HIV Disparities Among Young Men in Brooklyn's House Ball Community

1. HIV Disparities In Brooklyn Among Young Men of Who Have Sex with Men in the House Ball Community Jeffrey M. Birnbaum, MD, MPH Executive Director, HEAT Program Associate Professor of Pediatrics and Public Health, SUNY Downstate Medical Center/Brooklyn, NY

2. HEAT, founded in 1992, is a program of SUNY Downstate Medical Center and is the only program of its kind in Brooklyn to offer age/developmentally appropriate, and culturally competent comprehensive care for HIV+ and at-risk youth, aged 13-24. • HEAT has focused HIV related clinical programming for perinatally infected youth, young women of color, young MSMs and transgender youth. • HEAT also serves high risk youth from the above populations categories who are HIV negative, providing HIV C/T, STD screening and treatment, PrEP/PEP services, hormonal therapy (transgender), mental health counseling and an array of prevention services.

5. What are the unique issues that put specifically young Black MSM at risk for HIV/AIDS and other STDs?

6. Impact of the Larger Societal & Cultural Influences Impact of Black Cultural Influences Marginalization of sexual identity by Black community Marginalization of Black identity by larger society Rejection by family and other support systems Societalhomophobia Devalued personhood “Abomination” messages from faith community HIV stigma Lack of HIV testing Lack of effective engagement in HIV care Increased morbidity and mortality

7. HEAT Responds to the Problem of HIV/AIDS in Young MSM of Color: • Outreach • HIV counseling and testing • Prevention • HIV care • PrEP services

8. Specific Healthcare Needs of YMSM/Gay Youth • Outreach to “ballroom” community and other venues for MSM/gay male youth are necessary to bring youth into care settings • Disclosure of sexuality in general as well as how it relates to engagement in care and HAART or PrEP adherence • Mental health issues: increased suicide rates, social isolation, peer support • High rates of homelessness • Clinical expertise in dealing with syphilis, anal STDs (eg. Condyloma, anal Pap smears/dysplasia/HPV/anoscopy, herpes, Gc/chlamydia, etc.)

9. Healthcare Outreach to the House Ball Community • The House Ball community is composed of groups (“houses”) of individuals participating in dance and fashion competitions known as balls, a long-standing feature of the NYC nightlife. • The House Ball community is predominantly Black and Latino MSM and transgender women. • Houses are social networks that vary in size and organization. Houses can also be seen as alternative family structures with “mothers”, “fathers” and “children”. • For many youth, the House Ball community provides a much needed social structure, support, and sense of family. • Many youth participate in the House Ball community through the “kiki” houses. • House and Ball communities are a critical access point for engaging these youth, both those at high-risk for HIV infection and those already HIV infected.

10. HEAT’s Core Prevention Activities for Young MSM from Communities of Color • Host House Ball “kiki” events to engage youth in the community on their own turf • HIV counseling and testing; community based STI screening • PrEP services • Many Men, Many Voices (3MV) • Many Men, Many Voices Plus (3MV+) • Vogue Theory • HBC adaptation of combined 3MV+Vogue Theory • Linkage to HIV care, PrEP, sexual health services

13. Issues Impacting HIV C/T for HBC Youth • Post-test counseling for an HIV+ youth in a house ball setting can be challenging-ballroom environment, presence of other house members outside HIV testing area; mental health staff; stigma issues pose a major barrier to linkage to care • Linkage to care is essential to any successful HIV testing effort with YMSM, in particular with the house ball community: • Solid contact information • Peer outreach • Fostering relationships with house leaders • Offering HIV care that is perceived by youth as “safe” and addresses all confidentiality concerns • Patient navigators • Meeting YMSM in neutral locations and escorting them to care

14. “Seven Deadly Sins” Ball Survey • Random cross-sectional survey done at a HBC ball event • 114 youth approached, acceptance rate 74.6%) • Age range: 16-29 years, 85% were youth of color; 7% were TG/MTF • Over 13% reported being HIV-positive • More than 42% reported being homeless at some point in their lives • 46% reported being financially stressed • Over 40% reported recent experiences of discrimination, either in school (37.5%), by the police (23.9%) or in housing (15.2%) • Youth who had experienced these social stressors were significantly less likely to have received an HIV test in the past year (p < .05)

15. “Seven Deadly Sins” Ball Survey • Participants reported high levels of concern about HIV, 48% of youth reported that they worry about HIV some, most or all of the time. • Youth’s responses indicated the importance of the HBC in their lives, with high percentages reporting feeling comfortable (57%), accepted (50%), and supported by (45%) the HBC. • These data demonstrated the feasibility of engaging HBC youth at ballroom events, and provided empirical support for intervention development

16. HEAT Program Findings, Transgender Youth 2002-2017

19. 3MV Plus: • an adaptation of the 3MV curriculum • targets Black YMSM 13-24 years who are already HIV+ • important tool for reducing horizontal transmission of HIV infection to new partners by personal risk • protecting themselves from re-infection with HIV as well as other STDs • adaptation would focus on the role of engagement in care, HAART adherence, CD4/viral load, STD presence, and the overall mental and physical health for HIV+ young people. • improved emotional health • social support of a group of HIV+ peers

21. Vogue Theory • A “home-grown” seven week group level intervention piloted by HEAT • Developed by two HBC leaders, Pony Zion/Devon Webster and Michael Roberson, in response to seeing the limitations of existing interventions, especially in the area of self-discipline, community-building and leadership development • Targets YMSM and other HBC youth, regardless of HIV status • Teaches youth how to vogue in the Balls as a means of instilling self-esteem, team-building, leadership skills and to curb the social isolation many YMSM experience. • Promotes positive youth development and creates a sense of community • Builds self-esteem by improving their vogueing skills and connecting with their peers • The goal is that this positive self worth, along with HIV risk reduction education and access to comprehensive services at HEAT, will lead to reduced risk taking • Facilitators introduce core values and instill the importance in creating positive results for a ballroom performance and navigating stressful situations in daily life with improved coping skills

24. Lessons Learned From HEAT’s Work With the HBC • Communities of support rather than simply communities of risk • Any agency working with HBC youth MUST become a part of the community • Intra-vention strategies: HIV/AIDS prevention activities that are conducted and sustained through practices and processes within at-risk communities themselves • Looking more closely at performance and other cultural nuances within the HBC in theory and practice to inform new and innovative HIV prevention programming • Cultural space of hope – the social knowledge of ballroom and a kinship system that both sustains the community and facilitates HIV/AIDS prevention

25. INNOVATION:Enhancing Engagement in HIV Prevention and Care in the House/Ball Community • Our combined adapted 3MV and Vogue Theory interventions are designed to reduce HIV risk specifically by enhancing cognitive appraisal, increasing positive coping strategies, and strengthening community-based resources for HBC youth. • First, this project is innovative in that it develops an intervention for the house/ball community (HBC), a group that has been previously understudied in HIV prevention and care. • Second, this project is innovative in the extent to which it has emerged from and is conducted in collaboration with HBC leaders. • Third, it is innovative in its focus on HBCmembers as the target of intervention, rather than a specific demographic group.

26. Let’s Collaborate!!!!! • What we have at HEAT: • An innovative intervention and some experience piloting it • Community participation and buy-in • A trusted clinical program to serve the participants • Intervention specialists/facilitators with experience • What we need from collaborators: • Partners with expertise in group behavioral interventions to address health disparities • Assistance in preparing grant submissions, intervention manuals and manuscripts • Data management; evaluation and analysis

27. THANK YOU!!