Pilot evaluation of the Making Employment Needs [MEN] count intervention: addressing behavioral and structural HIV risks in heterosexual black men

Impact of a livelihood intervention on gender roles and relationship power among people with HIV

OBJECTIVE

To evaluate the impact of an agricultural livelihood intervention on gender role conflict and sexual relationship power among people with HIV (PWH) in western Kenya.

DESIGN

Study participants were enrolled in Shamba Maisha , a cluster randomized controlled trial of an agricultural intervention conducted among PWH across 16 health facilities during 2016-2020. Intervention participants received a water pump, seeds, and agricultural and financial training; control participants received standard of HIV care.

METHODS

We assessed men's views on masculinity and gender roles via the validated gender role conflict score (GRCS; range 18-78, higher = greater gender role conflict). We measured gender power imbalances among women via the validated Sexual Relationship Power Scale (SRPS), which combines subscales of relationship control and decision-making dominance (range 1-4, higher = female holds more power). We compared changes over the study period by arm using longitudinal multilevel difference-in-difference linear regression models accounting for clustering of facilities using the intention-to-treat cohort.

RESULTS

We enrolled 720 participants (366 intervention, 354 control); 2-year retention was 94%. Median age was 40 and approximately 55% of participants were female. Among men, after 24-months the decrease in GRCS scores was 4.3 points greater in the intervention than the control arm ( P  < 0.001). Among women, the intervention resulted in 0.25 points greater increase in the SRPS compared to the control arm ( P  < 0.001).

CONCLUSIONS

Shamba Maisha resulted in less gender role conflict in men and greater sexual relationship power for women. Agricultural livelihood interventions may be a powerful tool to improve gender power imbalances, which may subsequently mitigate poverty and food insecurity.

Vil NM, Bond KT, Mitchell JW, Juarez AC, Lambert F, Muheriwa SR, McMahon J. Dimensions of Sexual Health Conversations among U.S. Black Heterosexual Couples

Sexual health communication is an important feature of healthy intimate relationships; however, some couples may avoid discussing difficult matters (e.g., HIV/STI testing, sexual satisfaction) to minimize interpersonal conflict. From October 2018 to May 2019 in New York State, we conducted a multi-method descriptive pilot study to characterize Black heterosexual couples' (N = 28) sexual health conversations. Partners individually completed an online sexual health/relationship survey before engaging in-person for a joint dyadic qualitative in-depth interview. Quantitative descriptive statistics demonstrated that most absolute score differences among couple's preferences for sexual health outcomes, communal coping and sexual relationship power were mainly small, but greatest regarding extra-dyadic sexual behaviors. A qualitative descriptive approach discerned, motivation and norms for sexual health conversations, and communication patterns. Thematic and content analysis revealed two central themes: initiating and sustaining sexual health conversations, and leveraging features of the couples to promote sexual health. Integrated findings indicate that couples possess varied communication patterns that operate with motivations for sexual health conversations toward subsequent sexual health promotion. Equitable and skewed communication patterns emerged as relationship assets that can be leveraged to optimize sexual health. There is also opportunity for future work to address communication regarding extra-dyadic behavior and preferences. Asset-based considerations are discussed.

Effectiveness of employment-based interventions for persons experiencing homelessness: A systematic review

