Abstract
African American young men who have sex with men and transgender persons are at elevated risk for HIV infection. House and Ball communities, networks of mostly African American gay, bisexual and transgender individuals who compete in modeling and dance, represent a prime venue for HIV prevention with these difficult-to-reach populations; however, little research exists on effective approaches to HIV prevention within these communities. Using a mixed-methods approach, the present study sought to document participation in HIV prevention activities of a sample from the Los Angeles House and Ball communities (N=263) in order to inform future service development. While 80% of participants were tested for HIV within the past 6 months, only 26% report HIV prevention program attendance. House leaders recommend a holistic approach to HIV prevention, one that incorporates attention to social problems beyond HIV, including poverty, housing difficulties, and lack of job training.
Keywords: HIV, African Americans, House and Ball, Prevention
Although comprising only 14% of the US population, African Americans (AA) account for 44% of new HIV infections (CDC, 2011a). Recent surveillance data show higher new HIV infection and prevalence rates among AA men who have sex with men (MSM) when compared with the overall AA and MSM populations (Prejean et al., 2011). The situation for AA young men who have sex with men (AAYMSM) is especially worrisome. AAYMSM accounted for 75% of all new HIV infections among adolescents ages 13–19 in 2008 and 63% of new infections among all YMSM (CDC, 2011b). While HIV incidence plateaued in the general population and among specific racial/ethnic groups between 2006 and 2009, there was a 48% increase in new infections among AAYMSM (Prejean et al., 2011).
Transgender persons, those who possess a gender identity and expression different from their biological sex (Israel & Tarver, 1997), are also at heightened risk for HIV infection (Nemoto, Operario, Keatley, Han & Soma, 2004). In the past 15 years, numerous studies have attempted to document HIV prevalence rates among male-to-female (MTF) transgender persons, with estimates ranging from 11% – 78%. A large, quantitative study (N=515) of transgender persons in San Francisco recruited through respondent-driven sampling estimated HIV prevalence for MTF transgender persons to be 35% (Clements-Nolle, Marx, Guzman & Katz, 2001) with African American participants nearly six times as likely to be HIV infected compared to other study participants. A more recent meta-analysis estimated the HIV prevalence among MTF transgender persons at 27.7%, with African Americans consistently possessing the highest rates of HIV across studies (Herbst, Jacobs, Finlayson, McKleroy, Neuman et al., 2008).
Despite significant need for HIV prevention among AAYMSM and transgender persons, little research has documented HIV service utilization among these difficult-to-reach populations. Potentially useful avenues for HIV prevention with these populations are House and Ball communities, networks made up largely of AAYMSM and transgender individuals (Phillips, Peterson, Binson, Hidalgo, & Magnus, 2011), which have been identified at potentially high risk for HIV infection (Murrill et al., 2008; Sterling, Stanley, & Thompson, 2000). A House has been defined by others as “a collective of people, frequently gay or transgender Black and Latino youth, who share a communal lifestyle” (Murrill et al., 2008, p. 1046); while these individuals do not live together, they are often a cohesive group who attend events together and offer each other social support. Balls are “underground events that reward individuals who win competitions focused around dance, athletics, and gender expression” (Kubicek, McNeeley, Holloway, Weiss, & Kipke, in press). The majority of studies with House and Ball Communities have taken place in on the East Coast (Murrill et al., 2008; Sanchez, Finlayson, Murrill, Guilin, & Dean, 2009; Phillips et al., 2011); however these communities are currently present in major cities across the United States including Oakland, Atlanta, Chicago, Philadelphia, Baltimore, and Washington, DC and Los Angeles (Arnold & Bailey, 2009).
There are between 35 and 50 nationally recognized Houses that actively participate in Balls (The Body, 2006). Ball competitions are held between Houses a few times each month as a way for Houses to meet and compete for prizes and recognition. Participants not affiliated with Houses, called “free agents”, can also compete to make themselves attractive for recruitment into the participating houses (Phillips, et al., 2011). The number of members in Los Angeles Houses ranges from five to thirty-five. House structures vary and may include various roles. The leaders of the Houses are generally called Mothers and Fathers, however, neither role is gender-specific. The Mother/Father is typically the founding member or appointed by the previous leaders (Phillips, et al., 2011) and is responsible for recruiting children to join the house. Children can be of any age and are rarely blood relatives of their House Mother/Father. Other roles besides House Mother/Father, include prince/princess, godfather/godmother, emperor/empress, and ambassador.
