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HIV/STD Prevention in Rural America

 
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Programs to Decrease Unprotected Male to Male Sex
 

In the U.S., the largest proportion of people with HIV/AIDS is men exposed to the virus by having sex with men. This is true for both rural and urban areas.[1] Consequently, MSM are a primary focus for HIV prevention interventions. Successfully implementing programs to reduce HIV and STD transmission among MSM is a particular challenge in rural areas in part due to discrimination and homophobia. This seems to apply regardless of whether men identify as gay or bisexual, and whether they are open or secretive about their behavior. Although there are few if any venues for men to socialize with other men in rural areas, social networks may provide a good way to recruit men into interventions. Some MSM are fearful of disclosing their behavior to avoid stigma, discrimination, and potential violence so they may be reluctant to openly participate in interventions. The following interventions begin to address some of these challenges. However, the first step in any rural HIV/STD behavioral intervention is to assess the community and identify local social networks. This requires gathering information about the accessibility of the target audience, their stage of readiness to change, the assets they bring, the social or sexual networks in which risk behaviors occur, and cultural as well as structural influences that might hinder or support the implementation of a program. Rural adaptations of MPowerment, Community PROMISE, and Many Men Many Voices are described along with two locally developed Tier 4 interventions, one of which utilizes the Internet. It is clear that more interventions addressing rural MSM and especially rural MSM of color are needed.

Target Audience - Men's Progams
Adult Men Who Have Sex with Men
Young Men Who Have Sex with Men
Sexually Active Men - Condom Use
Rural MSM Who Access the Internet

Adult Men Who Have Sex with Men

ManREACH

Target Behaviors and Behavioral Determinants
Unprotected male to male sex; lack of venues for safe socialization; perceived lack of power and social support.

Description
Adaptation of MPowerment (DEBI from Original Compendium) www.mpowerment.org
This community-level intervention builds positive connections among men of all ages who identify as gay, bisexual, or queer and live in rural Colorado. Regional events are hosted in varying locations. Events offer a safe space for sharing information, socializing, building support, and promoting safer sex. Modeling healthy behavior and mentoring are guiding principals. Statewide gatherings are held each summer. ManREACH uses a statewide steering committee to plan events.

Adaptation
Core elements have not been altered. The intervention has been modified to include rural MSM of all ages and takes advantage of rural isolation and beauty to provide inviting safe venues for activities.

Evidence
The original intervention showed a decrease in unprotected sex and a reduction in new HIV infections but these outcomes have not been measured in the adapted program. The program continues to increase its reach to rural men who identify as gay or homosexual.

Recommendations
Holding events at multiple sites throughout the state during months with good weather increases participation. Developing leadership with statewide representation of rural MSM is a critical component for success.

Where Implemented
Rural Colorado, statewide

Contact Information
www.manreach.org,
info@manreach.org

 

 

IMSexED – Instant Message Sex Education

Target Behaviors and Behavioral Determinants
Lack of knowledge about HIV/STD risk behaviors, disease symptoms, HIV testing, clinic and testing locations, local resources.

Target Audience     
Internet users, especially men who have sex with men (MSM) who use     online chatrooms and sexual hook-up sites.

Description
IMsexED builds on the current popularity of the internet to reach rural MSM and engage them in HIV-prevention education in a cost-effective way. “Ed” is personified as a condom-like caricature and has a profile which informs viewers that his function is to provide sexual health related information and referrals. The IMsexED character currently makes itself conspicuously available on gay.com, adam4adam, lifeout.com, blackgaychat.com, Yahoo Messenger, Facebook, Twitter and can be e-mailed at IMsexED@arcw.org. Depending on the limitations of each particular internet site, IMsexED will typically and proactively provide information (in the form of bullet points) on common sexual-health-related topics such as HIV/STD risk factors, disease symptoms, HIV testing, clinic locations, breaking news/studies, links to helpful sites, statistics, etc. In addition to posting important information, SexED invites folks to ‘Instant Message’ or ‘Private Message’ for more detailed information on sensitive or personal matters.