Employment is frequently desired by persons who experience homelessness yet is often elusive. Little is known about the range and effectiveness of employment-based interventions evaluated in existing literature on key psychosocial outcomes including employment participation, mental well-being, housing tenure, community integration and substance use. To identify and synthesise existing studies, we conducted a systematic review of effectiveness using the methodology proposed by the Joanna Briggs Institute (JBI) following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Following the removal of duplicates, we screened 13,398 titles and abstracts, and reviewed 79 studies at the full-text review stage using two independent raters. A total of 16 studies met criteria for inclusion in a narrative synthesis and were subjected to critical appraisal. The majority of studies were conducted in the US (n = 14; 87.5%) with other studies published in Canada (n = 1; 6.3%) and Australia (n = 1; 6.3%). Interventions evaluated in existing studies included combined substance use and vocational skills interventions (n = 7; 43.8%), supported employment (n = 6; 37.5%), and integrated supports including an employment component (n = 3; 18.8%). The effectiveness of these interventions on employment, mental well-being, housing tenure, community integration, and substance use is presented. Findings suggest that research evaluating employment interventions for persons who experience homelessness is in an early stage of development. Researchers and practitioners may consider collaborating with persons with lived experiences of homelessness and practitioners in co-designing and modifying existing approaches to target key outcomes more effectively. Policymakers may consider allocating resources to such initiatives to further the development of practice and research aimed at supporting persons who experience homelessness to secure and sustain employment during and following homelessness.

The Stroman Effect: Participants in MEN Count, an HIV/STI Reduction Intervention for Unemployed and Unstably Housed Black Heterosexual Men, Define Its Most Successful Elements

Interventionists often prioritize quantitative evaluation criteria such as design (e.g., randomized controlled trials), delivery fidelity, and outcome effects to assess the success of an intervention. Albeit important, criteria such as these obscure other key metrics of success such as the role of the interactions between participants and intervention deliverers, or contextual factors that shape an intervention’s activities and outcomes. In line with advocacy to expand evaluation criteria for health interventions, we designed this qualitative study to examine how a subsample of Black men in MEN Count, an HIV/STI risk reduction and healthy relationship intervention with employment and housing stability case management for Black men in Washington, DC, defined the intervention’s success. We also examined the contextual factors that shaped participation in the study’s peer counseling sessions. We conducted structured interviews with 38 Black men, ages 18 to 60 years (M = 31.1, SD = 9.33) who completed at least one of three peer counseling sessions. Analyses highlighted three key themes: (a) the favorable impact of Mr. Stroman, the lead peer counselor, on participants’ willingness to participate in MEN Count and disclose their challenges—we dubbed this the “Stroman Effect”; (b) the importance of Black men intervention deliverers with relatable life experiences; and (c) how contextual factors such as the HIV/AIDS epidemic, needs for housing and employment services and safe spaces to talk about challenges, and absentee fathers shaped participation. We discuss the study’s implications for sustainable programs after funding ends and future multilevel health interventions to promote health equity for poor urban Black men.

A systematic review of early adoption of implementation science for HIV prevention or treatment in the United States

OBJECTIVE

To provide the first systematic review of the early adoption of implementation science for HIV prevention or treatment in the United States. We identified primary research studies that addressed implementation of HIV prevention or treatment in the United States and qualitatively assessed the reporting of implementation outcomes and intervention descriptions.

METHODS

We searched PubMed, PsycInfo, and CINAHL databases for evaluations of HIV prevention or treatment interventions that at least reported one implementation outcome and were published between 2014 and 2018. We used the 12-item Template for Intervention Description and Replication to assess study interventions.

RESULTS

A total of 2275 articles were identified. Thirty-nine studies met inclusion criteria. Of these, 84.6% used quantitative methods with 5% being hybrid effectiveness-implementation studies and 15% used qualitative methods. No studies cited a formal theoretical framework for implementation science. Acceptability and feasibility were the most frequently reported implementation outcomes. Eligible studies were diverse with regard to demographic categories. Most interventions focused on HIV prevention, particularly risk-reduction strategies. HIV treatment interventions targeted linkage to care and adherence to medications. Key implementation outcome findings indicated that these interventions are feasible and acceptable in the real world.

CONCLUSION

HIV implementation science could support dissemination of HIV prevention or treatment in the United States, although HIV treatment interventions are limited. Theoretical frameworks and key implementation outcomes like fidelity, penetration, and appropriateness could promote the rigor of future HIV treatment implementation research, helping the field deliver the promise of HIV prevention or treatment efforts in the United States.

