Date of Degree
Doctor of Public Health (DPH)
Community Health and Social Sciences
Community-Based Research | Community Health | Community Health and Preventive Medicine | Gender and Sexuality | Public Health | Public Health Education and Promotion
YMSM, mixed methods research, HIV prevention, HIV intervention fatigue, behavioral interventions
Background: Young gay, bisexual and other men who have sex with men (YGBM) of color are disproportionately affected by HIV and bear the burden of the disease in the United States. Gay and bisexual men – referred to in surveillance systems as men who have sex with men (MSM) – continue to be the risk group most severely affected by HIV in the United States. The dissertation study explored factors related on HIV prevention intervention participation, HIV testing and sexual risk behaviors among YGBM ages 13-29 in the Bronx. Additionally, this dissertation endeavored to study the concept of “intervention fatigue”, a component HIV prevention fatigue, which is the occurrence when prevention messages are so common to participants in the target group that they become tiresome background noise and are subsequently ignored while participating in HIV prevention behavioral interventions. The conceptual framework for this dissertation project was operationalized using Gelberg’s update of the Andersen’s Model for Healthcare utilization to create the Behavioral model for vulnerable populations. The goal of this dissertation was to: 1) to conduct a case study to incorporate feedback on recommendations for best practices for the delivery of HIV prevention services to YGBM, 2) to explore factors related to “intervention fatigue” as it applies to YGBM in the Bronx, and 3) to explore factors of HIV prevention intervention participation, HIV testing and outcomes among YGBM of color.
Methods: A mixed methods approach, both qualitative and quantitative methods, was used for this dissertation study. As part of the qualitative component in depth interviews were performed with BOOM!Health Prevention staff and to inform a case study to incorporate their feedback on recommendations for best practices in delivering HIV prevention services to YGBM. With qualitative methodology, I assessed how to operationalize intervention fatigue and what factors influence this fatigue. Focus groups exploring HIV risk, testing and participation in HIV prevention interventions were conducted at BOOM!Health with a total of twenty-three (23) cisgender YGBM, one (1) transgender woman and (1) gender non-binary individual between the ages of 17-29 years old. These youth were recruited using social networks, and with the assistance of BOOM!Health staff. Quantitative data analysis was utilized to assess the relationship between intervention participation and HIV testing. The sample included a total of 2,198 clients, 2,058 cisgender men who identify as gay, bisexual or MSM (YGBM) and 140 young transgender women. Significant differences between clients who participated in HIV prevention services and clients who did not participate in HIV prevention services at BOOM!Health during this three-year period were assessed using bivariate analyses to generate χ2 statistics, t-tests and associated probabilities. The outcome variable of interest was utilization of HIV prevention services (which included either having at least one HIV test and/or participation in at least one HIV prevention intervention (group level or individual level) in 2014-2016). Covariates included: sex with men, sex with females, sex with transgender females, sex with men for drugs, sex with men who had unknown HIV status, sex with anonymous male partners, sex with men while high on drugs or intoxicated, recent sexually transmitted disease (STD), engaging in sex work and previous incarceration. Variables with significant chi-square results at p < .05 were included in a binary logistic regression model.