While the House and Ball communities have been identified as populations of importance for HIV prevention activities, there remains limited information regarding successful integration of HIV services within this community (Kubicek et al., in press; Phillips et al., 2011). A recent literature review by Phillips and colleagues (2011) identifies several HIV prevention activities conducted within House and Ball communities in New York and Chicago, including the formation of Houses specifically devoted to HIV prevention, such as the House of Latex in New York City. These Houses sponsor Balls with HIV prevention themes and encourage communication about HIV prevention within the House and Ball communities through dissemination of HIV prevention messages by leaders within the House and Bally communities. A similar event, the Ovahness Ball, sponsored by a local HIV prevention agency in Los Angeles, is held on an annual basis. However, limited information is available on the success of these programs and, to our knowledge, no published literature exists documenting community members' perceptions of these types of activities.
The present study seeks to: (1) describe the types of HIV prevention activities that are currently being utilized by Los Angeles House and Ball communities and those who attend Los Angeles Ball events; (2) document community leaders' perceptions of these approaches; and (3) offer recommendations for future HIV prevention activities with House and Ball communities.
Methods
The present study utilized a number of different methods including a survey administered at House and Ball events and semi-structured one-on-one interviews with House and Ball community leaders. The study was a collaborative effort between the research team and the House and Ball communities. As such, the House and Ball community members were involved in the study design and methods development through participation in a community advisory board (CAB). All study procedures were presented to local House leaders in order to ensure that the methods were not intrusive to the community's activities and that methods were appropriate for the target population.
Quantitative Data Collection and Measures
We conducted a confidential survey to better understand the HIV risk and protective behaviors among persons involved in the Los Angeles House and Ball communities. Individuals were recruited regardless of gender, sexual identity or behavior in order to represent the entire community of individuals attending Balls in Los Angeles. Between February 2009 and January 2010, 263 unduplicated surveys were completed at 12 survey events (e.g., Balls). House and Ball community members were eligible to participate if they attended an event during the study time period and had not previously participated in the research survey.
Sampling procedures were modeled after the Healthy Young Men's Study, with venue selection and participant recruitment adapted for the target community (Ford, et al, 2009). Recruitment venues were categorized into three types: Balls, House meetings, and community events. Events and venues included in the sampling frame had at least a 2-hour time period with an expected yield of at least 4 House and Ball community members. Private survey areas were created at Balls and other events through the use of portable “voting booths” designed for the project. Sampling periods typically occurred during late-night or early-morning hours.
Study staff approached persons who entered the designated venue to assess eligibility. A total of 296 people were found eligible to take the survey; 287 (97%) completed the survey and a total of 263 (89%) unduplicated surveys were completed (24 surveys were deemed duplicates through reviewing demographic and other survey data). Eligible persons were escorted to the private survey booths to complete the data collection activity. Respondents completed a 30–45 minute audio, computer-assisted self-interview (ACASI) survey on site. All respondents provided written informed consent. For persons younger than 18, a waiver of parental permission was obtained. Participants received a $40 incentive for completing this survey.
The study's, quantitative survey assessed social and demographic characteristics, sexual identity and attraction, experiences of racism and homophobia, participation in the House and Ball communities, past 3-month sexual behavior, lifetime and past 3-month substance use, social and sexual networks, HIV and STI testing behaviors, HIV status, access to preventive and health services, connection to communities (e.g., racial/ethnic, religious, school, work, House, Ball) and mental health. Data specific to HIV prevention service utilization are presented in this paper.
