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. 2009 Jun;99(6):1008–1012. doi: 10.2105/AJPH.2008.140558

Learning From Successful Interventions: A Culturally Congruent HIV Risk–Reduction Intervention for African American Men Who Have Sex With Men and Women

John K Williams 1,✉, Hema C Ramamurthi 1, Cleo Manago 1, Nina T Harawa 1
PMCID: PMC2679795  PMID: 19372517

Abstract

Few HIV prevention interventions have been developed for African American men who have sex with men or who have sex with both men and women. Many interventions neglect the historical, structural or institutional, and sociocultural factors that hinder or support risk reduction in this high-risk group.

We examined ways to incorporate these factors into Men of African American Legacy Empowering Self, a culturally congruent HIV intervention targeting African American men who have sex with men and women.

We also studied how to apply key elements from successful interventions to future efforts. These elements include having gender specificity, a target population, a theoretical foundation, cultural and historical congruence, skill-building components, and well-defined goals.

AFRICAN AMERICAN MEN WHO have sex with men (MSM) or who have sex with both men and women (MSMW) have the highest HIV prevalence among African Americans and among other racial/ethnic groups of MSM.1–3 However, HIV risk behaviors alone do not explain the disproportionate HIV rates among African American MSM.4,5 Attention to the sociocultural challenges facing African American MSM is needed.

Only 1 published HIV behavioral intervention targets African American MSM6; none specifically target African American MSMW. Inclusion of culture is believed to improve the ability of public health programs to meet members' needs.7–9 However, inherent abstractness and a lack of operationalized definitions and cultural competency pose challenges for those designing and implementing interventions.10–14 Understanding the experiences of African American MSM requires attention to definitions of what it means to be African American and of male sexuality that are rooted in African American history and culture. Choices regarding identification with gay or bisexual labels and disclosure of Black same-gender sexual activities must be contextualized within African American communities.15–17

Health improvement among African American MSM requires attention to racism; gender role expectations; connection to partners, families, and communities; and HIV-related stigma.18–22 Double minority status is made worse by high HIV rates and perceived responsibility for spreading HIV.23–25 Even if family and community provide social support, homophobia and racism can deter African American MSM from disclosing their sexuality and seeking HIV prevention and care.26 Interventions must engage protective factors and address structural or institutional and sociocultural barriers to prevention.

DEVELOPING A SUCCESSFUL INTERVENTION

We reviewed the Centers for Disease Control and Prevention's Compendium of HIV Prevention Interventions With Evidence of Effectiveness27 and identified 6 key elements of successful interventions. These elements were incorporated into a culturally congruent intervention, Men of African American Legacy Empowering Self (MAALES), a community-based HIV risk-reduction intervention targeting African American MSMW.

Components of the Intervention

MAALES involves 6 group sessions lasting 2 hours each and conducted over 3 weeks, with booster sessions at 6 and 18 weeks after the main intervention. Sessions 1 and 2 focus on past experiences and their effect on behaviors and sexual decision-making, sessions 3 and 4 focus on current behaviors and sexual and drug risk reduction, and sessions 5 and 6 focus on sustaining risk reduction. The primary goals of MAALES are to decrease unprotected intercourse, decrease the number of sexual partners, and decrease use of drugs and alcohol before sexual intercourse while increasing racial and cultural pride and reducing HIV stigma and gender role conflict. MAALES has several key elements. MAALES targets African American MSMW of any HIV status.

Theoretical foundation. We combined elements of the theory of reasoned action and planned behavior,28,29 empowerment theory,30 and the critical thinking and cultural affirmation model.31,32

According to the reasoned action theory, safer-sex norms, positive attitudes regarding prevention, and perceived control are necessary to reduce HIV risk behaviors.28,29 Empowerment theory facilitates personal strategies for risk reduction. The critical thinking model, developed in African American communities, teaches critical thinking31 and promotes positive mental health and elements of African American history and culture, such as collectivism and spirtuality.33 Empowerment theory and the critical thinking model address issues of oppression, race/ethnicity, gender, HIV stigma, and sexual identity that may influence intentions or perceived ability to adopt preventive behaviors.34–38

Cultural and historical congruence. Along with ethnically matched community facilitators, MAALES incorporates historical and cultural elements. Two sessions each focus on the past, present, and future. Participants discuss historical events such as slavery, the Tuskegee syphilis study, and the Million Man March within the sociocultural context of being an African American MSMW, as well as associated feelings of oppression, mistrust, and unity.22

Sexual decision-making is addressed within the framework of identifying historical and personal stressors and coping with feelings that may lead to sexual risk taking. Stereotypes and language describing African American sexuality and masculinity are explored through contemporary media and prose.19 Experiences of perceived racism and discrimination, such as being ignored, struggling to find employment, and being stopped by the police,39 and consequent feelings that may lead to sexual risk taking are also discussed.

