Creating partnerships for HIV prevention among YMSM: The Connect to Protect Project and House and Ball Community in Philadelphia

Abstract

Community participation in prevention research has emerged as an important resource for identifying and addressing HIV risk factors and populations that may be more susceptible to these risks. This paper focuses on the coalition at the Philadelphia site of Connect to Protect®: Partnership for Youth Prevention Interventions (C2P), and the partnerships developed to work with an understudied subgroup of YMSM, the House and Ball Community (HBC). The authors describe the coalition’s process of identifying HIV risk factors, developing objectives and prevention activities, such as increased access to HIV counseling and testing, and building partnerships with the HBC community. Local HIV testing data from C2P affiliated events , additional outcomes, and future directions for the coalition to continue these efforts are presented.

INTRODUCTION

The House and Ball Community

The House and Ball Community (HBC) was created to help form “both a social and support network” (Kilpatrick, 2007) for young mainly African American LGBT individuals and is comprised of two components: houses organized in a family type structure and balls where individuals from houses come together and compete against each other to win prizes. Arnold and Bailey (2009) state that, “Generally, in ballroom culture, there are no houses without balls and there are no balls without houses (p. 174).” This “community has always been a refuge for kids rejected by their biological families. Often compared to fraternities and sometimes even gangs…Young men and women who don't have gay friends, family members or role models can meet people dealing with the same issues (Kilpatrick (2007).

The House family structure consist of “mothers” and/or “fathers” who have created houses, recruited “children,” and instructed children about House and Ball Community norms and rules. Importantly, mothers and fathers as well as “grand parents” and “god parents,” who tend to be older members of the House and Ball Community, also act as role models for the children both in the House and Ball Community and in life outside the Community. Members of houses, and the Community at large, are given freedom of gender and sexual orientation expression, and many typical societal norms in these regards are abandoned within the House and Ball Community (Arnold & Bailey, 2009). Often adolescents join houses due to a lack of support or rejection from biological family members and other communities due to sexual orientation or gender identity stigma. Houses are responsible for the creation, planning, and implementation of balls.

Balls are events where houses and individuals come together to socialize and “engage in dance and performance competitions” (Murrill, et el, 2008) with individuals often winning trophies or cash prizes. Organization of balls takes weeks to months and includes finding a space, deciding on a theme, and advertising. “House parents recruit and prepare their children to compete in runway categories that are based on the deployment of performative gender and sexual identities, vogue and theatrical performances, and the effective presentation of fashion and physical attributes “(Arnold & Bailey, 2009).” Balls provide members of the HBC with a creative outlet, the opportunity to express themselves in a supportive environment, and create a space where social networking thrives. Also of importance is the opportunity that balls provide for changes to an individual’s social standing within the HBC. A person who is particularly good in one or several competition categories, has been a member of the HBC for a significant length of time, and has established him or herself as a leader in the Community may be deemed a Legend or Icon of the House and Ball Community.

Originating in 1920’s Harlem, New York City, the HBC has always existed for LBGT individuals in the African American and later Latino communities (Kilpatrick, 2007). In the late 1980’s different HBC began to emerge in other large American cities, including Baltimore, Washington DC, Atlanta, Charlotte, Cleveland, Chicago, Dallas, Houston, Los Angeles, Oakland, and Philadelphia. In Philadelphia, where the first ball was held in 1989, most of the members within this community are adolescents with some older individuals who predominantly hold leadership positions. No data exist that provide basic demographic information regarding the local HBC and all current information is based on observation and interaction with the HBC and was obtained through the work of the Connect to Protect project of Philadelphia.

Connect to Protect

The goal of the Connect to Protect (C2P) project is to decrease HIV transmission among adolescents, aged 13 to 24 years, through structural level change in the environments where youth interact. Structural level change in HIV transmission is described as impacting “the environment(s) that typically exist outside of individual participation or control” (Ziff, et Al, 2006) to reduce the rates of HIV within the community. Changes at the structural level include modifications to resource availability, physical environment, organizational systems, and laws or policies. Each C2P project is designed to meet their community’s specific needs through a local coalition that is community-based and community-lead. Each coalition identifies their community’s needs, develops a plan of action, and works toward implementing a set of strategies to address lowering HIV transmission through structural level changes. Acknowledging that there are factors that may impact HIV risk behaviors among different communities, additional considerations are made to address subpopulations that may be at greater risk.