Qualitative Data Collection and Measures
Between July 2008 and December 2009, 26 respondents were identified and recruited to participate in semi-structured qualitative interviews. Through our community engagement activities and participant observations, we identified and approached each of the local leaders to participate in this portion of the data collection; all leaders who we approached agreed to participate in the study. Follow-up phone calls and emails were made to confirm interview dates and times; at that time, three House leaders did not return our messages. Participants included at least one parent or leader from each of the fifteen Los Angeles Houses. The interview discussion guide was designed to gather in-depth information on the structural, social, and cultural characteristics of the Houses; challenges members experience in the House and Ball scene; perceived benefits of participation; House rules, activities, and communication; relationships within and outside the House; values, norms, and expectations related to HIV/STI risk behaviors; and receptiveness to interventions. Each interview lasted 1.5 to 2.5 hours and was digitally recorded, professionally transcribed and checked for accuracy. All interviews were conducted in the P3 project offices or at a convenient location (e.g., coffee house). Respondents were provided a $45 incentive for completing the interview. This study was approved by the Committee on Clinical Investigations at Children's Hospital Los Angeles.
Data Analysis
Descriptive analyses were conducted using the Statistical Package for the Social Sciences, Version 19 (IBM, 2011). Frequency distributions on key variables related to demographics (Table 1), STI and HIV Testing (Table 2) and HIV prevention services (Table 3) are presented in the present paper.
Table 1.
Descriptive characteristics of total sample (n = 263) and males only (n = 233)
| Total Sample | Males Only | |
|---|---|---|
|
|
||
| Variable name | Mean or N (% or SD) | Mean or N (% or SD) |
| Age (Range: 17–53) | 23.74 (6.16) | 23.74 (6.16) |
| Age category | ||
| 17–20 years | 78 (30) | 70 (30) |
| 21–25 years | 131 (50) | 119 (51) |
| 26+ years | 34 (21) | 44 (19) |
| Gender | ||
| Male | 233 (89) | 233 (100) |
| Female | 17 (7) | – |
| Transgender (MTF) | 11 (4) | – |
| Other | 2 (1) | – |
| Primary ethnicity | ||
| Native American | 7 (3) | 5 (2) |
| Asian / Asian American/ Pacific Islander | 3 (1) | 3 (1) |
| Black / African American | 218 (83) | 194 (83) |
| Latino / Hispanic | 17 (7) | 15 (6) |
| White / Caucasian | 2 (1) | 0 (0) |
| Other | 16 (6) | 16 (7) |
| Multiethnic | 85 (32) | 72 (31) |
| Residential status | ||
| Family | 98 (37) | 92 (40) |
| Own place/apartment | 128 (49) | 109 (47) |
| Friends/partner/House/Ball members | 32 (12) | 28 (12) |
| No regular place/other | 5 (2) | 4 (2) |
| School/work combined | ||
| In school | 51 (19) | 47 (20) |
| In school, employed | 65 (25) | 58 (25) |
| Employed | 91 (35) | 83 (36) |
| Not in school, not employed | 56 (21) | 45 (19) |
| No medical insurance | 54 (21) | 45 (19) |
| Sexual identity | ||
| Gay / other same sex | 173 (66) | 166 (71) |
| Straight | 25 (10) | 7 (3) |
| Bisexual | 64 (24) | 59 (25) |
| Don't know | 1 (0) | 1 (0) |
| Attraction | ||
| Men only | 137 (52) | 117 (50) |
| Men and women | 111 (42) | 103 (44) |
| Women only | 9 (3) | 7 (3) |
| Neither / don't know | 5 (2) | 5 (2) |
Table 2.
STI testing and treatment among total sample (n = 263) and males only (n = 233)
| Total Sample | Males Only | |
|---|---|---|
|
|
||
| Variable name | N (%) | N (%) |
| STI test (ever) | 234 (89) | 207 (89) |
| STI diagnosis (ever) | 71 (27) | 62 (27) |
| STI type1 | ||
| Gonorrhea | 33 (13) | 29 (12) |
| Syphilis | 19 (7) | 17 (7) |
| Chlamydia | 33 (13) | 27 (12) |
| Herpes | 12 (5) | 10 (4) |
| HPV/Genital warts | 17 (7) | 16 (7) |
| Hepatitis A/B | 9 (3) | 7 (3) |
| Hepatitis C | 11 (4) | 9 (4) |
| Scabies/Crabs | 13 (5) | 12 (5) |
| Other | 7 (3) | 7 (3) |
| STI Treatment2 | ||
| Community public health clinic | 22 (28) | 21 (30) |
| School/work clinic | 7 (3) | 6 (9) |
| Doctor's office | 31 (40) | 27 (39) |
| Hospital ER | 9 (12) | 9 (13) |
| Hospital Clinic | 12 (15) | 9 (13) |
| No treatment | 6 (8) | 6 (9) |
Among full sample
Among those testing positive for an STI
Table 3.
