Student Name National University Professor’s Name COH 692 Public Health Capstone Project

Student Name

National University

Professor’s Name

COH 692 Public Health Capstone Project

Date

We accept this capstone project on behalf of the Community Health Department, School of Health and Human Services, National University.

_____________________________________ _____________ Faculty: Date

________________________________________ _____________ Program Director: Date

Abstract

The Human Immunodeficiency Virus (HIV) is a pandemic that continues to spread throughout all parts of the world. Currently over 1.1 million people are living with the virus in the United States alone. The men who have sex with men (MSM) demographic in the U.S. is disproportionally affected by HIV, as they account for over sixty five percent of those currently infected. In this study a systematic review was conducted to determine the effectiveness of various HIV interventions aiming to increase MSM testing and risk reduction behaviors. A comparison and contrast was performed to see how different intervention methods (face to face, internet, telephone, computer, social media, or chat room) impacted the target population. All the HIV interventions included in this study were successful in either increasing testing habits or decreasing the high-risk behaviors of MSM. Findings suggest that the best way to intervene on MSM is through a combination of various methods that synchronize their efforts towards the target population. The implementation of HIV interventions is vital in reducing HIV incidence within the MSM demographic.

Keywords: Human Immunodeficiency Virus, intervention, HIV testing, condom use, monogamy, substance abuse, men who have sex with men

Introduction

The Human Immunodeficiency Virus (HIV) is a pandemic that continues to spread throughout all parts of the world. Currently over 35 million people are living with the virus globally, with the United States accounting for over 1.1 million of that total (Centers for Disease Control and Prevention [CDC], 2016a). The number of new cases each year average 2.1 million worldwide with the United States contributing to fifty thousand of this aggregate (World Health Organization [WHO], 2016; National Institutes of Health [NIH], 2016). Since the inception of HIV in the 1980’s it has claimed the lives of over 39 million people worldwide, and continues presently to average 1.5 million deaths per year globally (WHO, 2016). The United States has a much lower mortality averaging 13.5 thousand each year (CDC, 2015a; Avert Global Organization, 2016).

Certain demographic groups and populations throughout the world have proven to be more severely affected by HIV than others. One of the groups that are disproportionally affected, particularly in the United States, are men who have sex with men (MSM). In the United States, today the MSM demographic consists of only two percent of the entire population (United States Department of Health and Human Services, 2014a). However, MSM account for over 65% of the total 1.2 million Americans infected with the virus (CDC, 2015b; Avert Global Organization, 2016). In addition, MSM account for over half of those newly infected with HIV each year in the United States (CDC, 2016b; Kaiser Family Foundation, 2014).

After initial HIV infection, it is possible for individuals to show no signs or symptoms for days to months after as the virus is replicating in the body. When nearing the end of this process infected individuals often experience flu like symptoms signaling that the body has seroconverted to being HIV positive. These symptoms can easily be mistaken for a casual illness resulting in HIV going undiagnosed. This is a main factor in how it is rapidly and unknowingly transmitted as well as why 13% of Americans who have the virus are unaware of their seroconversion status (CDC, 2016a). HIV testing is the only way to identify those who have the virus and is crucial in reducing new cases as well as improving the health of those who are already infected by providing treatment. In addition, reducing high risk behaviors such as unprotected intercourse, having multiple sex partners, and substance abuse is key when aiming to halt the spread of the virus.

Purpose Statement

The purpose of this descriptive systematic review is to demonstrate that HIV interventions within the MSM community are both necessary and effective when aiming to increase testing practices and reduce high risk behaviors. A comparison and contrast will be performed to see how intervention methods impacted the target population.

Research Questions

What type of HIV intervention methods are available and have been performed on MSM?

What are the strategies within each intervention that have demonstrated successful in increasing HIV testing /reducing high risk behaviors?

What are the strategies within each intervention that have demonstrated unsuccessful in increasing HIV testing/ reducing high risk behaviors?

Are HIV intervention and prevention efforts necessary to maintain or raise the testing rate of MSM?

Do personal knowledge, attitudes, and beliefs play a factor in MSM testing?

Do certain intervention methods greatly outweigh the success of another?

