Real-World Strategies to Engage and Retain Racial–Ethnic Minority Young Men Who Have Sex with Men in HIV Prevention Services

Abstract

Racial/ethnic minority young men who have sex with men (YMSM)—particularly African Americans and Hispanics/Latinos—are at particularly high risk for HIV infection. Devising strategies to improve engagement and retention in HIV prevention services among minority YMSM is critical if the United States is going to achieve the National HIV/AIDS Strategy goal of reducing HIV health-related disparities. This article presents findings from a national summit on racial/ethnic YMSM services convened by the Substance Abuse and Mental Health Services Administration-funded Center of Excellence on Racial and Ethnic Minority Young Men Who Have Sex with Men and Other Lesbian, Gay, Bisexual, and Transgender Populations (YMSM + LGBT CoE) in September 2015. The summit included (1) subgroup discussions focused on issues related to treatment access, outreach/engagement/retention, continuing care/recovery support, and health literacy for minority YMSM; and (2) a ranking process, where the NIATx Nominal Group Technique was used to identify the strategies and approaches that summit participants believed to be most promising for engaging and retaining minority YMSM in HIV prevention services. Analyses of results from summit activities highlight four key cross-cutting strategies—utilizing peers, providing holistic care, making services fun, and utilizing technology—as critical for engaging minority YMSM in HIV prevention care. Examples of programs that utilize these strategies and implications of these findings for policy and practice are discussed.

Introduction

Among adolescents and young adults in the United States (US), rates of HIV infection are significantly higher for males than females,¹ and male-to-male sexual contact accounts for the vast majority of HIV infections.¹ Due to issues related to sexual risk behavior, mental health, substance use, stigma, discrimination, and victimization, young men who have sex with men (YMSM) have particularly high rates of HIV infection.^{2

–10}

For racial and ethnic minority YMSM, these challenges are even more profound. YMSM of color are at increased risk for negative health outcomes due to poverty, racism, limited health insurance, low health literacy, limited familiarity with HIV prevention techniques, and socioeconomic problems.^10

–16 Further, minority YMSM often face discrimination from both racial/ethnic communities (homophobia) and from the LGBT community (racism).^17

–22 Adolescent Hispanic/Latinos and African American adolescents and young adults are at significantly higher risk for contracting HIV infection than non-Hispanic/Latino white adolescents and young adults.¹ Thus, devising strategies to limit the spread of HIV among Hispanic/Latino and African American YMSM is critical for public health and essential if the US is going to achieve the National HIV/AIDS Strategy goal of reducing HIV-health related disparities.^23,24

Enhancing the delivery of effective prevention services—such as HIV testing, linkage to care, antiretroviral therapy, access to condoms and sterile syringes, behavioral interventions, and screening for sexually transmitted infections²⁵—for racial/ethnic minority YMSM will be critical to addressing the high rates of HIV infection among these populations. Yet, despite pressing need,²⁶ there are few documented evidence-based HIV-related interventions for racial/ethnic minority YMSM.^27

–33 Although minority YMSM have significant strengths and high levels of resilience, providers nonetheless have significant challenges promoting sexual health and limiting HIV risk for these populations.^34,35 In this article, we present results from a national convening of treatment providers with experience using innovative approaches to engage and retain minority YMSM in HIV prevention services. Summit findings highlighted strategies that many of the most experienced and innovative providers across the country find to be most promising in engaging and retaining minority YMSM in HIV preventive care and provide insights on other services that providers across the country can use when working with minority YMSM clients.

Methods

In September 2015, the Substance Abuse and Mental Health Services Administration-funded Center of Excellence on Racial and Ethnic Minority Young Men Who Have Sex with Men and Other Lesbian, Gay, Bisexual, and Transgender Populations (YMSM + LGBT CoE) convened a 2-day National YMSM Provider Summit in Hollywood, California. Individuals who work in programs that specialize in the delivery of mental health, substance use disorder, and HIV services were invited to apply to participate in the summit through advertisements on the YMSM + LGBT CoE website, listservs linked with the YMSM + LGBT CoE, and contacts of the YMSM + LGBT CoE National Advisory Board members. Through their activities working with LGBT service providers across the US, the YMSM + LGBT CoE and its Advisory Board members are well connected to many of the most experienced and innovative HIV service providers in the nation.