Microenterprise Intervention to Reduce Sexual Risk Behaviors and Increase Employment and HIV Preventive Practices Among Economically-Vulnerable African-American Young Adults (EMERGE): A Feasibility Randomized Clinical Trial

Economic vulnerability, such as homelessness and unemployment, contributes to HIV risk among U.S. racial minorities. Yet, few economic-strengthening interventions have been adapted for HIV prevention in this population. This study assessed the feasibility of conducting a randomized clinical trial of a 20-week microenterprise intervention for economically-vulnerable African-American young adults. Engaging MicroenterprisE for Resource Generation and Health Empowerment (EMERGE) aimed to reduce sexual risk behaviors and increase employment and uptake of HIV preventive behaviors. The experimental group received text messages on job openings plus educational sessions, mentoring, a start-up grant, and business and HIV prevention text messages. The comparison group received text messages on job openings only. Primary feasibility objectives assessed recruitment, randomization, participation, and retention. Secondary objectives examined employment, sexual risk behaviors, and HIV preventive behaviors. Outcome assessments used an in-person pre- and post-intervention interview and a weekly text message survey. Several progression criteria for a definitive trial were met. Thirty-eight participants were randomized to experimental (n = 19) or comparison group (n = 19) of which 95% were retained. The comparison intervention enhanced willingness to be randomized and reduced non-participation. Mean age of participants was 21.0 years; 35% were male; 81% were unemployed. Fifty-eight percent (58%) of experimental participants completed ≥ 70% of intervention activities, and 74% completed ≥ 50% of intervention activities. Participation in intervention activities and outcome assessments was highest in the first half (~ 10 weeks) of the study. Seventy-one percent (71%) of weekly text message surveys received a response through week 14, but responsiveness declined to 37% of participants responding to ≥ 70% of weekly text message surveys at the end of the study. The experimental group reported higher employment (from 32% at baseline to 83% at week 26) and lower unprotected sex (79% to 58%) over time compared to reported changes in employment (37% to 47%) and unprotected sex (63% to 53%) over time in the comparison group. Conducting this feasibility trial was a critical step in the process of designing and testing a behavioral intervention. Development of a fully-powered effectiveness trial should take into account lessons learned regarding intervention duration, screening, and measurement.Trial Registration ClinicalTrials.gov. NCT03766165. Registered 04 December 2018. https://clinicaltrials.gov/ct2/show/NCT03766165.

Evaluation of the Making Employment Needs (MEN) Count Intervention to Reduce HIV/STI Risk for Black Heterosexual Men in Washington DC

The primary aim of this study was to evaluate the impact of MEN Count, a race- and gender-tailored three-session counseling intervention, on HIV/STI incidence as well as housing and employment. A two-armed quasi-experimental design was used to compare MEN Count to an attention comparison condition focused on stress reduction, from March 2014 to April 2017. Participants (N = 454) were Black heterosexual men in Washington DC, largely recruited from an STI clinic. Multivariate difference-in-difference regressions assessed whether the intervention was associated with significant changes in the outcomes set, which included nonviral STI incidence, sexual risk categorization, housing, and employment. Significant improvements over time were observed across both treatment arms for all outcomes (p < .05). Reductions in unemployment were significantly greater for intervention than for control participants (AOR unemployment = 0.48, 95% CI [0.23, 0.99]). Improvements in other outcomes did not differ significantly by treatment group. In dose analyses, participants receiving all intervention sessions were significantly less likely than control participants to have experienced homelessness in the 90 days prior (AOR= 0.31, 95% CI [0.10, 0.96]) and to be unemployed (AOR = 0.37, 95% CI [0.14, 0.96]). The MEN Count intervention offers a promising approach to address structural risk factors for STI, but not STI itself, among this largely STI clinic-based sample.

Feasibility of Assessing Economic and Sexual Risk Behaviors Using Text Message Surveys in African-American Young Adults Experiencing Homelessness and Unemployment: Single-Group Study

Background

Text messages offer the potential to better evaluate HIV behavioral interventions using repeated longitudinal measures at a lower cost and research burden. However, they have been underused in US minority settings.