Definitions of Terms

Men who have sex with men (MSM) – a person who is anatomically male that has or had sex with other anatomic males at any point in time

HIV interventions – programs designed to improve the health status of individuals, groups, or entire populations by promoting behaviors and practices that are conducive to remaining HIV negative

HIV incidence – the number of new cases of HIV that surface in each period

Seroconversion -the point in time when HIV antibodies have developed and become detectable in the blood via testing

High risk behavior- an activity or lifestyle that increases an individual’s chances of suffering from a certain ailment, injury, or condition

Monogamy- the practice of having sexual relations with only one exclusive partner

Substance abuse- excess use and/or dependence of a legal (alcohol) or illegal (drugs) addictive substance

Review of Literature

The National HIV/AIDS Strategy [NHAS] released in 2010 outlines the importance of HIV interventions within the MSM community. This approach calls for the most efficient prevention strategies to be combined and implemented at much higher rates in the areas that are the most severely affected by the virus. As a response to this strategy the CDC provided extra funding to government and state entities for expanding HIV prevention and testing projects. Over a three-year period, this funding enabled its benefactors to provide testing to 2.8 million Americans, which diagnosed 18,432 MSM as HIV positive (CDC, 2013).

MSM Attitudes and Testing Behaviors

To increase the amount of MSM testing in the United States it is necessary to assess MSM attitudes, behaviors, and testing habits. Various studies have been completed on this subject over the past 10 years and have shown that inquiring about the testing habits of MSM has a positive effect on their actual testing habits (Oster et al., 2014; St. Lawrence et al., 2015; Phillips et al., 2013). The research performed by Oster et al. studied MSM in five separate U.S. cities from 1994 through 2011 to request information about their current HIV testing habits and risk behaviors. No judgment or counseling was given to the participants, simply an anonymous behavioral survey along with a list of optional testing facilities. Twelve months later the same participants were re-surveyed, and demonstrated significant increases in HIV testing than the year prior (Oster et al., 2014).

Another factor known to influence MSM HIV testing is that medical providers are not consistently offering it (Mimiaga et al., 2009; Phillips et al., 2013). Medical providers do not always perform a social history check with patients that would trigger them to order HIV testing after realizing they are working with high risk MSM. Since some MSM patients are not consistently counseled on the importance of knowing their HIV status, getting tested can be low on their priority list. Other factors affecting HIV testing include MSM believing the notion that they have very little risk of becoming infected due to having repeated minimal sex partners (St. Lawrence et al., 2015).

High Risk Behavior

High risk behavior is an activity or lifestyle that increases an individual’s chances of suffering from a certain ailment, injury, or condition. In the case of MSM, high risk behavior is a factor known to influence HIV incidence (Silan et al., 2013). Some of the most common high risk behaviors MSM exhibit in the United States include unprotected anal intercourse, having multiple sex partners, and injection drug use (CDC, 2011). Other behaviors that are not as common but do play a factor in MSM HIV incidence include oral sex, prostitution, and alcohol use (CDC, 2011). Having a sexually transmitted infection (STI) at the time of HIV exposure also increases the chance of potential infection as an individual’s immune system is already compromised. Since it is known that the MSM community has an increased risk of contracting STI’s compared to the rest of the U.S. population, this is a contributing factor to the spread of HIV (CDC, 2015b). HIV interventions that aim to reduce various types of high risk behaviors including condom use, abstinence, and monogamy will be examined later in this analysis.

Condom Use

Among all MSM high risk behaviors, unprotected anal intercourse is considered the most dangerous type of behavior contributing to HIV incidence within this community (CDC, 2015c). There are several factors that contribute to MSM choosing not to use condoms while partaking in sexual activity. One of which must do with personal attitudes towards condoms. An internet study completed the United States found that most MSM believe condoms to be unreliable and unpleasant to use (Klein, H. & Kaplan, R. L., 2012). However, participants in this same study stated that they would not object to using a condom if their partner asked them to (Klein, H. & Kaplan, R. L., 2012). Another reason MSM fail to use condoms is from having low support from their peers. Data from a study conducted in three major U.S. cities confirm that perceived low peer support of condom use is associated with unprotected anal intercourse among MSM (Carlos et al., 2010). The method that MSM utilize to meet sexual partners has also shown to have an influence on condom use. A 2011 study confirms that MSM who meet their sexual partners in an online outlet are more likely to partake in unprotected anal intercourse (Ostergren, J. E., Rosser, B. R., & Horvath, K. J., 2011). This includes any internet forum, social media, or chat room activity. Other reasons MSM do not use condoms include believing they are at a low risk, being in a monogamous relationship, and being under the influence of alcohol or drugs.

