Abstract
In 2018, the Health Resources and Services Administration (HRSA), HIV/AIDS Bureau (HAB), through the Ryan White HIV/AIDS Program (RWHAP) Part F: Special Projects of National Significance (SPNS) Program, launched a new multiyear study to address the national goals to end the HIV epidemic. Two of those goals continue to be increasing access to care and optimizing health outcomes for people with HIV and reducing HIV-related health disparities and health inequities. 1
This initiative, Implementation of Evidence-Informed Behavioral Health Models to Improve HIV Health Outcomes for Black Men Who Have Sex with Men (hereafter the Black MSM Initiative), sought to adapt and implement evidence-informed or evidence-based approaches for linking, engaging, re-engaging, and retaining Black MSM with HIV in medical care and supportive services. Unique to this initiative, the recipients were required to integrate behavioral strategies into these approaches that address the specific needs of Black MSM with HIV with the ultimate goal of improving health outcomes.
At the time this initiative was conceptualized, there were compelling data to suggest that a more targeted approach to addressing the gaps in care and treatment for Black MSM with HIV was needed. Despite decreasing overall HIV incidence in the United States and overall improvements in HIV health outcomes for people with HIV, Black people in the United States continue to have higher HIV incidence rates and poorer health outcomes when compared with other racial and ethnic groups. 2 According to the CDC, Blacks/African Americans accounted for almost half (44.3%) of all new HIV diagnoses in 2015, among whom, 38.4% were gay and bisexual men. 3
Among all subpopulations with new HIV diagnoses, Black MSM were the most affected subpopulation. If current HIV diagnoses rates persist, about 1 in 2 Black MSM in the United States will be diagnosed with HIV during their lifetime compared with 1 in 11 White MSM. 4 Since then, this trend has remained consistent. Black/African American people accounted for 42% (15,305) of 36,801 new diagnoses in the US and dependent areas in 2019. 5 Of this, 79% (9123) identified the exposure category as male-to-male sexual contact, while 3% (298) were exposed through male-to-male sexual contact and injection drug use. Among men who have sex with men (MSM) with diagnosed HIV infection at year-end 2014, 74.1% received any HIV care, 57.7% were retained in continuous care, and 61.2% had reached viral suppression. Younger MSM and Black or African American (Black) MSM had the least favorable HIV care outcomes. 6
Similar disparities also existed within the RWHAP at the time. In 2015, the RWHAP served 533,036 clients, and among them 47.1% were Black/African American. 5 Among male clients, Blacks/African Americans comprised the largest racial/ethnic group (41.2%) of RWHAP clients. African Americans also comprised one-third of MSM clients, but 60.1% among MSM were aged 13–24 years. Although the percentage of Black/African American men who were retained in care (78.6%) was close to the national RWHAP average (80.6%), the percentage who achieved viral suppression was slightly lower (78.9%) than the national average (83.4%). Among all MSM racial/ethnic groups, viral suppression was lowest for Black African Americans (77.7%). 7
Black MSM with HIV face a number of comorbidities and challenges that impact their ability to engage or remain in care. Studies have shown Black MSM experience more frequent and severe consequences of substance use than do White MSM, leading to health disparities such as poorer health outcomes. 8 Once diagnosed with HIV, Black MSM are at higher risk of having poor health outcomes, and those negative outcomes are further compounded by behavioral health issues such as depression, substance use, and histories of trauma, all of which may influence their ability to access clinical or behavioral health care. 9
Among Black MSM with HIV, the stress that accompanies experiences of discrimination based on their race, sexual orientation, and HIV status adds to their cumulative burden of stress and increases their vulnerability for depression and anxiety.
Traditionally, the RWHAP Part F SPNS program has previously supported the development of innovative models of care. However, given the existence of evidence informed and evidence-based models of care that focused on young MSM of color prevention models designed for Black MSM, SPNS chose to allow for the adaptation and implementation of these existing models. The National Alliance of State and Territorial AIDS Directors Center for Engaging Black MSM across the Care Continuum (CEBACC), with funding from the US Department of Health and Human Services Minority HIV/AIDS Fund, created an inventory of evidence-informed interventions for Black MSM with HIV across the care continuum. CEBACC identified best practices and effective models for HIV clinical care and treatment in order to increase the capacity, quality, and effectiveness of health care providers to screen, diagnose, link, and retain Black MSM in HIV clinical care. 10
In addition, the National Institute of Mental Health (NIMH) identified two previous RWHAP SPNS demonstration models as evidence-informed interventions for addressing behavioral health. The Black MSM initiative purposefully built upon this work by adapting and implementing four interventions specifically to address the behavioral health needs of Black MSM with HIV to improve their engagement and retention in care: (1) Youth Focused Behavioral Health Case Management, (2) Brothers United/Damien Center Linkage to Care, (3) Strength Through Youth Livin’ Empowered (STYLE), and (4) Project Silk.
The specific goals of the Black MSM initiative were to adapt, implement, and evaluate the implementation of HIV treatment service models and approaches that include both medical and behavioral health components. The eight recipients and Evaluation Provider selected for this endeavor provided services to >805 individuals and followed >758 in the longitudinal multisite evaluation. In this special supplemental issue of AIDS Patient Care and STDs, the Black MSM Initiative Study Group presents its findings and lessons learned from over the 4-year project period.
These articles represent 4 years of focused and deliberate work of the recipients. Over the 4-year project period, the demonstration sites were able to successfully implement their programs even in the midst of the global COVID-19 pandemic that forced many to adapt their adaptations to allow for continued services. As reflected in the articles to come, evaluations have found improvements in several key outcomes of interest, including retention in care, receipt of HIV prescriptions, and viral suppression. Most notably, these articles will present both process and outcome evaluation findings from the multisite evaluation as well as local evaluations representing four diverse approaches to providing services.
Last, but by no means least, you will hear from frontline staff who highlight their direct observations on the implementation of these intervention models, with lessons learned that can be applied in future studies. It is hoped that the forthcoming implementation tools and materials, along with the findings and lessons learned captured in this supplement, will lead to the adoption of these HIV care models that incorporate behavioral health services by other Ryan White HIV/AIDS Program providers.