Objective

This study aims to examine the feasibility of assessing economic and sexual risk behaviors using text message surveys.

Methods

We conducted a single-group study with 17 African-American young adults, aged 18-24 years, who were economically disadvantaged and reported prior unprotected sex. Participants received a text message survey once each week for 5 weeks. The survey contained 14 questions with yes-no and numeric responses on sexual risk behaviors (ie, condomless sex, sex while high or drunk, and sex exchange) and economic behaviors (ie, income, employment, and money spent on HIV services or products). Feasibility measures were the number of participants who responded to the survey in a given week, the number of questions to which a participant responded in each survey, and the number of hours spent from sending a survey to participants to receiving their response in a given week. One discussion group was used to obtain feedback.

Results

Overall, 65% (n=11/17) of the participants responded to at least one text message survey compared with 35% (n=6/17) of the participants who did not respond. The majority (n=7/11, 64%) of the responders were women. The majority (n=4/6, 67%) of nonresponders were men. An average of 7.6 participants (69%) responded in a given week. Response rates among ever responders ranged from 64% to 82% across the study period. The mean number of questions answered each week was 12.6 (SD 2.7; 90% of all questions), ranging from 72% to 100%. An average of 6.4 participants (84%) answered all 14 text message questions in a given week, ranging from 57% to 100%. Participants responded approximately 8.7 hours (SD 10.3) after receiving the survey. Participants were more likely to answer questions related to employment, condomless sex, and discussions with sex partners. Nonresponse or skip was more often used for questions at the end of the survey relating to sex exchange and money spent on HIV prevention services or products. Strengths of the text message survey were convenience, readability, short completion time, having repeated measures over time, and having incentives.

Conclusions

Longitudinal text message surveys may be a valuable tool for assessing HIV-related economic and sexual risk behaviors.

Trial Registration

ClinicalTrials.gov NCT03237871; https://clinicaltrials.gov/ct2/show/NCT03237871

Microenterprise intervention to reduce sexual risk behaviors and increase employment and HIV preventive practices in economically-vulnerable African-American young adults (EMERGE): protocol for a feasibility randomized clinical trial

Background

Economic vulnerability, such as homelessness and unemployment, contributes to the HIV risk among racial minorities in the U.S., who are disproportionately infected. Yet, few economic-strengthening interventions have been adapted for HIV prevention in economically-vulnerable African-American young adults. Engaging Microenterprise for Resource Generation and Health Empowerment (EMERGE) is a feasibility randomized clinical trial of an HIV prevention microenterprise intervention with integrated text messages (“nudges”) that are informed by behavioral economic principles. The trial aims to reduce sexual risk behaviors and increase employment and uptake of HIV preventive behaviors.

Methods/design

In total, 40 young adults who are African-American, aged 18–24, live in Baltimore City, have experienced at least one episode of homelessness in the last 12 months, are unemployed or underemployed (fewer than 10 h per week), are not enrolled in school, own a cell phone with text messaging, and report at least one episode of unprotected or unsafe sex in the prior 12 months will be recruited from two community-based organizations providing residential supportive services to urban youth. Participants will undergo a 3-week run-in period and thereafter be randomly assigned to one of two groups with active interventions for 20 weeks. The first group (“comparison”) will receive text messages with information on job openings. The second group (“experimental”) will receive text messages with information on job openings plus information on HIV prevention and business educational sessions, a mentored apprenticeship, and a start-up grant, and business and HIV prevention text messages based on principles from behavioral economics. The two primary outcomes relate to the feasibility of conducting a larger trial. Secondary outcomes relate to employment, sexual risk behaviors, and HIV preventive practices. All participants will be assessed using an in-person questionnaire at pre-intervention (prior to randomization) and at 3 weeks post-intervention. To obtain repeated, longitudinal measures, participants will be assessed weekly using text message surveys from pre-intervention up to 3 weeks post-intervention.