To be considered for the conference, applicants were required to provide a 250-word description of their experience serving at-risk YMSM populations and the innovative work they were doing with these groups. Fifty-four individuals applied to attend the summit, and YMSM + LGBT CoE staff ranked applicants based on their experience and their program's level of innovation, resulting in a composite score. YMSM + LGBT CoE staff then selected 34 individuals with the highest composite scores to attend the summit, ensuring that programs from all parts of the country would be well represented. Twenty-seven of the 34 invitees attended the summit. Four other individuals—two YMSM living in the Los Angeles area, one LGBT service provider in the Los Angeles area, and one expert in YMSM services from a Los Angeles area university—also attended the summit. In total, 31 individuals participated in the summit.

Summit activities and procedures are illustrated in Fig. 1.

FIG. 1.

Summit activities and procedures.

On the first day of the summit, participants broke into four subgroups, each of which discussed four preselected domains related to engaging and retaining minority YMSM in HIV preventive care: (1) access to services; (2) outreach, engagement, and retention; (3) continuing care and recovery support, and (4) health literacy.

On the second day of the summit, each of the subgroups reported their discussions to the larger group. Summit facilitators then utilized the NIATx Nominal Group Technique (NGT) process³⁶ to (1) record ideas and strategies that were presented; (2) discuss ideas and strategies that were presented; (3) engage in an initial round of voting to rank strategies based on perceived importance and utility; (4) facilitate discussion of the preliminary voting results; and (5) conduct final voting on which strategies are most promising ways to engage and retain minority YMSM in HIV prevention services. Subsequently, the research team conducted a content analysis³⁷ of the results from the NGT process to identify the strategies and approaches that summit participants reported to be most promising in each of the four domains—access to services, outreach/engagement/retention, continuing care/recovery support, and health literacy—as they related to engaging and retaining minority YMSM clients in HIV prevention services.

Results

Participant characteristics

See Table 1 for a description of the programs represented at the summit and participant characteristics.

Table 1.

Young Men Who Have Sex with Men Summit Participant Characteristics (N = 31)

Gender, n (%)
Male	20 (65.0)
Female	10 (32.0)
Transgender	1 (3.0)
Race/ethnicity, n (%)
White	9 (29.0)
African American	14 (45.0)
Asian	1 (3.0)
Hispanic/Latino	7 (23.0)
Education level, n (%)
Associate's degree	2 (6.5)
Bachelor's degree	14 (45.0)
Master's degree	13 (42.0)
Doctorate or equivalent	2 (6.5)
Region, n (%)
Northeast	10 (32.0)
South	8 (26.0)
Midwest	4 (13.0)
West	9 (29.0)
Type of program, n (%)
Community Health Program	4 (13.0)
Addiction Treatment Program	3 (10.0)
Criminal Justice	2 (6.0)
University	4 (13.0)
HIV/AIDS Services	5 (16.0)
Health Department/Government	3 (10.0)
LGBT Center/Agency	7 (23.0)
Hospital	2 (6.0)
Nonprofit Agency	1 (3.0)

Subgroup discussions

In subgroup discussions of the four domains, 25 strategies to enhance engagement and retention of minority YMSM in preventive HIV services emerged. As detailed in Table 2, subgroup discussions highlighted six strategies and approaches in the access to service domain, seven strategies and approaches in the outreach/engagement/retention domain, seven strategies and approaches in the continuing care/recovery support domain, and five strategies and approaches in the health literacy domain. Some strategies and approaches—including the use of peers, making services fun and welcoming, utilizing technology, and providing holistic care—emerged from discussions in several of the domains.

Table 2.

Full List of Strategies and Approaches from Subgroup Discussions

Domain	Strategies and approaches
Access to services	• Encourage participation with peers
	• Establish a welcoming environment
	• Make it fun and empower clients
	• Colocate, integrate, and coordinate care across organizations that are knowledgeable about and sensitive to YMSM issues
	• Develop a network to share resources with other organizations and maximize the impact of YMSM services available in the community
	• Utilize social media and technology to engage and educate YMSM
	• Be a resource and make the experience enjoyable
	• Create a safe culture
Outreach/engagement/retention	• Use social media
	• Involve and utilize community knowledge and resources
	• Be aware of service fatigue
	• Vary messages
	• Use incentives to encourage participation
	• Create safe spaces that have a youthful look and feel
Continuing care/recovery support	• Active peer participation
	• Assess and meet basic needs
	• Support transition to adulthood
	• Help build life skills
	• Assure that workforce is trained on issues related to race, ethnic, ageism, sexism, gender identity, and sexual orientation
	• Assure staff commitment to working with YMSM
	• Technology
Health literacy	• Peer involvement in creating content
	• Edutainment (blending education and entertainment)
	• Use plain language to communicate
	• Repeat key messages

YMSM, young men who have sex with men.