The Philadelphia C2P coalition identified one such subpopulation of adolescents at greater risk for HIV in the House and Ball Community, and developed a working partnership with this community to initiate structural level changes to increase HIV prevention education and HIV testing. Despite its prominence among men who have sex with men in many urban areas, very little has been published about the HBC subpopulation and HIV risk factors. As the HBC consists primarily of young, African American, men who have sex with men (YMSM) we can extrapolate from national and local data (CDC, 2010), and local observation, that HIV rates in this community are high. Recently emerged studies have also recognized the importance of the HBC to HIV prevention among YMSM (Arnold & Bailey, 2009; Murill, et al, 2008; Sanchez, Finlayson, Murrill, Guilin, & Dean, 2009).

METHODS

The Partnership Building Process Between the C2P Coalition and the HBC

Within the Adolescent Medicine Trials Unit (AMTU) of the Adolescent Trials Network (ATN) for HIV/AIDS Interventions of the Children’s Hospital of Philadelphia, the C2P coalition consists of partnerships fostered with a variety of staff from community-based organizations, government agencies, educational institutions and health care agencies. Staff representatives include interventionists, HIV testers, administrators, researchers, government liaisons, and outreach staff. Additionally, key members of the coalition are youth participants from the a locally adapted version of the Mpowerment Project (Kegeles, 1996), a community-based intervention identified by the Centers for Disease Control and Prevention (CDC) as an Effective Behavioral Intervention (DEBI) to decrease HIV transmission among YMSM also implemented via the ATN. Mpowerment recruits YMSM to plan social events at which youth create and deliver safer sex messages and provide peer-led prevention outreach. These youth serve as representatives of the focus population, and some are also members of the Philadelphia HBC. Using a root cause analysis process (Willard et al, in this issue), C2P ATN staff facilitate discussions at meetings, guiding partners to identify risk factors that impact HBCyouth. The root cause analysis consists of identifying factors that affect HIV risk and then determining the reasons behind these factors. Once a list of factors and reasons is reviewed by the coalition, relying on member expertise and research found in the literature, prioritization and consensus building is used to inform the coalition’s next objectives.

Data describing the partnership building process and its outcomes are based on multiple sources. These data sources are (a) working group meeting notes, (b) subcommittee meeting notes, in this case specifically notes from the Ballroom committee meetings, and (c) community activity logs. After each meeting, notes are reviewed by the C2P staff to determine the important factors to present to the coalition in order to have discussions in which the sources of these factors are identified and structural change objectives created to address the factors. Since all discussions, emerging issues and factors raised by the coalition are documented in the data sources, the authors performed a review of these documents to extract (a) root causes identified by the coalition, (b) any new structural changes that would impact this Community, (c) reasons or factors that contribute to risk, and (d) sectors represented by coalition members. Data presented in this paper represent those factors, reasons, risk behaviors and ideas found most frequently in these documents.

The data show that amidst this process, discussions turned to a specific subgroup of YMSM, the HBC. HBC members expressed that there is a lack of outreach and education geared toward this community and that new strategies are needed to address this void. As the coalition identified risk factors pertinent to the HBC, the coalition set in motion the strategic planning process to develop activities and implement structural changes to increase HIV prevention education and testing among these youth. Among the initial steps was recruitment of members of the HBC to join the coalition efforts. Additionally, C2P turned to the youth participating in Mpowerment who were also members of the HBC. These youth included YMSM new to the HBC and some who were well established. Initial discussions with these youth provided insight into how to best approach HBC leadership, such as House Mothers and Fathers or Legends, and engage the youth. Additionally, some C2P coalition members are social service providers who are also current or past HBC members. These members were asked to lend their expertise and eventually to assume leadership positions in furthering C2P objectives related to HBC youth. Through these existing connections, C2P was introduced to the HBC with sufficient legitimacy to initiate dialogue, propose prevention strategies and develop additional partnerships.

RESULTS

Identifying Associated Risks and Initial Prevention Strategies

Since there is very little in the literature about the risk behaviors or seroprevalence rates of House and Ball Communities, our knowledge about HBC youth risk comes primarily from the discussions documented in the data sources previously described In the review of these sources dating from February 2007 to February 2010 the following risk factors and challenges were mentioned most frequently in our data sources:

1. Unknown HIV status/low rates of HIV testing: Fear, lack of access and stigma of being HIV positive discourage these youth from seeking HIV testing and counseling

2. Coercion: HBC youth may engage in sexual acts to gain membership in a house or gain access to Iconic HBC members

3. Crime: Participation in balls requires high fashion, price of admission and other costs forcing some youth to steal funds, clothing and accessories

4. Exchanging sex for money or a place to stay: LGBT youth suffer disproportionately from housing insecurity (National Alliance to End Homelessness, 2009), and youth in the HBC are also at risk for homelessness.