Evidence    
There is extensive anecdotal evidence that “clients” are using IMSexED to get useful information and find resources.

Recommendations
Nine months of planning went into the creation of the IMsexED protocols, which include specific information regarding; ISP negotiations, message content, resource/referral lists, internet terminology, internet etiquette and program documentation/evaluation techniques.

Where Implemented
Wisconsin AIDS Resource Center of Wisconsin

Contact Information
Paul Jacob,, HIV Prevention Specialist
AIDS Resource Center of Wisconsin
920-437-7400, ext. 3110

paul.jacob@arcw.org

 

Target Behaviors and Behavioral Determinants
Enhanced self esteem around racial/ethnic status and sexual behaviors, unprotected male to male sex; improved partner negotiation and communication skills.

Description    
A 7-session
group-level DEBI intervention for men of color who have sex with men (MSM) who may or may not identify as gay. 3MV addresses factors that influence the behavior of men of color who have sex with men: cultural, social, and religious norms; interactions between HIV and other sexually transmitted diseases; sexual relationship dynamics; and the social influences that racism and homophobiahave on HIV risk behaviors.  

Evidence

3MV participants reported significantly greater reductions in any unprotected anal intercourse with casual male partners; a trend for consistent condom use during receptive anal intercourse with casual male partners; and significantly greater reductions in the number of male sex partners and greater increases in HIV testing

 

Where Implemented

Mississippi State Department of Health

New Mexico AIDS Services

 

Contact Information
Mississippi State Department of Health, HIV Division

(601) 576-7723

    

New Mexico AIDS Services

(505) 938-7100 or (888) 882-AIDS

 

 

Young Men Who Have Sex with Men

Target Behaviors and Behavioral Determinants
Unprotected male to male sex among young MSM; lack of adequate knowledge about safer sex behaviors; lack of venues for safe socialization; perceived lack of power and social support.

Description
Adaptation of MPowerment (DEBI)
Developed by and for young, rural MSM ages 16-24, this community-level DEBI is directed by a small core group (8-10) of gay and bisexual young men with support from AIDS service organization staff. The intervention has four integrated activities. Formal outreach is conducted by teams that create their own social events to attract young rural MSM and promote safer sex. In contrast, informal outreach involves the core group members discussing safer sex with friends. M-groups are peer-led 2-3 hour meetings of 8-10 young rural MSM to discuss factors contributing to unsafe sex. Through skills-building exercises, the young men practice safer sex negotiation and correct condom use skills.
 Free condoms are provided at all meetings. *MpowerMT also hosts a yearly Young Men’s Health Retreat in the spring of every year. All MSM ages 16-24 are invited to spend a weekend at a secluded lodge to get to know one another, share information, and learn new things regarding sexual, mental, and physical health. These events are facilitated by the Montana Gay Men’s Task Force and qualified therapists. These weekends are free to participants and food and lodging are provided for the three day event. An ongoing publicity campaign attracts young men throughout the state to the project by word of mouth, the Internet, and articles or advertising in gay newspapers. The program also identifies and targets locations and events where the target audience can be found such as PRIDE events, GSA dances, and drag shows.

Adaptation
Core elements remain intact and this is the age group of the original DEBI. *MpowerMT has been modified to reflect rural culture by discussing issues pertinent to the group such as discrimination and social isolation.


Evidence
The original intervention showed a decrease in unprotected sex and a reduction in new HIV infections but these outcomes have not been measured in the adapted program. Pre and post-event knowledge assessments consistently show a gain in risk reduction knowledge of 80% for those completing the assessment.
Recommendations This intervention is intended to have local adaptations and works well in rural Montana to reach the entire community of young gay and bisexual men and support safer sex behaviors through community empowerment.