HIV testing and prevention among total sample (n = 263) and males only (n = 233)
| Total Sample | Males Only | |
|---|---|---|
|
|
||
| Variable Name | N (%) | N (%) |
| Last HIV test | ||
| Less than 3 months ago | 128 (49) | 118 (51) |
| Between 3 and 6 months ago | 77 (29) | 70 (30) |
| More than 6 months to 1 year ago | 26 (10) | 20 (9) |
| More than 1 year ago | 19 (7) | 13 (6) |
| Never tested | 6 (2) | 5 (2) |
| Don't know / refused to answer | 7 (3) | 7 (3) |
| HIV testing location | ||
| Rapid testing in a van | 29 (12) | 26 (12) |
| Rapid testing at a clinic | 53 (21) | 50 (23) |
| At a clinic (NOT rapid testing) | 67 (27) | 57 (26) |
| At a doctor's office | 100 (40) | 87 (40) |
| Returned for results1 | 169 (99) | 146 (99) |
| HIV status | ||
| Positive | 14 (5) | 13 (6) |
| Negative | 238 (91) | 210 (90) |
| Don't know | 3 (1) | 3 (1) |
| Refused to answer | 8 (3) | 7 (3) |
| Exposure to HIV Prevention Services | ||
| Pamphlets or flyers | 220 (84) | 198 (85) |
| Intervention programs | 69 (26) | 63 (27) |
| Individual counseling services | 43 (16) | 37 (16) |
| Other services | 38 (15) | 32 (14) |
From most recent HIV test (N = 171; 148)
The qualitative analysis for this manuscript utilized a “constant comparative” approach, an aspect of grounded theory that entails the simultaneous process of data collection, analysis and description (Glaser, 1992; Glaser and Strauss, 1967). In this process, data are analyzed for patterns and themes to discover the most salient categories, as well as any emergent theoretical implications. As the data are collected, they are immediately analyzed for patterns and themes, with a primary objective of discovering theory implicit in the data. Interview transcripts were included in the analysis. Atlas.ti (2004) was used for coding and analysis of relationships between and within text segments.
Members of the research team reviewed an initial sample of interviews to identify key themes, which formed the basis of the project codebook. Codes focusing on a range of topics were identified and defined based on the key constructs included in the discussion guide. The codebook was modified as needed, and once finalized, three members of the research team were responsible for coding the interviews. Inter-coder reliability was assessed through double coding a sample of approximately 15% of the interviews. Differences in coding were discussed and resolved by the research team. The open coding process included refining codes based on the data. Codes related to values, norms and expectations related to HIV/STI risk behaviors, participation in HIV prevention activities, and receptiveness to future interventions were included in the current analysis.
Results
Survey data provide a profile of the Los Angeles House and Ball communities. The majority of participants described their primary race/ethnicity as Black/African American (83%). Smaller percentages identified their primary race ethnicity as American Indian/Native American (3%), Asian/Asian American/Pacific Islander (1%), Latino/Hispanic (7%), White/Caucasian (1%), or some other ethnicity (6%). The average age was approximately 24 years, with 50% of the sample being 21–25 years old. A majority of the respondents reported living either in their own place/apartment (49%) or with family (37%). Many participants reported being employed or both in school and employed (60%); however, approximately 20% reported being neither in school nor employed.