Monogamy

Monogamy is the practice of having sexual relations exclusively with one partner. This practice typically occurs because of two individuals entering a relationship as they discuss/agree to the parameters of that relationship. Monogamy can be adhered to for part of, or throughout the entire life of a relationship. When monogamy is broken by any means (cheating or temporary break up) it puts individuals in that relationship at an increased risk of contracting HIV. Recent studies on the MSM population have shown that most new cases of HIV transmission occur when individuals report being in a monogamous relationship (Gass et al., 2012; Hoff, C. H., & Beougher, S. C., 2010a; Goodreau et al., 2012). In fact, it is estimated that almost 70% of newly HIV positive MSM contracted the virus from their main sex partner (Brady et al., 2013).

This disparity can be better understood by examining several elements. First it is vital to understand that an overwhelming majority of MSM in the U.S. do not practice condom use while in monogamous relationships (Darbes et al., 2014). Evidence shows that high rates MSM are practicing deviant sexual behavior (cheating) outside of their monogamous relationships (Gass et al., 2012). Another factor is that MSM couples are negotiating and agreeing to participate in non-monogamous sexual behaviors both together and/or separately. This is practice is often referred to as an “open relationship”. Studies have found that when pertaining to instances of open relationships, MSM have consistent high rates of participating in unprotected anal intercourse with both their primary and secondary sexual partners, with the lack of condom use occurring most often with the primary partner (Darbes et al., 2014; Brady et al., 2013).

Although there have been mixed reviews, recent research has shown that open relationship agreements that are functioning well for MSM couples can be used as a means to reduce HIV transmission (Hoff et al., 2010b). However, setting strict parameters within the open relationship is crucial to be effective. Such parameters include using condoms with all non-primary partners, progressively communicating with all partners on personal boundaries/limitations, and knowing the serostatus of all partners involved. This requires that all parties involved are tested. There is evidence showcasing that being satisfied in a MSM relationship was significantly associated with a couple’s ability to having and agreeing with their sexual agreement (Mitchel et al., 2012). Several interventions have been performed on the MSM community specifically targeting couples who are in, or have experimented with an open relationship. The purpose of the interventions was to educate MSM couples on living a healthy monogamous lifestyle as well how they can reduce their HIV risk if in open relationship. These studies have shown to both increase monogamous intentions among MSM and reduce high risk behaviors (Beougher et al., 2015; Darbes et al., 2014; Blashill et al., 2014; Darbes et al., 2012; Brady et al., 2013; Mitchell, J. W., 2013).

Substance Abuse

The men who have sex with men community is at a disproportionately higher risk for substance abuse then the rest of the United States population. Per CDC (2016c), MSM are more inclined to use alcohol and drugs, have higher rates of substance abuse, and continue this abuse later into their lives more so than the general population. Research has found that alcohol and drugs are used by MSM to self-treat mental or physical issues like anxiety or erectile dysfunction (CDC, 2016c). Anxiety can be experienced by MSM because of homophobia or heterosexism, which both induce negative connotations towards same sex sexual practices. Recent research shows that homophobic and heterosexist encounters have an influence on increased MSM substance abuse (Spector, A. Y., & Pinto, R. M., 2011).

Not all MSM substance abuse is due to the mental or physical issues that they encounter. Research has shown that many MSM indicate that they abuse alcohol and drugs for recreational and/or personal enjoyment purposes (Klein, H. 2011; Ramirez-Valles et al., 2008). Participants in various HIV studies conveyed a liking of being under the influence while having sex rather than being sober, with a majority expressing a preference for illegal drug use over alcohol (Klein, H. 2011; Ramirez-Valles et al., 2008). This practice is prevalent in MSM across the United States, especially among those under 40 years of age (Kerr, D. L., Ding, K., & Chaya, J., 2014). Some of the most common illegal drugs utilized by MSM include cocaine, ecstasy, crystal methamphetamine, and marijuana (McCabe et al., 2009).