Results: Through the qualitative component of the dissertation research (aim # 1), eight themes emerged through in-depth interviews with BOOM!Health staff in the case study, that were identified as either facilitators and/or barriers to YGBMSM accessing HIV prevention services or services that this community direly need to reduce HIV risk: (1) basic needs, (2) incentives, (3) staff reflects the community (LGBT/People of Color), (4) need for peer health educators, (5) recruitment utilizing sub communities such as the house ball community, (6) packaging messages, (7) homophobia, and (8) HIV stigma. In an exploration of factors related to “intervention fatigue” among YGBM participating in HIV prevention services in the Bronx (aim # 2), I found that these men did not experience fatigue participating in interventions per say, but they do prefer innovative approaches and locally developed, or adaptations of evidence-based interventions as opposed to CDC DEBIs. The focus group component of the dissertation study identified life circumstances impacting YGBM, including homelessness, incarceration and the impact of previous involvement in foster care and unsupportive families. Other issues that were mentioned included food insecurity and the need for employment programs that include job placement. When discussing accessing HIV prevention services, many participants stated they were tested for HIV frequently, between 3-6 times a year. The participants made their preference for locally adapted interventions very clear which provide up to date HIV prevention information, include modules on PrEP and PEP, and also utilize social marketing tools that emphasize intervention participants creating and posting unique prevention messaging on social media for their friends and peers. Most participants stated there was a lack of gay sex/anal sexual health education outside of HIV prevention interventions offered by community-based organizations. When focus group participants were asked if intervention participation influenced condom use, there was a mixed response, some stated they used condoms and others did not. Intervention participation has increased PrEP awareness among YGBM, but there were varying opinions about the use of PrEP (some participants were willing to try it while others were afraid of side effects). Participants were asked about other issues impacting health and access to HIV prevention services and three themes that were discussed across the focus groups included homophobia/stigma, incentives and the need for mental health services. In the quantitative component of the dissertation study (aim # 3), significant differences between clients who participated in HIV prevention services and clients who did not participate in HIV prevention services at BOOM!Health during this three-year period were assessed using bivariate analyses to generate χ2 statistics, t-tests and associated probabilities. The exposure was compared between client groups who utilized HIV prevention services in 2014-2016 and those who did not receive services during this period. There was a difference in age of clients who participated in HIV prevention services versus those who did not (23 years old vs. 25 years old). The race/ethnicity composition for both groups did not significantly differ, many clients in both groups were Black or Latinx. However, there was a significant difference in housing status, 50% of clients who participated in HIV prevention services were homeless, unstably housed (i.e couch-surfing) or in temporary housing, compared to 28% of clients in the group who did not access prevention services ( χ 2 =110.86, p < 0.001). In comparing the two groups, those who received prevention services were more likely to report having engaged in sexual activities that put them at risk for HIV. Those who engaged in HIV prevention services were significantly more like than those who did not, to have engaged in a range of behaviors that would put them at risk for HIV. Variables that were significant in bivariate analyses were included in a binary logistic regression model: sex with females, sex with anonymous male partners, sex with men while high on drugs or intoxicated, recent sexually transmitted disease (STD), as well as housing and history of incarceration, to investigate a possible relationship between these variables and the outcome variable, HIV prevention service utilization (using the framework of the Behavioral model for vulnerable populations to identify traditional and vulnerable domains). The results of the logistic regression analysis show that an association exists between previous incarceration, housing, and accessing HIV prevention services. Clients who have been previously incarcerated were significantly more likely to access HIV prevention services (AOR = 2.06; 95% CI 1.37-3.09). Housing had a negative association with HIV prevention service utilization (AOR= 0.40; 95% CI 0.33-0.48). Additionally, the following sexual health risk factors were positively associated with accessing HIV prevention services in this study, such as previous sexually transmitted infection, anonymous sex with men, and sex with cisgender women. Clients who had a recent STD were more likely to engage in HIV prevention services (AOR = 1.97; 95% CI 1.07-3.64). Clients who had a were anonymous sex with men, more likely to engage in HIV prevention services (AOR = 1.52; 95% CI 1.18-1.97). Clients who had sex with cisgender women (in addition to having sex with males as part of the study inclusion criteria) were four times more likely to participate in HIV prevention services (AOR=4.05; 95% CI 3.26-5.22). When adding lack of health insurance to the regression model as an enabling factor, as part of the traditional domain of the Behavioral model for vulnerable populations, it had a negative association on HIV prevention service utilization.
Conclusion: Through my dissertation research, I learned that when engaging YGBM, tremendous importance of not only providing HIV prevention education and services, giving immediate support through incentives therefore, competing or basic needs must also be addressed. Staff delivering HIV prevention programming should be representative and/or knowledgeable of the community they serve but also these youth should have a role in developing and disseminating messages. Participants did not experience fatigue participating in interventions per say, but they respond more favorably to interventions that employ innovative approaches. I conclude this dissertation with the following strategic goals that could improve the delivery of HIV prevention services. First, there should be an enhancement of data collection and improved access to technology; second, there must be an investment in developing peer programs, with access to training and certification, and finally, HIV service agencies should create “a one stop shop” and provide participants with co-located services to address basic needs and cross-system involvement.
Lopez, Bianca V., "AN EXAMINATION OF HIV RISK, TESTING AND PREVENTION INTERVENTION PARTICIPATION AMONG VULNERABLE YOUTH" (2020). CUNY Academic Works.