5. Needle sharing: Some HBC members identify as transgender. Appearance is extremely important and linked to competitions, so use of injection hormones or silicone is present.

6. Multiple partners: The party atmosphere surrounding balls creates a setting that may encourage sexual acts with casual partners.

7. Younger men with older partners: The celebrity of older Legends and Icons makes them appealing to younger house members.

8. Travel: Balls occur in various cities and it is common for youth to travel to compete where they may enter into a new sexual network.

The C2P coalition continued to analyze the root causes of risk and gather information about these youth. They decided to focus on two primary objectives: a) to increase prevention outreach and b) to increase HIV testing opportunities for HBC youth. The coalition identified their key members and invited other members of the HBC to form a subcommittee that would focus entirely on these efforts. Former and current members of the HBC joined the coalition and C2P members were invited to meetings of the House Ball Council, the local group consisting of Philadelphia house leadership. At all of these meetings, discussions about the best methods to communicate prevention messages to these youth without disturbing the social aspects of the community were deliberated.

These discussions led to prevention activities led by coalition youth who volunteered to conduct outreach at balls and other ballroom events. They provided safer sex kits, recruitment information and other resources. This successful outreach led to small reoccurring events called Ball Tape Night, where DVDs of past balls in Philadelphia were shown and participants were asked questions about HIV/AIDS and other STDs, for prizes. Additionally, safer sex kits were provided, condom demonstrations performed and the events were held at a location where free and anonymous HIV testing was conducted by a C2P affiliated CBO.

As the partnerships continued to grow and develop, plans were made among Philadelphia houses and C2P affiliated community partners to co-sponsor a prevention themed ball, and to-date five balls in total were held through this partnership. The challenge of including HIV/AIDS awareness and safer sex messages into a ball was easily overcome by incorporating them into several of the competition categories with the advisement of our HBC partners. Examples of these categories are “Virgin Runway: Hit the Runway with A Safer Sex Message All in Black”; “Executive Realness: Bring Us the Your Plan for a New HIV/AIDS Grant”; and “New Face: Wear Your Red Ribbon”. Safer sex kits and HIV and STD information were provided at the balls and HIV counseling and testing made available through a mobile testing unit operated by a C2P community partner. In total over 740 people attended these five balls.

The C2P coalition developed strategies to encourage youth to test at the balls. These strategies included, peer outreach, providing free admission to those who obtained an HIV test and offering a “Tested as a House” category awarding $500 to the house with the most members tested. All those who were tested were under the age of 24 and the majority were YMSM of color. Table 1 shows the results of the HIV testing.

Table 1.

Number of Youth Tested for HIV at Philadelphia Balls 2007–2009

Event	Number Tested	Number HIV+	Percent HIV+
Hollywood Ball: August 2007	8	3	37.5
Keke Ball: March 2008	18	1	5.5
Keke Ball: April 2008	6	1	16
Glamorous Life Ball: June 2008	33	13	39
Double Platinum Ball: June 2009	31	1	3.2

Accomplishing Structural Changes Through the Partnership

The fact that newly identified HIV positive YMSM are being found at these events raises major concerns that there may be other youth unaware of their HIV status among House and Ball youth and that they are not linked to clinical care. Additionally, these youth are potentially unknowingly exposing other young men within this community to HIV, further making the case to develop prevention efforts appropriate for the HBC. It is common for these young men to meet sex partners at Balls or to date within their house. Yet, the seropositivity rate of this population is still unknown at this time. Engaging a community mobilization approach whereby the C2P staff and community members identify the causes of problems and determine resources needed for change (Kim-Ju, Mark, Cohen, Garcia-Santiago, and Nguyen 2008) the C2P coalition created a package of structural change objectives to address these issues. Upon finalizing the objectives, the coalition approached the House Council to present the objectives and elicit their feedback and participation to ensure their success. Several Houses gave the coalition their commitment to support these endeavors and between February 2008 and April 2008 the following four objectives were completed:(1) House Council will put into practice quarterly community meetings open to House Children and CBO representatives to discuss prevention and health issues; (2) Three HBC houses in Philadelphia will agree to implement a prevention activity at all ball events; (3) Three HBC houses in Philadelphia will have at least one house member trained by an AIDS service organization to provide HIV prevention education for youth and; (4) A workshop track focusing on prevention in the HBC was permanently added to the roster for the annual AIDS Education Month discussing best practices and new approaches.

