A range of approaches can be used to address barriers to support Black men who have sex with men (MSM) along the HIV continuum of care, according to a review of US interventions. All 14 interventions reviewed were associated with at least one statistically significant outcome on linkage to care, retention in care, medication adherence, and/or viral suppression.
Most interventions were delivered on an individual and/or interpersonal level; however, three also made system-level changes. Many harnessed social media, texts, apps, or other technologies. Notably missing were interventions focusing on behaviourial health or social determinants of health such as housing.
Black MSM in the United States face individual and structural bias, stigma, discrimination, and racism for multiple aspects of their identity. They experience inequities in housing, income, employment, education, involvement in the justice system, and exposure to community violence, among other things.
Despite engaging in behaviours that pose a risk for HIV at equal or lower rates, Black MSM are 72 times more likely to be diagnosed with HIV compared to the general population. Those who are living with HIV experience disparities along the continuum of care, including lower rates of viral suppression.
This review published in the December issue of The Lancet HIV aims to accelerate the adoption and expansion of public health interventions that improve outcomes along the HIV continuum of care for Black MSM. It was led by Hilary Goldhammer of the Fenway Institute, a health and research institute in Boston that serves gender and sexual minorities and those living with HIV.
Building upon a 2013 review of HIV interventions focusing on Black MSM, researchers searched for peer-reviewed original research published between 2013 and 2020. Eligible studies had quantitative outcomes related to HIV linkage to care, care engagement and retention, medication adherence, and/or viral suppression in the US.
To be included, the study population had to be at least 50% Black MSM, or other men who have sex with men. In cases where demographics were reported separately, the sample need to be at least 50% Black and 50% MSM, or at least 75% male, 50% Black, and 50% gay or bisexual.
Fourteen interventions were included. Ten included sites in the US South and eight focused on MSM under the age of 34. This profile aligns with the overall demographics of the HIV epidemic among Black MSM.
Most interventions (n = 10) took a multi-faceted approach by aiming to impact multiple outcomes along the HIV care continuum. The most common outcome of interest was medication adherence (n = 10), and the least common was linkage to care (n = 3). Typically, there are larger race-related disparities in adherence, retention and viral suppression than linkage to care among MSM.
Level of intervention
Interventions can focus improving health outcomes using an interpersonal, individual, or systemic approach, or a combination. The interpersonal level often focuses on social support to address barriers such as anticipated or enacted stigma. Individual interventions address personal factors such as denial of status or poor understanding of HIV. Systems interventions focus on things like inconvenient clinic hours and location, or lack of coordination between providers within a system.
Of the 14 interventions, half focused on one level – five individual, one interpersonal, and one system. The rest were multi-level interventions – five included interpersonal and individual strategies, and two focused on systems and the individual-level.
Intervention spotlight: Project Identify, Navigate, Connect, Access, Retain, and Evaluate (IN-CARE) is a multi-level intervention in Chicago focused on linking out-of-care MSM living with HIV into care. Systemic factors were addressed first through intensive case finding, outreach, and strengthening referral partnerships. Once enrolled in care, the individual-level barriers were addressed through six to nine months of peer health navigation, peer-led group education focused on retention, and access to primary care, laboratory services, and medication.
At follow-up (either 6 or 12 months depending on how long they were enrolled in the study), linkage to care for Black MSM in the study increased from 0% to 90%, and retention increased from 0% to 73%. Forty-seven per cent of Black MSM in the study achieved viral suppression, which was 44% at baseline for all participants.
Only two of the interventions were developed exclusively for Black MSM living with HIV, although all the interventions used strategies known to minimise barriers to optimal HIV outcomes for this population. These included curricula addressing factors like racism and medical mistrust, and social support to counteract marginalisation stemming from structural discrimination.
Interventions used a range of strategies to increase cultural appeal, responsiveness, and relevance. Many sought input from Black MSM during intervention design, and several reported that engagement continued during implementation and monitoring. For example, a video intervention used actors reflective of the intended audience, and the script was reviewed by people living with HIV.
Three interventions relied on peers to deliver education, social support, or counselling. Peers were always living with HIV and most, but not all, were also Black gay and/or bisexual men.
Intervention spotlight: My Personal Health Guide is an interpersonal and individual-level intervention in Chicago developed for Black MSM living with HIV aged 18-34. A smartphone app used a customisable avatar of a Black man to provide social support, motivational statements, and education to improve medication adherence. The app also had reminder alerts, adherence monitoring, and tracking of side-effects. A series of iterative focus groups with young Black MSM influenced the app features, graphics, language choices, avatar appearance, and customisation options.
The small pilot study lost 25% of participants to follow up. However, those who did use the app liked it and found it valuable. At three months, medication adherence improved from 59% to 88% (p = 0.10) among participants who had pill count data and confirmed app usage.
Six interventions used technology, such as the internet, social media, text messages, virtual reality, video interventions, and/or smartphone apps to reach and engage Black MSM. Technology-based interventions were largely acceptable and effective, particularly in regard to medication adherence. However, lost or stolen phones, changing phone numbers, and application compatibility posed feasibility challenges.
Intervention spotlight: weCare is an interpersonal and individual-level intervention in North Carolina that trains a peer health educator to message young MSM and transgender women through existing social media apps. The health educator answers questions, offers social support, uses theory-informed scripted messages to promote health behaviours, sends reminders, and offers guidance on navigating the HIV healthcare system.
At twelve months, missed appointments decreased from 68% to 53% among participants (p = 0.04) and viral suppression increased from 61% to 89% (p = 0.0001).
On the horizon
To get a sense of what interventions for Black MSM are coming down the pipeline, researchers also looked at pilot studies, published research protocols, and formative data which met the eligibility criteria for inclusion. Encouragingly, half of the upcoming interventions were developed specifically for Black MSM and all used methods to increase cultural relevance.
Many upcoming interventions used similar strategies to those that were reviewed. Two focus on increasing existing assets and internal coping, motivation, and autonomy. Research shows social services and interventions can promote the intrinsic resilience shared by Black MSM. If these interventions are successful, it may pave the way for more resilience-based interventions.
The types of studies and sample sizes suggest that results may be generalisable to other populations of Black MSM living with HIV. Most studies occurred in clinics or community-based organisations, so these findings may be particularly valuable to organisations with similar resources and populations of focus.
However, the review authors did not evaluate study methodology, and therefore did not assess the quality of evidence. Most studies had follow-up periods of only six to twelve months, making it impossible to know whether benefits from the interventions would continue over time and possibly leading to underestimation of the effects of system-level interventions which can take longer to yield measurable change.
The review highlighted many promising interventions, yet notable gaps remain, particularly interventions focusing on things like mental health, substance use, and housing. Rather than waiting for a traditional evidence base, the authors urge public health providers to find new and emerging interventions and assess their effectiveness in real-world settings using an implementation science approach.
This approach allows for evaluating clinical outcomes while simultaneously assessing barriers and facilitators to integration and uptake of the intervention. The authors also recommend using a mix of qualitative and quantitative methods to better understand the mechanisms that drive the effects of interventions and the impact of the local setting.
Eliminating disparities and ensuring equitable access to care and treatment is essential to ending the HIV epidemic. The authors urge public health providers to continue to identify, pilot, evaluate, and scale up interventions to improve health outcomes along the HIV continuum of care among Black MSM living with HIV.
Goldhammer H et al. HIV care continuum interventions for Black men who have sex with men in the USA. The Lancet HIV 8: e776-e786, 2021.
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