Where Implemented
Montana

Contact Information
www.mtgayhealth.org

1-888-713-4683    
    

 

 


VIBES (Very Informed Brothers Engaged for Survival)

Target Behaviors and Behavioral Determinants

Unprotected male to male sex among young African American men; lack of cultural pride; perception of lack of power; lack of condom negotiation and relationship negotiation skills; lack of personal sense of responsibility for sexual safety; lack of goal-setting skills, lack of problem-solving skills.

Description

VIBES is a theory guided, research based group-level six-session behavioral HIV prevention intervention for young rural African-American MSM. The intervention develops decision-making and condom negotiation skills, helps youth create risk reduction strategies, and advances cultural empowerment.

Evidence

Youth who participated in the VIBES intervention experienced significant gains in condom use and risk reduction skills as compared to a control group of youth receiving basic HIV education. Effectiveness data are being collected currently.

Recommendations

Please see the VIBES curriculum for lesson plans, and implementation suggestions. Illinois Department of Public Health provides training on this intervention.

Where Implemented

Illinois, Indiana

Contact Information

VIBES

Jeffery Erdman at Champaign-Urbana Public Health District
(217) 239-7827
jerdman@c-uphd.org

 

Target Behaviors and Behavioral Determinants

Positive identify development;  positive youth development; reduced unprotected male to male sex; increased perception of HIV risk; increased risk reduction skills; increased peer education skills.

Description

Locally developed intervention provides 8 hours of training to peer educators to facilitate HIV risk reduction education among 18-24 year old men who have sex with men. After training, peer educators are supported monthly meetings and booster sessions. YEAH! is based on positive youth development theory and incorporates a popular opinion leader approach through which the “coolest guys share the coolest information and distribute the coolest condoms.”  The program   develops protective youth assets including confidence, competence,  character, connections, and contributions to their community. In addition, YEAH! places socially marketed condom dispensers in venues where young MSM congregate.  Focus groups with members of the target population determined the most appropriate educational approaches and selected the branding for the intervention.

Evidence

Pilot evaluation results demonstrated that peer educators achieved statistically significant gains in knowledge (p<.001, n=23), comfort talking about HIV risk behaviors (p=.005, n=20), confidence talking about HIV risk behaviors (p<.001, n=21), and self-efficacy for HIV prevention and peer education (p<.001, n=21.    Qualitative data from peer educators showed that many participants perceived YEAH! to have contributed to their leadership development and most believed they had an impact at the community level.

 

Between June 2010 and February 2011, YEAH! distributed approximately 11,000 condoms through peer educators and condom dispensers, providing opportunities to open discussions about reducing HIV risk behaviors with clients. Peer educators participated in formal community-based peer education activities at the Bisexual, Gay, Lesbian, and Straight Alliance at the University of South Carolina, South Carolina Pride, South Carolina Black Pride, an educational event at the College of Charleston (SC), and in a World AIDS Day panel discussion.  Peers also report engaging in regular conversations about HIV/AIDS in public venues (e.g. bars) and at parties or other gatherings with their peers. 

Recommendations

Please see the VIBES curriculum for lesson plans, and implementation suggestions. Illinois Department of Public Health provides training on this intervention.

Where Implemented

Midlands of South Carolina

Contact Information

yeahcolumbia@gmail.com

     Ryan C. Wilson, MEd

 

 

Sexually Active Men - Condom Use

Target Behaviors and Behavioral Determinants
Inconsistent and incorrect condom use among rural African American and Latino men, women, youth, and MSM; lack of skills to use condoms correctly and consistently; lack of condom use negotiation skills; lack of social norms and social support to promote condom use.

Description
VOICES/VOCES (DEBI)
VOICES/VOCES is a group-level 45-minute video-based program that encourages condom use, and improves negotiation skills. Small groups of 3-8 watch a 20-minute video, discuss difficulties experienced trying to use condoms, and brainstorm strategies to increase condom use. There are two versions, one tailored for an African American audience and another (bilingual) for a Latino audience. Free condoms are distributed as part of the program.