From the success of these structural changes, the coalition continued to work with the HBC to provide HIV prevention activities. The C2P youth and community partners continued to provide suggestions and support for the use of social events to disseminate prevention messages and safer sex kits, and provide opportunities for HIV testing. Collaborations across agencies participating in the C2P coalition became the norm, each bringing available resources to the table. Over the course of three and a half years, 16 social events specifically for the ballroom community in Philadelphia were held with attendance reaching almost 2000 people. Some of these youth attended multiple events increasing their exposure to HIV/AIDS prevention education, and safer sex messages.

These successful strategies are attributed to the strategic partnerships and community mobilization efforts of the C2P coalition and the Philadelphia HBC. In response to the identification of individuals who are living with HIV in this community, the C2P coalition initiated meetings with the local health department and other key stakeholders to inform them of these findings and to orient them to the HBC. Coalition members discovered that many providers are working with HBC youth but were not aware of what was involved with being a member of the HBC. Some providers have reported that this increased knowledge has improved their ability to engage HBC youth. As a result of these partnerships, more leaders and members of the Ballroom community recognize the need for HIV/AIDS awareness and prevention in their community. These partnerships have led to increased dialogue between providers and this community, as well as increased visibility for both, whether it be on the agency level or at Ballroom events and meetings. Additionally, HIV prevention providers are also enhancing their capacity to serve HBC youth through this increased knowledge and exposure. Many HBC leaders are increasingly receptive to offers of prevention services from organizations. In particular, most ballroom community members readily accept prevention outreach and safer sex materials distributed at events, as well as welcome opportunities for venue based HIV testing.

DISCUSSION

With direct interaction with the HBC and its past and present leaders, Connect to Protect Philadelphia has been able to observe the structural nature of the local HBC, create a coalition of HBC members to analyze root causes of high HIV rates in the community, and develop several structural level changes to address increasing HIV prevention messages and education and HIV testing in the HBC. Connect to Protect efforts and data have enabled local community based organizations to increase their interaction with the HBC to offer a variety of serves as well. The C2P coalition in partnership with the HBC is currently continuing to analyze and strategize to develop structural change to improve linkage to care rates among the HIV positive identified HBC youth as well as improve upon HIV prevention education and HIV testing opportunities. Bringing these two groups together, the HBC and providers through C2P, to analyze and discuss the risks these youth face is improving the prevention strategies in Philadelphia. The observation, analysis, and determination of several potential causes of higher rates of HIV infection within the local HBC provides future researchers and service providers an opportunity to examine root causes of HIV in their local HBC and implement changes to reduce HIV infections.

HBC events provide an opportunity to implement HIV prevention outreach initiatives and HIV testing at a venue with high-risk youth, but not without challenges. The greatest challenges identified by C2P are related to linkage to care. Oftentimes balls occur during late night and early morning hours, with a typical start time of between midnight and 2AM and end time of between 6AM and 8AM. Due to the timing of balls, linking individuals who have tested HIV positive to care during such hours is difficult and should be a concern for organizations planning testing services. Additionally, it is not uncommon for balls to change date, time, or venue, even at the last possible moment. The unexpected and unpredictable nature of balls is well known within the ball community and participants are not discouraged by such occurrences; however from a prevention program perspective, this presents staffing challenges as well as difficulty in securing a space that allows for late night activity with many young people. Prevention staff members must have flexibility in their schedules and accept working during atypical hours.

Weaknesses in this study that limit our ability to draw more definitive conclusions are related to sources of data. At the time of this study, the seroprevalence among the HBC in Philadelphia is completely unknown. We can include this subgroup among the greater population of those that acquire HIV infection via risk factors as men who have sex with men. However, without demographic data of HBC youth it is difficult to conclude what proportion of HIV infections are also HBC members. Another limitation lies in the need to maintain anonymity among our youth population, making it difficult to follow HBC youth as they engage in some of the activities described implemented by the coalition. The importance of keeping young people safe from the dangers stigma can cause, such as violence or rejection due to sexual orientation or HIV status makes it necessary for investigators to protect the identity of participants.

Future research that can describe seroprevalence within HBC communities in different cities would improve our ability to aim prevention resources to this population. Social and sexual network study designs may shed light on partner selection trends within and across cities with House and Ball communities. More information and input is needed from key stakeholders in this community and studies that survey House and Ball opinion leaders and youth about the trends, behaviors and needs of this community can better inform prevention efforts with the HBC. Since House and Ball Communities can be found in most major cities in the United States, additional data that describes partnerships of this nature in other cities can improve our understanding and ability to support the House and Ball Community.