When MSM partake in substance abuse activities it increases their chances of participating in other high risk sexual behaviors, which amplifies their overall risk of contracting HIV. Various HIV interventions have been implemented on the MSM community that specifically target alcohol and illegal drug users. The purpose of the interventions was to inform MSM of the consequences that stem from substance abuse as well as how it can influence sexual behavior decisions that lead to an HIV diagnosis. These interventions have had success in both decreasing MSM substance abuse and/or intentions to engage in substance abuse activities (Wong et al., 2008; VanDevanter et al., 2011; Kurtz et al., 2013; Mansergh et al., 2010a; Spector, A. Y., & Pinto, R. M., 2011; Mansergh et al., 2010b; Carrico et al., 2014).

Intervention Methods

Many HIV interventions in the past have utilized a physical face to face or group approach to convey a message to a target audience. Other in person intervention strategies include counseling, social networking and partner counseling/referral strategies. There are also types of proven alternative intervention strategies that have opened the door to new opportunities, not requiring the researchers to physically meet or speak to their target audience. Some of these various strategies include internet/computer based, chat room, text messaging, and social media interventions. All strategies used within the last 10 years will be reviewed to determine their effectiveness in increasing HIV testing practices and decreasing high risk behaviors within the MSM community.

Face to Face Interventions. Face to face HIV interventions can be implemented on various levels within a target population depending on the desired outcome. Some of the most common levels are individual (one on one), group level (more than one participant), and community level (an entire population). Individual level HIV interventions can be delivered through trained professionals, educators or even peers and usually involve educating to modify attitudes, knowledge, and beliefs about HIV. Group level HIV interventions typically build on information found at the individual level with added training exercises such as role playing, decision making, and physical practice (i.e. how to put on a condom correctly). Lastly, community level HIV interventions are constructed to inspire populations to make a behavior change. It usually cannot be completed in short periods as it can take time for individuals to collectively make behavior changes. This type of intervention is typically reinforced by a large-scale entity such as high ranking members of a community, deliberate advertising, or by social media within a specific target population. It is also possible to have a cross over method for example an intervention being performed at the individual level but then having the findings consolidated or crossed with others like it to establish trends or variances in data. Recent studies have shown that face to face interventions have a positive impact on MSM HIV testing practices and counseling across all levels (Stephenson et al., 2011; Baytop et al., 2014; Stephenson et al., 2015; Halkitis et al., 2011).

eHealth Interventions. Some of the most recent HIV interventions to emerge involve no physical face to face contact. eHealth interventions utilize technology to provide opportunities for MSM to get information electronically delivered in a more convenient and personal setting. These types of interventions can be provided in various ways including chat rooms, social media, email, and even text messaging, most of which require internet connection. Web/internet use has gained massive popularity over recent years with 85% of American adult males using it regularly in 2015 (Pew Research Center, 2015). Therefore, it presents immense opportunities for MSM HIV health interventions of various types.

Computer and Internet Interventions. HIV Interventions implemented for use on the computer via internet has several advantages. A key advantage is that it offers the participant interactivity with programs specifically designed to identify high risk behaviors and influence testing. Users can be faced with questions and decision making scenarios within its context. This method can be formatted to be useful in an individual or group intervention. It also has the potential to have a very wide-ranging scope due to existing online. There are proven HIV research studies that illustrate the effectiveness of computerized/internet intervention methods with significant increases in testing and reductions in risk behavior (Erausquin et al., 2009; Kegeles et al., 2012; Hirshfield et al., 2012). All studies presented MSM with computer training interventions via online video, or interactive programing and were assessed before/after viewing the material.

Chat Room Interventions. Since the inception of the internet research has shown a substantial growth in the amount of MSM using chat rooms to meet sex partners (St. De Lore et al., 2012; Hirshfield et al., 2012). It has also been found that the MSM who use online chat services to meet sex partners are more prone to partake in unprotected anal intercourse as well as other HIV high risk activities (Paul et al., 2010; St. De Lore et al., 2012). Chat room interventions are implemented into the same chat services that MSM utilize to meet their sex partners. A live human counselor signs into the open forum chat services and offers participating MSM free safe sex counseling and HIV testing information. An advantage of this type of intervention is that the interventionist is always a live person and never automated. This can provide an active collaborative experience between the interventionist and the participating MSM where they can hold constructive conversations about high risk behaviors. Another advantage to using chat rooms is the interventionist can provide counseling in an atmosphere where MSM naturally gather. Numerous studies have successfully applied chat room HIV interventions to MSM, all of which yielded MSM having either increased cognizance of high risk activities, increased testing behaviors, or both (St. De Lore et al., 2012; Moskowitz et al., 2009; Rhodes et al., 2010).