Nominal group technique process results

At the conclusion of the Nominal Group Technique process, summit participants identified three strategies that they considered most promising in engaging and retaining YMSM clients for HIV prevention services in each domain.

Access to services

1. Encouraging participation with peers (22 votes): Participants voted the use of racial/ethnic minority YMSM peers to be the most effective tool to increase access to and utilization of HIV prevention services. Participants reported that peers are particularly valuable since they have experiences that can be used to tailor services to meet the needs of local minority YMSM populations. In addition, peers often have connections within neighborhoods where minority YMSM live and can serve as well-respected representatives of treatment agencies within otherwise hard-to-reach communities. As public faces of organizations that serve minority YMSM, peers can both spread awareness and serve as positive role models for individuals who are not yet engaged in treatment, but would benefit from services.

2. Establishing a welcoming environment (20 votes): Providers highlighted the need to ensure that service environments are welcoming for minority YMSM, particularly since many are accustomed to being marginalized due to racism and discrimination. Preparing providers to welcome and serve all individuals—regardless of their gender or racial identity—is critical, as is assuring that staff are familiar with terminology and language that are appropriate for all clients. Further, services need to be culturally responsive as providers can improve engagement and retention if they are willing and able to accommodate the linguistic preferences of prospective clients and provide services that are sensitive to their cultural backgrounds and preferences.

3. Making it fun and empowering (16 votes): As they shared their experiences serving minority YMSM, providers highlighted the centrality of making services enjoyable as a strategy to enhance access and utilization. Offering food and hosting social events in conjunction with HIV testing were mentioned by many participants as a way to bring unengaged youth in to their programs. In addition, providers reported that bringing services out into community locations where minority YMSM normally congregate recreationally (e.g., night clubs, coffee shops, and parks) is an effective way to engage them in initial discussions about health that eventually lead them to present for services. In the course of these interactions, providers also work to make prospective clients feel empowered. By sharing stories of clients who have overcome the challenges they face as minority YMSM, providers reported that they are able to motivate prospective clients to initiate services.

Outreach, engagement, and retention

1. Being a resource and making treatment enjoyable (26 votes): Participants highlighted that being a resource that can help with a variety of needs, both health and nonhealth related, is critical to engage and retain minority YMSM in services. By holistically addressing client needs related to housing, poverty, hunger, and relationships from the outset of treatment, providers can engage new clients by addressing their basic needs beyond those related to behavioral and sexual health. In addition, participants reported that making services enjoyable is essential to engaging and retaining new clients in treatment. Many discussants mentioned having entertainment and games as ways to engage clients or blending humor with educational materials to disseminate health information in a more engaging manner. To ensure that events are appealing, participants highlighted the importance of having minority YMSM themselves—either peer providers or clients—come up with ideas for outreach and engagement activities.

2. Creating a safe culture (24 votes): Discussions revealed that many minority YMSM have significant difficulties with their families and loved ones. Because of this, they may be reluctant to show vulnerability or to share feelings that make them uncomfortable or ashamed. By tailoring services to foster a sense of belonging and making minority YMSM feel safe, participants reported that they help clients feel more at ease and willing to share their experiences when they come in for treatment.

3. Using social media (13 votes): Summit participants highlighted the utility of social media—particularly Twitter and Facebook—in conducting outreach and engagement for minority YMSM. By using social media to provide prevention and treatment information, remind clients about appointments, and engage them in chat groups focused on health and well-being, providers reported that they are able to efficiently and effectively enhance services while keeping their clients engaged in care.

Continuing care and recovery support

1. Peer participation (21 votes): Participants emphasized that having peers heavily involved in the delivery of services is key to assuring that minority YMSM utilize continuing care and recovery supports. Incorporating peers into service delivery can improve the cultural responsiveness of services by ensuring that minority YMSM are served by individuals with similar life experiences who have faced similar challenges. In addition, peers can incorporate their knowledge of minority YMSM preferences and culture into service planning to make treatment as appealing as possible for minority YMSM clients.