Discussion

This study will be one of the first U.S.-based feasibility randomized clinical trials of an HIV prevention microenterprise intervention for economically-vulnerable African-American young adults. The findings will inform whether and how to conduct a larger efficacy trial for HIV risk reduction in this population.

Trial registration

ClinicalTrials.gov, NCT03766165. Registered on 4 December 2018.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3529-7) contains supplementary material, which is available to authorized users.

Re-entry experiences of Black men living with HIV/AIDS after release from prison: Intersectionality and implications for care

RATIONALE

Both the HIV epidemic and incarceration disproportionately affect Black men in the United States. A critical period for incarcerated Black men living with HIV/AIDS is re-entry into the community, which is often associated with adverse health outcomes. Additionally, Black men living with HIV/AIDS involved in the criminal justice system are burdened by multiple, intersecting disadvantaged identities and social positions.

OBJECTIVE

This study aimed to examine community re-entry experiences among Black men living with HIV/AIDS from an intersectional perspective.

METHOD

In-depth, semi-structured interviews were conducted with 16 incarcerated Black men in Wisconsin, at pre-release from prison and six months after re-entry. Thematic analysis guided by intersectionality theory was used to analyze interview transcripts.

RESULTS

Seven emerged themes included Intersectional Identities and Social Positions, Family Support, Neighborhood Violence, Relationship with Law Enforcement, Employment, Mental Health Concerns, and Medical Care and Medication Management. Intersecting identities and social positions interact with factors at multiple levels to inform health and HIV care. A conceptual framework was developed to illustrate relationships among themes.

CONCLUSIONS

Findings demonstrate the relevance of intersectionality theory in HIV care with Black men involved in criminal justice system. Incorporating a social-ecological perspective into intersectionality framework could be useful in theoretical and empirical research. Disenfranchised communities may particularly benefit from interventions that address community- and systemic-level issues.

"The Financial Is the Main Issue, It's Not Even the Child": Exploring the Role of Finances in Men's Concepts of Fatherhood and Fertility Intention

Despite demonstrable need, men’s utilization of sexual and reproductive health services remains low. This low utilization may particularly affect low-income men, given the disproportionate prevalence of unintended pregnancy in low-income populations. Bolstering men’s utilization of sexual and reproductive health services requires understanding the services that are most relevant to them. Semistructured interviews about fatherhood, fertility intention, and contraceptive use were conducted with 58 low-income Black and White men in Pittsburgh, Pennsylvania. The interviews were analyzed using content analysis to determine common themes that were most relevant to the men interviewed. The primacy of financial stability emerged as a dominant theme in men’s perceptions of fatherhood readiness, successful fathering, and fertility intentions. However, men had children despite feeling financially unprepared, and their contraceptive use was not always congruent with their stated fertility intentions. Some men described financial services as a feature of family planning services that they would find useful. Because of the salience of financial stability in preparation for fatherhood, integrating financial counseling and job skills training into the context of sexual and reproductive health services could be a useful structural intervention to increase men’s use of family planning services and to provide them with the support they say they need as fathers.

HIV-Related Communication and Safe Sex Practices among Heterosexual Black Men: A Qualitative Report

HIV prevention efforts have given limited attention to the influence of social norms on the process of communicating about safer sex practices among heterosexual Black men. To address this and inform the development of an HIV prevention behavioral intervention for heterosexual African American men, we conducted computerized, structured interviews with 61 men living in high HIV prevalence neighborhoods in New York City to participate in either one of the five focus group interviews and/or an in-depth qualitative interview. Participants had a mean age of 33 years, 25% held less than a high school education, 66% earned an annual income of $10,000 or less, and 86% had a history of incarceration Qualitative analysis was used to identify emergent themes within the domains of condom use communication, HIV status disclosure with sexual partners, and general HIV knowledge among peers. Thematic analyses revealed that communication was hindered by (1) low perception of risk of sex partners (2) relationship insecurities and (3) HIV stigma within the community and between sex partners. Most communication related to condom use was based on their perception of their sex partner's HIV risk and fear of contracting HIV and/or a partner's reaction to proposing or using condoms. Discussions related to HIV status elicited concerns of being labeled as HIV-positive or leading to unprotected sex. Communication among peers was rare due in part to the stigma of HIV in the Black community. Effective HIV interventions for heterosexual should include communication strategies that address the cultural norms that influence safe sex practices.