The middle 2 sessions focus on current sexual and drug risk behaviors, with case vignettes illustrating how past experiences influence sexual decision-making. Role playing and interactive exercises address communication and safer-sex negotiation skills. The last 2 sessions center on sustaining HIV risk reduction, emphasizing collectivist ideals, and reinforcing individual health commitments. Cultural and religious messages contradicting HIV prevention are challenged.

The program also includes West African Ghanaian Adinkra symbols, which convey historical or cultural messages. For example, the fihankra, a symbol for house or compound, means safe enclosure and is used to create a safe group space; sankofa, a symbol of a bird looking over its shoulder, suggests that progression only occurs by knowing the past. These symbols are visual anchors for content and historical linkages to Africa.

Specific skill-building components. These include effective communication techniques, safer-sex negotiation, and correct condom use. Proper condom use is an important skill for African American MSMW, because rates of condom use errors and failure are high.40–43

Well-defined objectives focusing on reducing HIV risk behaviors. The objectives for each MAALES session and activity are defined for facilitators. Table 1 summarizes these and illustrates how theory-based activities are linked to expected outcomes.

TABLE 1.

Theory-Based Curriculum and Target Outcomes of MAALES

Session Activities Applied Theory Target Outcome
Session 1: Fihankra symbol (safe enclosure)
Introduction of MAALES program.
Introduction of group members, facilitators and staff; cultural elements include Fihankra group, Ashe affirmation circle, and so on. CTCA Empowerment theory Increase racial and cultural pride.
Discussion: what does it mean to be an African American man in America? Includes critical review of music lyrics, survey of realness, masculinity, and so on. CTCA Empowerment theory Increase racial and cultural pride.
Discussion: past contributions, moving forward. CTCA Empowerment theory Increase racial and cultural pride.
Session 2: Sankofa bird (examining the past)
Discussion: HIV in African American communities. Includes challenging myths. TRA/TRP Empowerment theory Decrease risky sexual behaviors.
Discussion: preserving African American identity and manhood. Includes challenging images and stereotypes. CTCA Empowerment theory Decrease risky sexual behaviors. Decrease drug and alcohol use with sexual intercourse. Increase racial and cultural pride.
Discussion: assessment of personal risk. Includes personal risk survey, case vignette of African American MSMWs with multiple HIV risk factors, and so on. TRA/TRP CTCA Empowerment theory Decrease risky sexual behaviors. Decrease drug and alcohol use with sexual intercourse.
Discussion: preserving personal and community health. TRA/TRP CTCA Empowerment theory Decrease risky sexual behaviors. Decrease drug and alcohol use with sexual intercourse. Increase racial and cultural pride.
Session 3: Bu Wo Ho (respect yourself)
Discussion: reasons for preserving health. Includes video clip. CTCA Empowerment theory Increase racial and cultural pride.
Discussion: health disparities. Includes genograms to identity familial health risks and those who may be supportive and collectivism. TRA/TRP CTCA Empowerment theory Decrease risky sexual behaviors. Decrease drug and alcohol use with sexual intercourse. Increase racial and cultural pride.
Discussion: safer-sex tools. Includes condom and lubricant options, condom and penis model, and so on. TRA/TRP Empowerment theory Decrease risky sexual behaviors. Decrease drug and alcohol use with sexual intercourse.
Discussion: communication about safer sex. Includes barriers; “why, you, and if–then” statements; “I” statements; individualism vs collectivism; and so on. TRA/TRP CTCA Empowerment theory Decrease risky sexual behaviors. Decrease drug and alcohol use with sexual intercourse. Increase racial and cultural pride.
Session 4: Wawa Aba (overcoming barriers)
Discussion: safer-sex options. Includes creating a safer-sex menu. TRA/TRP CTCA Empowerment theory Decrease risky sexual behaviors. Decrease drug and alcohol use with sexual intercourse.
Discussion: specific measureable action-oriented realistic and timely (SMART) goals; realistic and personal goals to improve health. TRA/TRP CTCA Empowerment theory Decrease risky sexual behaviors. Decrease drug and alcohol use with sexual intercourse.
Discussion: HIV testing. TRA/TRP Empowerment theory Decrease risky sexual behaviors. Decrease drug and alcohol use with sexual intercourse.
Discussion: sexually transmitted diseases. TRA/TRP Empowerment theory Decrease risky sexual behaviors. Decrease drug and alcohol use with sexual intercourse.
Session 5: Akoko Nan (protect; love through discipline)
Discussion: revisiting SMART goals. Includes addressing personal goals and overcoming sociocultural barriers to improve health. TRA/TRP CTCA Empowerment theory Decrease risky sexual behaviors. Decrease drug and alcohol use with sexual intercourse.
Discussion: critical thought for making choices. Includes the stop, think, outline options and plan (STOP) technique, applying STOP for high-risk heterosexual and bisexual situation, illustrated with contemporary video clips. TRA/TRP CTCA Empowerment theory Decrease risky sexual behaviors. Decrease drug and alcohol use with sexual intercourse. Increase racial and cultural pride.
Discussion: alcohol and substance abuse. Includes case study. TRA/TRP CTCA Empowerment theory Decrease risky sexual behaviors. Decrease drug and alcohol use with sexual intercourse.
Discussion: cultural affirmation for safer sex. Includes Adinkra symbols. TRA/TRP CTCA Empowerment theory Decrease risky sexual behaviors. Decrease drug and alcohol use with sexual intercourse. Increase racial and cultural pride.
Session 6: Ohene (foresight and wisdom)
Discussion: revisiting SMART goals. Includes progress and commitment toward achieving personal goals. TRA/TRP CTCA Empowerment theory Decrease risky sexual behaviors. Decrease drug and alcohol use with sexual intercourse.
Discussion: planning. Includes outlining options for sexual and general health. TRA/TRP CTCA Empowerment theory Decrease risky sexual behaviors. Decrease drug and alcohol use with sexual intercourse. Increase racial and cultural pride.
Discussion: condom review. Includes reviewing skills, sharing knowledge about condoms and lubricants, and so on. TRA/TRP Empowerment theory Decrease risky sexual behaviors. Decrease drug and alcohol use with sexual intercourse.
Discussion: synthesis. Includes reviewing and implementing ways to achieve individual and community sexual and general health. TRA/TRP CTCA Empowerment theory Decrease risky sexual behaviors. Decrease drug and alcohol use with sexual intercourse. Increase racial and cultural pride.
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Note. MAALES=Men of African American Legacy Empowering Self; CTCA=critical thinking and cultural affirmation; TRA/TRP=theory of reasoned action and planned behavior; MSMW=men who have sex with men and women.