Eighty-nine percent of respondents identified their gender as male, with 66% identifying as gay or some other same-sex sexual identity. Although only 24% of participants identified as bisexual, 42% reported attraction to both men and women. Slightly over half the sample reported attraction to men exclusively (52%). Complete demographic information on the study sample is presented in Table 1.
STI/HIV Testing and Treatment
STI and HIV testing rates were high among the study sample (Table 2). Nearly 90% of participants reported having ever been tested for an STI. Those who reported testing positive for an STI previously (27%) received treatment at a variety of facilities, including community or public health clinics (28%), doctor's offices (40%), hospital clinics (15%) or emergency rooms (12%). The vast majority of participants had been tested for HIV in their lifetime (98%), with over 88% testing within the past 6 months. Respondents' HIV testing was performed at various locations, including mobile vans (12%), clinics (48%), or private doctor's offices (40%). While the majority of participants had seen advertisements and flyers with HIV prevention messages (84%), there appeared to be limited exposure to other HIV prevention services. Only a quarter of participants had ever participated in a formal HIV prevention program (26%) and a smaller percentage had received HIV prevention counseling (16%).
Five percent of participants reported testing positive for HIV (n=14). Of these, the mean age of HIV diagnosis was approximately 25.5 years (SD=8.5) and 4 had been told by a doctor that they had AIDS. All of those diagnosed with AIDS had sought treatment; 3 of those diagnosed with AIDS were currently receiving antiretroviral medication; none reported difficulty accessing HIV services.
Experiences with HIV Prevention
Qualitative data provided possible reasons for limited experiences with formal HIV prevention services in this population. Participants described community events that incorporated prevention activities, such as HIV testing to gain free admission to Balls, with mixed emotion. Some felt that this type of prevention activity was useful because it offered testing at locations convenient to participants, eliminating barriers to testing due to distance from clinics and lack of transportation. However, others described HIV testing at Balls as suboptimal because many community members did not want to find out that they were HIV-positive in an environment where they were trying to focus on competition and socialization. For example, one House leader made the following comment when asked whether or not Balls would be optimal locations for HIV prevention activities:
You can offer little, you know, if you need this type of card or something but not like let's go in the back and talk or nothing because there is nobody that's going to be feeling like that right now.
Another house leader echoed this sentiment when describing an experience where the HIV prevention message of a Ball became diluted throughout the course of the evening:
That event, in the beginning it was cool but it eventually it became they stopped talking about the issue at hand. You know what I am saying. They stopped talking about the issue which was, it was supposed to have been about HIV and AIDS and they were supposed to do some awareness in there. It became just a Ball as time went on; they forgot about the issue that the Ball was surrounded on.
Some Balls included performance categories related to HIV prevention, such as creative ways to use condoms and latex in costumes or presentation of safer sex information as a prerequisite for performance. One community leader mentioned the following example:
Before they performed…we made them come to the front of the runway first with a big billboard indicating the five ways HIV is transmitted. So it begins with that, so if they have it wrong…we say step to the side so we can let them know we have to educate them. But then if they are right we allow them to vogue and get their tens, which means they can make it to the next round.
Incorporating HIV prevention messages into Balls was described by some as a creative and fun way to educate participants. These creative ways of educating the community extended beyond Balls; one community member spoke about a performance he was preparing for an AIDS day event:
We were coming up with this skit where one of us is going to come down and one of us is going to be gonorrhea and then one of them is going to be syphilis and we are going to be all tore up and then [NAME] is going to come down and she is going to be flawless and she is going to be AIDS. Her name is going to be AIDS and…it's telling you like, just because I am beautiful and glamorous that doesn't mean the I don't have [AIDS]—that's the whole thing in it.
When considering prevention Balls and other techniques providers used to incorporate HIV prevention messages into the Ball competitions, some parents felt that while the messages were incorporated with the best intentions, it could take away from the fun and excitement of the Balls themselves – the primary reason people attend. Some community leaders explicitly wanted to preserve the structure of the Balls as performance and entertainment venues and indicated that testing and prevention messaging at Balls should be secondary to the social and competitive aspects of Balls. For example, one House leader remarked:
I also think that people are becoming like tested out. They are like, “I am just so sick of hearing about HIV testing.” I think that a lot of people don't come to Balls wanting to hear about HIV. They really don't. And that's why it can't be first and foremost.