2. Creating safe and appealing spaces (19 votes): Participants agreed that delivering services in spaces that feel both safe and appealing is critical for retaining minority YMSM in continuing care and recovery support services. YMSM often feel alienated from their communities, and having physical environments and décor that are both comforting and appealing can help clients feel more at ease and willing to discuss sensitive issues. Taking steps to make service settings feel less like clinical spaces and more like places where YMSM would want to spend time can mitigate some of the reluctance youth have about receiving services.

3. Meeting basic needs (15 votes): Participants reported that providing holistic person-centered care in addition to services that focus on sexual health is critical for engaging minority YMSM in continuing care and recovery supports. Minority YMSM often face pressing challenges related to housing, economic, and legal issues, and providers sometimes need to prioritize these needs over other health-related services to keep them coming in for services.

Health literacy

1. Technology (26 votes): Summit participants agreed that technology and social media are critical for enhancing health literacy of minority YMSM. Since many minority YMSM grew up in the digital age, they may be more comfortable discussing personal topics related to sexual health online than in person. In particular, participants mentioned that many of their clients prefer getting health information from blogs, websites, and social media rather than from healthcare providers. Moreover, participants emphasized that any use of technology needs to be usable on smartphones since many minority YMSM rely on mobile phones exclusively for Internet and social media access.

2. Peer involvement (21 votes): Participants agreed that minority YMSM are more receptive to health education messages when they are delivered through peers. They reported that clients are less likely to feel judged when receiving messages about sexual health from peers instead of health professionals and that they are more likely to feel a sense of ownership over information they receive from people they know have had similar life experiences.

3. Edutainment (13 votes): Summit participants believed that health information for minority YMSM needs to be both educational and entertaining. Such edutainment, as one participant termed it, communicates health information through games or other forms of entertainment, such as web series or comic strips. Similarly, events that blend recreation, humor, and educational messages can simultaneously educate clients while also facilitating their engagement with treatment.

Cross-cutting strategies

Across topic areas, there was significant overlap in strategies that participants found to be most promising. The four cross-cutting strategies identified in subgroup discussions and the NGT process in more than one domain were as follows:

1. Peer services: Involving racial/ethnic minority YMSM with personal experience receiving services is critical. Peers can serve as positive role models for minority YMSM, help fight stigma by representing YMSM populations and service programs in the community, and make invaluable contributions to treatment by bringing client perspectives to programming and services.

2. Holistic care: Although minority YMSM have service needs related to behavioral and sexual health, they often face a variety of legal and socioeconomic challenges. By making care holistic and designing it to help YMSM address all of their life challenges, providers can better engage minority YMSM in treatment.

3. Fun: To engage racial/ethnic minority YMSM in treatment, it is important to make services enjoyable. Continually devising creative strategies to make services novel and appealing is critical.

4. Technology: Many YMSM are highly proficient in technology, and services need to include digital platforms—particularly social media—since they are major sources of health information for youth. Although some clients may not have access to smartphones or computers, it is nonetheless critical to integrate technology into client engagement and retention activities.

Program examples

To illustrate how these strategies and approaches have been utilized in real-world programs, below are descriptions of programs run by summit participants who have incorporated peer services, holistic care, fun, and technology into their efforts to engage and retain minority YMSM in HIV care.

1. Peer services: KC Care Clinic (Kansas City, MO): At the KC Care Clinic, peer educators operate as integral members of healthcare teams that provide services for clients living with HIV. Peer educators provide clients with information about HIV; how to communicate with doctors and service providers; how to understand laboratory test results; issues surrounding medication resistance and adherence; medications; managing side effects; safe sex; exercise; and nutrition. In addition, peers provide clients with links to community resources, hope, personal support, self-management strategies, and options to support medication adherence. Having personally experienced HIV treatment, they have a strong understanding of barriers to HIV treatment and medication adherence, as well as strategies that can be helpful in overcoming these barriers. Peer services are targeted to reach clients who are preparing to start HIV medications, individuals changing HIV medication regimens, pregnant women who are diagnosed with HIV, clients who struggle keeping medical appointments, and persons who would like to improve their relationships with their healthcare team.

2. Fun: Trillium Health (Rochester, NY): Trillium Health has devised several creative programs to engage YMSM in their community. It has established Vogue Nights, where part of the clinic space is opened to be used as practice space for young men interested in dancing. These nights serve a dual purpose as they give local YMSM an opportunity to meet other YMSM in a safe community-oriented space while also giving them a chance to see the clinic and learn about the services it offers. In addition, Trillium is beginning to develop open mic nights at a local gay-friendly coffee shop and panel discussions that bring in community members to discuss health-related and other issues of interest to local racial/ethnic minority YMSM.