Social Media Interventions. Social media is a relatively new method that individuals utilize to maintain communication. This type of media includes applications such as Facebook, Twitter, Tumblr, and Instagram that allow its users to post pictures/videos and chat with each other in an online forum. This type of media can be accessed through various outlets including computers, mobile phones, and tablets. Research has shown that social media has a consistent growing popularity within the MSM demographic, particularly with those who use it to meet sex partners. (St. De Lore et al., 2012; Phillips et al., 2014). Therefore, it is feasible to implement HIV interventions within social media outlets known to be frequented by MSM.

While MSM exploit all applications of social media (including those that heterosexuals utilize) to meet/communicate, there are other outlets specifically created for the MSM community. Examples of such outlets include but are not limited to Grindr, Jacked, Adam4Adam, and Scruff. These applications allow its users to create personal profiles showcasing their interests, intentions, and even location proximate to others. After a profile is created the user can communicate with others through online chat and then decide to meet in person. Various research suggests that MSM who utilize social media of any kind for meeting sex partners are more likely to perform HIV high risk sexual activities, therefore making social media an opportune venue for interventions (Young et al., 2013; Phillips et al., 2014). Some of the few HIV interventions performed using social media have generated data suggesting that it aided in either decreasing risk behaviors, increasing testing behaviors, or both (Ramallo et al., 2015; Young et al., 2014). Some of the activities performed in interventions included posting HIV prevention ads on various social media applications as well as actively attempting to chat with individuals about risk reduction and testing practices. More research is needed in the social media area.

Methods

Journal article gathering will be conducted through online databases such as EBSCO Host, PubMed, and ProQuest, all of which are provided by National University. Keywords initially searched will be HIV intervention AND men who have sex with men (MSM). The search will then be narrowed by adding in more keywords that are specific to the topic. These keywords include HIV testing, eHealth, face to face intervention, computer intervention, internet intervention, social media intervention, condom use, monogamy, substance abuse, and HIV risk reduction. Additional narrowing for keywords may be required as the search continues. All articles collected will be analyzed by title to determine if they pertain to the topic of this paper. Articles will then be further narrowed by sorting through the abstracts and keywords. Final article selection will be determined by those that are most pertinent to the topic.

Inclusion/Exclusion Criteria

Peer reviewed journal articles will have utilized in this paper to find only legitimate and accurate sources of data. Articles from reputable state or government agencies will also be included in this paper for statistical and explanatory purposes. Only articles written from 2007 through 2016 will be used to keep all research as current as possible. All intervention research must have been performed in the United States or countries with similar levels of industrialization such as countries of Western Europe or Australia to be included in this study. Finally, all articles used will contain interventions performed on MSM (or supporting material), excluding minors, and will only be written in the English language.

Research Design

This study will use a qualitative design approach, in which a systematic review will be conducted to determine the necessity and effectiveness of various types of HIV interventions that target MSM. Effectiveness will be measured by increases in HIV testing and/or reduction in HIV behavioral risk factors. MSM intentions to increase testing or reduce high risk behaviors will also be considered effective as not all interventions have the same follow up procedures that track if participants followed through. A comparison and contrast will be performed to see how different intervention methods impacted the target population.

Assumptions

Since all articles used in this paper will be peer reviewed or from state/government agencies, it is assumed that all studies contained in the articles were performed accurately and are also ethically sound. It is also understood that HIV will continue to be a disease that disproportionally affects the MSM community. It is assumed that evaluations made within this paper can be used to make inferences about the United States MSM population.

Limitations

Since this paper is a systematic review of various HIV interventions within the MSM community a limitation that could occur is selection bias. Not all participants in the numerous studies were chosen randomly. While results of this study will be able to be generalized across MSM in the United States, its results cannot be inferred about MSM worldwide. Results are also not able to be generalized to young or elderly MSM as they have not been evaluated in this study. Lastly there is a chance that any observed behavior changes in MSM could be due to the participants knowing they are being evaluated and therefore purposely behaving differently.

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