House and Ball leaders described the importance of educating House members on HIV prevention. Several House Mothers and Fathers, individuals charged with caring for the welfare of their House members, choreographing performances, and coaching House members on performing, spoke about their responsibility for educating House members about HIV in both formal and informal settings. For example, one House Parent described starting conversations about HIV prevention in House meetings by putting HIV on the meeting agenda. Another emphasized the effectiveness of casual conversations about HIV initiated by House parents rather than prevention agencies:
People are beginning to talk about [HIV] at the House meetings or whatever and I think in a more effective way than a prevention agency does because they talk about it in normal conversations. You know what I mean?
These descriptions of talking to House members about STI/HIV prevention were common among House Parents. However, this view of the House Parent's role of HIV prevention educator did not extend to all community leaders. For example, one community leader cited competing interests of House Parents, stating, “The House parent, their main priority is trying to win runway,” suggesting HIV prevention should be the role of someone other than a House Parent, such as a community agency worker.
Community Recommendations
Participants felt strongly that successful HIV prevention activities with House and Ball communities must be based on positive rapport and mutual trust between service providers and community members. When asked what ideas, suggestions and/or recommendations she had for successful HIV prevention program implementation, one House Mother responded:
Trust and reliability, those are the key things that people look for when they want to confide in a company, an agency, or even a person. So…as long as you are able to provide that extra mile discretion or privacy then you are going to be okay. So, those are some of the most important things to just remember or to take into consideration because they want to be able to come to you. I think that people…are ready but as long as those things are in play.
Discretion and privacy were themes that played prominently in other qualitative interviews. When asked about barriers to HIV prevention service, one House leader emphasized the importance of privacy when working with the House and Ball community, stating, “Well one thing that's going to always be difficult when dealing with people of color is discretion. Period.” This respondent went on to state:
That's the main thing that people worry about. They will rather travel out of the area to get services than to deal with services right now in your own neighborhood because of people they might see. They will never go to the free clinic because it's free, its common and they might see someone that they know there.
These data indicate that attention to the ways in which privacy is protected may be of prime importance to members of House and Ball communities.
While many community leaders spoke favorably of service providers offering HIV prevention to the community, one House leader described experiences of broken confidentiality with a service provider, stating “The kids are not confident in the agencies…because they have broken so many rules of confidentiality.” This sentiment of related to the importance of building trust between the House and Ball Community and service providers was echoed by another House leader, who stated:
Okay, well there are some organizations that are really here for us. As opposed to other places where like, “We have been used up before. We don't trust you guys, so just stay away.”
The issue of feeling used by service providers and researchers was raised by another House leader, who stated the following when asked how future HIV prevention efforts might be most successful:
Talk at them like you're here to help them, not here just to get some information from them or use them for some information. You know what I am saying because that's basically what they get. Are you going to just give me fifty dollars to use my name or use me for your study and duh, duh, duh and that's it. When you really don't get into them or get the core part of it or even much understand them.
The importance of truly helping the community beyond HIV prevention was echoed by other House and Ball leaders, who described in detail the difficulties faced by members of the Los Angeles House and Ball communities. House parents spoke of homelessness, participation in sex work, and limited job skills as much more pressing issues for their House children than HIV prevention. One House mother stated the following:
It's like what do you have to live for? Or you need some shoes, you need some clothes, you can't do this, you can't do that, and then you can't go get a job. You don't have a diploma. You don't have no resume skills. You don't have interviewing clothes. You know what I am saying, you don't even have a stable place to live.
Comments like these were prominent across interviews. Many House and Ball community leaders stressed the needs of House members beyond HIV prevention information, suggesting that an HIV prevention program in isolation may not be effective unless it also addresses the other issues faced by House and Ball community members.
Yeah, some of those people are homeless. Some of them have no job. Counseling, yeah sometimes people need people to talk to and they don't know other than their family members because they feel like their family might…they might feel uncomfortable. I think counseling is a good thing, housing for people who need it, ways to find a job, those kinds of things.