Adaptation
Originally developed and tested for men and women of color attending STD clinics, this video has been used in rural Florida, Mississippi, New York, Ohio, Pennsylvania, South Carolina, Tennessee, and Wyoming with MSM, rural youth under 18, young adults ages 19-24, drug users (including those who inject), incarcerated men, and in the community in business, school, and faith-based settings.

Evidence
When implemented in the original STD clinic setting, fewer STDs occurred in the group that saw the video and participated in the discussion. It is difficult to collect evidence of behavior change for participants in this single session intervention. However, in sites that collected post-intervention data, participants are more likely to report an intention to use condoms consistently after the single session than before.

Recommendations
Core elements are easy to deliver with fidelity in many rural settings with a variety of audiences. It is a “great one time program” that does not require too many resources and minimal recruitment.

Where Implemented
Pennsylvania Department of Health, Johnstown, PA

Chattanooga CARES
Albany County Public Health (WY)
Duvall County Public Health (FL)
Florida Community Prevention Center
Green County Public Health (OH)
Low Country Healthcare, South Carolina
Mississippi State Department of Health

Contact Information
Commonwealth of Pennsylvania Department of Health, Johnstown, PA
814-533-2205

 

Rural MSM Who Access the Internet


Project HOPE - Internet Risk-Reduction Intervention

Target Behaviors and Behavioral Determinants
Unprotected male to male sex; sex with multiple partners linked through Internet dating services; lack of information and motivation to change behavior; lack of skills and self-efficacy to reduce risk behaviors with Internet sex partners; lack of social norms that support safer sex behaviors.

Description
This theory guided and research based three-session individual Internet intervention uses banners tailored to different ethnicities to recruit MSM into the intervention. The interactive illustrated interventions teach basic information about HIV transmission and prevention, help participants rethink how they can decrease their specific risk behaviors using real life scenarios, and help motivate participants to change behaviors. The intervention can be accessed at www.wrapphome.net but active recruitment through banner placement has been discontinued at this time.

Evidence
Those who completed the three sessions report decreased occurrences of unprotected sex, increased condom use, and decreased number of sexual partners (if person started with 2 or more). The long-term maintenance of these changes is not known.

Recommendations
Tailor messages to cultural values for each ethnicity. Repeated interventions work better than one time interventions. This intervention reaches hidden rural populations and protects their anonymity but may require active recruitment.

Where Implemented
Wyoming Rural AIDS Prevention Project (WRAPP)

Contact Information
Ann Bowen, WRAPP, University of Wyoming 1000 East University Ave, Laramie, WY 82071
(307) 766-4327

 

Target Behaviors and Behavioral Determinants
Client-identified risk behaviors include unprotected male to male sex and drug use before and during sex; client-identified behavioral determinants include lack of social networks that support safer sex behaviors; attitudes toward safer sex behaviors; lack of skills and self-efficacy to negotiate safer sex in some social situations.

Description
For this locally-developed individual level intervention, HIV prevention staff conduct risk reduction counseling sessions via the Internet, either in chat rooms or through instant messaging, to assist high-risk individuals in creating brief HIV risk reduction plans, assist them with skills-building, and refer them to HIV testing and other appropriate prevention services. This intervention builds on Social Cognitive Theory, Stages of Change, and Diffusion of Innovations Theory. It works to reach MSM in rural areas where services are scarce and/or distance impedes clients from accessing services.

Evidence
This intervention has not measured behavioral outcomes due to confidentiality concerns. Clients involved in the counseling report satisfaction with this method of obtaining information and referrals.

Recommendations
Choose the websites that community members log on to often; identify the times of day that clients access these sites; be upfront when online in identifying staff as being from a health center; be prepared to always offer referrals. Ethical issues such as protecting confidentiality should be addressed prior to beginning online counseling. Advising clients of security limitations and encrypting emails may be advisable.

Where Implemented
Rural Illinois

Contact Information
Illinois Department of Public Health
312-814-4846

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