The Stepping Stones and Creating Futures intervention to prevent intimate partner violence and HIV-risk behaviours in Durban, South Africa: study protocol for a cluster randomized control trial, and baseline characteristics

BACKGROUND

Preventing intimate partner violence (IPV) remains a global public health challenge. Studies suggest urban informal settlements have particularly high levels of IPV and HIV-prevalence and these settlements are rapidly growing. The current evidence base of effective approaches to preventing IPV recognizes the potential of combining economic strengthening and gender transformative interventions. However, few of these interventions have been done in urban informal settlements, and almost none have included men as direct recipients of these interventions.

METHODS

Stepping Stones and Creating Futures intervention is a participatory gender transformative and livelihoods strengthening intervention. It is being evaluated through a cluster randomized control trial amongst young women and men (18-30) living in urban informal settlements in eThekwini Municipality, South Africa. The evaluation includes a qualitative process evaluation and cost-effectiveness analysis. A comparison of baseline characteristics of participants is also included.

DISCUSSION

This is one of the first large trials to prevent IPV and HIV-vulnerability amongst young women and men in urban informal settlements. Given the mixed methods evaluation, the results of this trial have the ability to develop a stronger understanding of what works to prevent violence against women and the processes of change in interventions.

TRIAL REGISTRATION

NCT03022370 . Registered 13 January 2017, retrospectively registered.

A global comprehensive review of economic interventions to prevent intimate partner violence and HIV risk behaviours

BACKGROUND

Intimate partner violence (IPV) and HIV are co-occurring global epidemics, with similar root causes of gender and economic inequalities. Economic interventions have become a central approach to preventing IPV and HIV.

OBJECTIVE/METHODS

We undertook a comprehensive scoping review of published evaluations of economic interventions that sought to prevent IPV and/or HIV risk behaviours.

RESULTS

Forty-five separate analyses of interventions met our criteria. Broadly, unconditional cash transfer interventions showed either flat or positive outcomes; economic strengthening interventions had mixed outcomes, with some negative, flat and positive results reported; interventions combining economic strengthening and gender transformative interventions tended to have positive outcomes.

CONCLUSIONS

The review highlighted a number of gaps. Specifically, there were limited studies evaluating the impact of economic interventions on female sex workers, young women, and men. In addition, there were missed opportunities, with many evaluations only reporting either IPV- or HIV-related outcomes, rather than both, despite overlaps.

Cluster Randomized Controlled Trial Evaluation of a Gender Equity and Family Planning Intervention for Married Men and Couples in Rural India

Background

Despite ongoing recommendations to increase male engagement and gender-equity (GE) counseling in family planning (FP) services, few such programs have been implemented and rigorously evaluated. This study evaluates the impact of CHARM, a three-session GE+FP counseling intervention delivered by male health care providers to married men, alone (sessions 1&2) and with their wives (session 3) in India.