Comments like these underscore the pressing needs faced by the Los Angeles House and Ball communities beyond HIV. In conjunction with our investigation into members' experiences with HIV prevention, these findings demonstrate the importance of health promotion, the utility of providers outside the community working with Houses to provide services, and the need for more comprehensive understanding of other issues facing the Los Angeles House and Ball Communities.
Discussion
These data from the House and Ball communities in Los Angeles have significant implications for HIV prevention service provision with this population. STI and HIV testing rates among these communities were higher than have been noted among YMSM in general (Mackellar, Valleroy, Anderson, Behel, Secura, et al., 2006; Schrager, Weiss, Wong, & Kipke, 2011; Sumartojo, Lyles, Choi, Clark, et al., 2008) and in previous studies of the New York City House and Ball Community (Murill et al., 2008). These high testing rates may be the result of the presence of service agencies at Ball events. During the time of the study, two prominent social service organizations were conducting outreach with the House and Ball Communities; while actual testing rarely occurred at events, referrals for testing and other service coordination was a part of outreach efforts. Regardless, the fact that the majority of House and Ball members were tested in the past 6 months is laudable.
Compared to the high numbers of House and Ball members reporting STI and HIV testing, a relatively small percentage indicated participation in HIV prevention intervention programs. Previous research with racially and ethnically diverse YMSM has raised concerns about the linkage between HIV testing and behavioral assessment in this population (Cederbaum, Holloway, & Shoptaw, 2012). Ball events may be one of the few opportunities in which HIV prevention professionals can engage House and Ball community members in discussions about HIV prevention. However, several House and Ball community leaders commented on the difficulty of implementing effective HIV testing and prevention messaging during Ball events. Participants recommended making HIV prevention messages secondary to the primary focus of Ball events, namely performing. One strategy for HIV prevention at Balls that House leaders felt was effective and recommended for future interventions was to incorporate prevention messages into performance categories at Balls. While Balls may not be ideal venues for individual behavioral counseling due to participants' competing interests, creative incorporation of HIV education into Ball performance categories may be an effective way to engage Ball attendees.
The importance of discretion in HIV testing was mentioned by several participants. Some described testing at Ball events as intrusive and too public for House and Ball community members who may feel stigmatized simply by entering an HIV testing van. In fact, this may be another barrier to engaging community members in meaningful discussions about linkages between HIV testing and behavior. If those being tested are more concerned about quickly entering and exiting the testing van and/or who saw them enter, they may be less likely to disclose risky behavior and participate in an in-depth conversation with HIV prevention professionals. A structural suggestion for HIV testing at Ball events made by House leaders was simply parking the testing van behind the venue or around the corner from the venue, offering House and Ball community members more privacy than testing directly in front of the entrance where other community members are congregating for admittance to the Ball.
The question of who best to conduct testing and offer HIV prevention outreach is a difficult one, as stressed by the participants in our study. Those who are already members of the community (e.g., House parents) have the access to and the respect of their House members. However, these House leaders may not always feel comfortable in the preventionist role and worry that their House members may not be candid with them due to privacy concerns. This information, coupled with suggestions that those from outside the community may be more effective in disseminating HIV information in a non-judgmental fashion, suggest the need for close partnership between HIV prevention professionals and community leaders. Since House parents spoke about the importance of HIV prevention, they may be willing to grant trusted community providers access to House meetings, where discussions of risk behavior and HIV prevention may be able to unfold in a less-pressured environment than in a rapid testing van or booth at a Ball. Other researchers have suggested a community participatory approach to HIV prevention intervention development with House and Ball communities (Sanchez, Finlayson, Murill, Guilin, & Dean, 2010); our results support further exploration of this strategy.
Although House leaders stressed the importance of HIV prevention in their community, their past experiences with HIV prevention outreach and research was sub-optimal. Stories of unwanted disclosure of HIV status and negative feelings about being “used” for research (or to meet funding requirements of community-based agencies) indicated strained relationships between the House and Ball community and the HIV prevention community. Skepticism among African Americans related to scientific research has been well documented (Kerkorian, Traube, & McKay, 2007; Northington Gamble, 1997) and should be given consideration when seeking to engage House and Ball communities in collaborative efforts.