Community Settings for the Intervention

MAALES was developed with 3 community agencies after extensive formative research involving 9 focus groups (n = 58) and 20 individual interviews. To emulate the settings in which this intervention will eventually be disseminated, pilot testing took place. Intervention testing is continuing at these community agencies, facilitated by their trained culturally competent staff. The agencies offer a range of health and social services—some related to HIV and others not—to a diverse clientele. Hence, there is little HIV or gay stigma associated with receiving services at these agencies, which increases receptivity.

Facilitators are African American men who have rapport-building skills that are essential for establishing and maintaining relationships with participants.44 They emphasize confidentiality throughout client interactions and use retention strategies45 whose effectiveness was demonstrated in another local study with African American and Latino bisexual MSMW.46

INITIAL EXPERIENCES

MAALES is still being tested, but early evaluations and qualitative case studies report high levels of satisfaction and favorable outcomes. One participant stated in a postintervention evaluation, “Everything was kept confidential; they make you feel like they have walked in your shoes. They make you feel like you have no [HIV] status.”

Participants overwhelmingly felt that they could relate to each other. One commented, “I loosened up and everything was okay and the participants were going through the same thing I was going through … being an HIV gay person.” Some participants started using condoms, and others reflected on their sexual behaviors: “[MAALES] got me taking a look at sexual behaviors … why my sexual behavior is the way it is, the class provokes thought.”

Given the need for more culturally congruent approaches, we hope that other researchers will find MAALES a useful template for addressing high-risk subgroups who have thus far been underserved in HIV prevention interventions. Emphasis must also be placed on dissemination of successful interventions into communities at risk.

Acknowledgments

This study was funded by the California HIV/AIDS Research Program (AL04-Cdrew-840) and the UCLA–Drew Project EXPORT (National Institutes of Health grant 1P20MD001148-01 and National Center on Minority Health and Health Disparities grant 2P20MD000182-06).

We thank the collaborating community-based organizations and their staff members for input into the study design, assistance with recruitment, and use of their facilities. These include the AmASSI Health and Cultural Center, JWCH Institute, Inc (Sergio Avina), and Palms Residential Care Facility (Tony Wafford and Kevin Pickett). We also acknowledge William Cunningham, MD, MPH, and Hector F. Myers, PhD, of UCLA and Trista Bingham of the Los Angeles County Department of Public Health for their input into the development of the proposal and study design.

Human Participant Protection

The institutional reviews boards of the University of California, Los Angeles, and Charles Drew University of Medicine and Science approved the protocols for the qualitative research and intervention phases of the study.

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