3. Holistic care: Hetrick-Martin Institute (New York, NY): The Hetrick-Martin Institute provides HIV services for YMSM and other LGBTQ populations within a comprehensive set of services where youth can obtain support with housing, mental health, academic enrichment, job readiness, and other services that support clients' development and success. Services are designed to provide a system of support to help clients achieve milestones appropriate to their development by creating a supportive environment and improving systems of support available to YMSM.

4. Technology: Warren-Vance Community Health Center (Henderson, NC): The Warren-Vance Community Health Center integrates multiple social media tools into the services it provides for clients living with HIV to maintain a healthy relationship with clients; aid in care, retention, and compliance; keep the clinic up to date with the communication tools used by youth; and have backup contact information when traditional methods fail. Case managers use social media as retention tools, utilizing Facebook and Facebook Messenger to communicate with clients who do not have a working phone, contact clients regarding logistical issues (e.g., transportation, clinic closures, appointment reminders), and search for clients who have fallen out of care. The clinic also uses Glide (a smartphone app that allows for video and text messaging) to help maintain relationships with clients, review client needs in real time, send text messages regarding medical appointments, and keep clients engaged in care by staying in contact. They also utilize Voxer, a smartphone app that allows phones to operate as walkie–talkies, to send and receive quick voice messages and give clients a way to get in contact with providers quickly. Another interactive app, Care4Today, is used to help clients track their medication adherence and also allows case managers to monitor and encourage clients to stay on schedule with their medications. Warren-Vance also has a Facebook page for clients to ask questions, learn, and share their experiences with HIV and HIV treatment with their peers.

Conclusions

Summit discussions highlighted promising strategies and approaches that some of the most experienced and innovative providers in the nation have found helpful in their efforts to engage and retain racial/ethnic minority YMSM in HIV services. By incorporating peers, holistic care, fun, and technology into the array of outreach, treatment, continuing care, and recovery services they deliver, providers may be able to address the significant challenge of engaging and retaining African American and Hispanic/Latino YMSM in HIV services. These strategies are currently being utilized in many programs across the US and are also integral components of the interventions that have proven effective at improving engagement and reducing HIV-related risk among minority YMSM.^27

–33 Thus, summit discussions, while generating knowledge about practices that providers find effective when serving minority YMSM, also underscore the importance of specific strategies and approaches that are key elements of the few evidence-based HIV-related interventions for minority YMSM.^27

–33 They also highlight the need to educate minority YMSM about HIV prevention and provide minority YMSM with support when they utilize HIV-related services, as has been reported in recent research.^15,16,38

It should be noted that a limitation of these findings is that they are strategies and approaches that providers themselves reported to be promising and their effectiveness is not empirically supported by any evidence or data collected by participating agencies. Further research is needed to determine if outcomes and data support providers' beliefs that these practices are effective at enhancing the engagement and retention of minority YMSM in HIV prevention services.

Nonetheless, the fact that these strategies emerged from a systematic process for elucidating perspectives of some of the most experienced and innovative programs in the nation, study findings point to potential directions both for research and for future HIV prevention program development. By blending these strategies with more traditional interventions to address sexual and behavioral health, providers may be able to take a major step toward better engaging and retaining minority YMSM in HIV services and addressing the glaring disparities in HIV transmission for these historically underserved high-risk populations.

Footnotes

Acknowledgments

This article was written with support from the Substance Abuse and Mental Health Services Administration's Center of Excellence on Racial and Ethnic Minority Young Men Who Have Sex with Men and Other Lesbian, Gay, Bisexual, and Transgender Populations (YMSM + LGBT CoE), Center for Substance Abuse Treatment Grant 5UR1-T102442-S1. The authors wish to acknowledge Michael Chaple, PhD, and Paul Warren, LMSW, from NDRI-USA, Anne Helene Skinstad, PhD, Lena Thompson, MPH, Matt Ignacio, MSSW, and ThankGod C. Ugwumba, BS, from the University of Iowa, and Charlotte Bullen, MHA, Maria Castro, BS, Albert Hasson, MSW, Grant Hovic, MA, Andrew S. Kurtz, MFT, and Jessica Sinks, BS, from Integrated Substance Abuse Programs, University of California, Los Angeles.

Author Disclosure Statement

No competing financial interests exist.

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