Beyond feelings that some researchers and community-based providers were not truly interested in the welfare of their community, participants in our study spoke of a range of other pressing concerns besides HIV that seemed to be ignored by the HIV prevention community. Those House members struggling with homelessness, joblessness, substance use, and sex work may be less likely to view HIV prevention as a topic of primary importance. Future HIV prevention efforts may benefit from a more holistic approach to HIV prevention; one that includes job training, housing placement, and a harm-reduction approach to substance use and sex work. As noted by National Institutes of Health (NIH, 2005), simultaneous targeting of multiple risk factors, integrating behavioral interventions into the treatment environment, and intervening at multiple systems levels are hallmarks of efficacious HIV prevention interventions. Further exploration of the needs of House and Ball community members beyond HIV may help to inform effective intervention development with this vulnerable population.
Limitations
The present study has limitations, which should be taken into account when interpreting the results. First, this study focused exclusively on the Los Angeles House and Ball communities. While a small percentage of participants in the quantitative phase of this study were from outside Southern California their presence at Los Angeles Ballroom events makes them a part of the extended Los Angeles community. Thus, generalizability of our study findings may not extend to House and Ball communities throughout the United States, especially because demographic and HIV testing patterns of our sample differed from previously studied House and Ball communities in other cities (Murill et al., 2008; Sanchez et al., 2010).
Limitations of collecting data in community settings resulted in a sample that may not be representative of all House and Ball community members attending Los Angeles Ballroom events. All data were based on self-report, which may be subject to social desirability bias. While use of ACASI data collection techniques should reduce social desirability bias (Newman et al., 2002), it is difficult to know whether this occurred in the present study. Low numbers of HIV-positive participants may indicate an under-reporting of HIV infection, especially since previous studies have demonstrated that large percentages of other House and Ball communities may be unaware of their infection (Murill et al., 2008). Future studies should incorporate the use of biomarkers to gain better epidemiological data on STI/HIV infection within this community.
Conclusion
Little information exists on the HIV prevention activities of House and Ball communities, especially those on the west coast. The present study allows for a better understanding of the facilitators and barriers to HIV testing and service provision in this community. Reports of mistrust of community agencies and researchers is disconcerting since successful partnerships through community-based participatory research and intervention have been shown effective with other largely African American communities (Madison, McKay, Paikoff, & Bell, 2000). Going forward, those in the HIV prevention community should seek to engage House and Ball community leaders in meaningful collaborations based on trust and the development of mutual HIV prevention agendas. Creative approaches to the incorporation of HIV prevention messaging and testing at House and Ball events may be effective with minimal modification; however, attention to the other pressing needs of this community besides HIV cannot be ignored.
Acknowledgements
The authors would like to acknowledge the contributions of the staff members who contributed to collection, management, analysis and review of these data: Veronica Abernathy, Teela Davis, Deandre Ellison, Judith Grout, Cody Haight, Nefe Iredia, Tattiya Kliengklom, Sylvia Lambrechts, Donna Luebbe, Griselda Monroy, Heather Reyes, Marcia Higareda, Luis Salazar, Sheree Schrager, Milton Smith, Flor Vindel, and Carolyn Wong. The authors would also like to acknowledge the insightful and practical commentary of the members of the P3 Advisory Board, the Mothers and Fathers from the House of Allure, House of Chanel, House of Ebony, House of Escada, House of Etro Galliano, House of Herrera, House of Garcon, House of Gotti, House of Lauren van Cartier, House of Mizarahi, House of Miyake Mugler, House of Revlon, House of Rodeo, and the House of Ultra Omni. We are especially grateful to all of the parents, leaders and members of the Los Angeles House and Ball communities for their commitment and willingness to share their diverse and often profound personal experiences as well as welcoming us into a part of their lives.
This study was funded by the National Institute on Drug Abuse of the National Institutes of Health (R01 DA22968). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute on Drug Abuse or the National Institutes of Health.
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