Methods and Findings

A two-armed cluster randomized controlled trial was conducted with young married couples (N = 1081 couples) recruited from 50 geographic clusters (25 clusters randomized to CHARM and a control condition, respectively) in rural Maharashtra, India. Couples were surveyed on demographics, contraceptive behaviors, and intimate partner violence (IPV) attitudes and behaviors at baseline and 9 &18-month follow-ups, with pregnancy testing at baseline and 18-month follow-up. Outcome effects on contraceptive use and incident pregnancy, and secondarily, on contraceptive communication and men’s IPV attitudes and behaviors, were assessed using logistic generalized linear mixed models. Most men recruited from CHARM communities (91.3%) received at least one CHARM intervention session; 52.5% received the couple’s session with their wife. Findings document that women from the CHARM condition, relative to controls, were more likely to report contraceptive communication at 9-month follow-up (AOR = 1.77, p = 0.04) and modern contraceptive use at 9 and 18-month follow-ups (AORs = 1.57–1.58, p = 0.05), and they were less likely to report sexual IPV at 18-month follow-up (AOR = 0.48, p = 0.01). Men in the CHARM condition were less likely than those in the control clusters to report attitudes accepting of sexual IPV at 9-month (AOR = 0.64, p = 0.03) and 18-month (AOR = 0.51, p = 0.004) follow-up, and attitudes accepting of physical IPV at 18-month follow-up (AOR = 0.64, p = 0.02). No significant effect on pregnancy was seen.

Conclusions

Findings demonstrate that men can be engaged in FP programming in rural India, and that such an approach inclusive of GE counseling can improve contraceptive practices and reduce sexual IPV in married couples.

Trial Registration

ClinicalTrials.gov NCT01593943

The promises and limitations of gender-transformative health programming with men: critical reflections from the field

Since the 1994 International Conference on Population and Development, researchers and practitioners have engaged in a series of efforts to shift health programming with men from being gender-neutral to being more gender-sensitive and gender-transformative. Efforts in this latter category have been increasingly utilised, particularly in the last decade, and attempt to transform gender relations to be more equitable in the name of improved health outcomes for both women and men. We begin by assessing the conceptual progression of social science contributions to gender-transformative health programming with men. Next, we briefly assess the empirical evidence from gender-transformative health interventions with men. Finally, we examine some of the challenges and limitations of gender-transformative health programmes and make recommendations for future work in this thriving interdisciplinary area of study.

Perceptions of HIV Risk and Explanations of Sexual Risk Behavior Offered by Heterosexual Black Male Barbershop Patrons in Brooklyn, NY

To describe HIV risk factors among adult heterosexual Black men recruited from four barbershops located in high HIV seroprevalent neighborhoods of Brooklyn, NY. Data on HIV-risk related behaviors and other characteristics were collected from barbershop clients. All participants (n=60) completed brief risk assessments; and a subset (n=22) also completed focus groups and/or individual interviews. Of the subset of 22 men, 68% were US born, 59% had been in jail/prison, 32% were unemployed; and during the 3 months before the interviews, 68% reported at least two partners and 45% reported unprotected vaginal or anal sex with two or more women. Emergent themes included: 1) the psychological function of multiple partnerships; 2) calculated risk taking regarding condom use; 3) the role of emotional attachment and partner trust in condom use; 4) low perceived HIV risk and community awareness; and 5) lack of relationship between HIV testing and safer sex practices. Interventions among heterosexual Black men should focus not only on increasing HIV awareness and reducing sexual risk, but also on contextual and interpersonal factors that influence sexual risk.

Incarceration and unstable housing interact to predict sexual risk behaviours among African American STD clinic patients

Given the dramatic racial disparities in the rates of HIV/sexually transmitted infections (STIs) among African Americans, understanding broader structural factors that increase the risk for HIV/STIs is crucial. This study investigated incarceration history and unstable housing as two structural predictors of HIV risk behaviour among 293 African Americans (159 men/134 women, mean age = 27). Participants were recruited from an urban sexually transmitted disease (STD) clinic in the southeastern U.S. Approximately half the sample had been incarcerated in their lifetime (54%), and 43% had been unstably housed in the past six months. Incarceration was independently associated with the number of sex partners and the frequency of unprotected sex. Unstable housing was independently associated with the frequency of unprotected sex. However, these main effects were qualified by significant interactions: individuals with a history of incarceration and more unstable housing had more sex partners and more unprotected sex in the past three months than individuals without these structural barriers. Implications for structural-level interventions are discussed.