIV Cost and Services Utilization Study found that after testing positive for HIV, African-Americans and Latinos experienced longer delays in receiving treatment than whites. ^3,4 Young men who have sex with men may face even greater challenges in getting the treatment they need, due to limited employment, poverty, lack of insurance, and HIV and sexual minority stigmas. Moreover, little is known about the clinical treatment experiences of YMSM, especially with regard to medication adherence and retention in care.

Among the exposure categories recognized by the Centers of Disease Control and Prevention (CDC), men who have sex with men (MSM) has had the highest numbers throughout the history of the HIV/AIDS epidemic in the U.S. ⁵ By 1998, the racial and ethnic demography of MSMs in the HIV/AIDS epidemic changed from majority white to nonwhite. ⁶ From 1994 to 2000, the CDC conducted a study of young men who have sex with men (YMSMs) in seven cities (Baltimore, MD; Dallas, TX; Los Angeles, CA; Miami, FL; New York, NY; San Francisco, CA; and Seattle, WA). The Young Men's Survey found high levels of HIV prevalence among YMSMs, especially those of color. ⁷ Overall HIV seroprevalance was 7%, but compared to white YMSMs, blacks were almost 5 times as likely to test seropositive as white YMSMs. Young multiracial men were four times and Latinos twice as likely to test HIV seropositive as their white peers. Only 18% of the YMSMs who tested HIV seropositive were aware of their infection before being tested, with just 7% of African-American YMSMs aware of their HIV seropositivity before receiving confirmatory test results. Among all HIV seropositive YMSMs, just 15% were receiving medical care for their HIV disease. ^8,9

Young MSM face many challenges in learning their HIV status, accessing treatment, remaining in care, and maintaining risk reduction behavioral changes. These challenges have included historically poor access to care, lack of experience with and negative perceptions of the health care system, unorthodox self-perceptions of sexual orientation, and HIV and sexual minority stigmas. All of these factors have made it difficult to assess their risks and to help them adopt protective behaviors.

In a national roundtable discussion sponsored by the Health Resources and Services Administration (HRSA) in 2000 to understand the epidemic among minority MSM populations, participants emphasized the role played by stigma in keeping people out of care. ¹⁰ Roundtable participants included individuals from the African American AIDS Policy and Training Institute; the Asian and Pacific Islander Health Forum; Bienestar; and the National Native American AIDS Prevention Center; as well as consumers and other individuals representing a wide range of perspectives. They stated that MSM fear condemnation from their families, their communities, and from service providers in a world where many view same-sex sexual activity as outside the “mainstream.” Additionally, roundtable participants noted that minority MSM are less likely than their white counterparts to identify as gay or bisexual.

In 2004, HRSA's HIV/AIDS Bureau (HAB) responded to these data by requesting applications for a new initiative to fund innovative demonstration projects focusing on HIV-positive YMSM of color through its Special Project of National Significance (SPNS) Program. The SPNS Outreach, Care, and Prevention to Engage HIV Seropositive Young MSM of Color initiative sought to identify model interventions for reaching, linking, and engaging young MSM of color in HIV/AIDS medical care and prevention services. The SPNS program recognized that a single approach could not be developed to ensure that HIV-seropositive YMSM of color are linked to and engaged in care, and provided with appropriate HIV prevention and risk reduction services. A combination of interventions would be required to address successfully the service needs of YMSM.

Earlier SPNS projects focusing on adolescents documented multiple insights in reaching out to high risk negative- and HIV-seropositive youth, including providing an array of needed services, communicating in a youth-sensitive manner, targeting recruitment, and tailoring services to meet their unique needs. ¹¹ The YMSM of Color initiative demonstration sites proposed to implement an array of services to include outreach, education, care, and prevention. However, throughout the course of the 5-year study, these services at times overlapped and formed a continuum of services addressing the needs of the initiative's participants. Additionally, these service areas took on varying degrees of importance with different initiative participants at different points in time.

The specific goals of the SPNS YMSM of color initiative were three-fold: (1) to conduct outreach to assist seropositive individuals learn their HIV status; (2) to link HIV-infected persons with medical care; and (3) to prevent transmission of HIV infection from targeted clients. Eight demonstration sites were selected to implement and evaluate innovative models for addressing the specific needs of the target population in their individual service delivery area. The demonstration sites included four community-based organizations serving YMSM of color, two public health departments, and two university-run programs. These grantees were AIDS Project East Bay (Oakland, CA); Bronx AIDS Services (Bronx, NY); Harris County Department of Public Health and Environmental Services (Houston, TX); Los Angeles County Department of Health Services (Los Angeles, CA); Men of Color Health Awareness Project (Rochester, NY); University of North Carolina at Chapel Hill, Department of Medicine, Division of Infectious Diseases (Chapel Hill, NC); Wayne State University Department of Pediatrics (Detroit, MI); and Working for Togetherness (Chicago, IL). Additionally, an evaluation and technical assistance center coordinated a multi-site evaluation of the models' effectiveness in reaching and engaging HIV seropositive YMSM of color in clinical, supportive, and preventive services. The Youth Evaluation Services (YES) Center of George Washington University School of Public Health and Health Services provided the demonstration sites with an array of program implementation and evaluation technical assistance over the course of the initiative.

In this special supplemental issue of AIDS Patient Care and STDs, the SPNS YMSM of Color Initiative Study Group presents its findings to further the understanding of the YMSM of color population and the unique challenges faced by the participants. It is hoped that these findings will lead to the adoption by other Ryan White HIV/AIDS Program grantees of the innovative interventions described herein. The successful replication of these models of care should lead to improved access to and retention in care, as well as the improved overall health, of YMSM color living with HIV infection.