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. Author manuscript; available in PMC: 2020 Oct 2.
Published in final edited form as: J HIV AIDS Soc Serv. 2019 Oct 7;18(4):399–416. doi: 10.1080/15381501.2019.1673868

Comparison of Two Distinct House Ball Communities Involved in an HIV Prevention Study: Baseline Data from the POSSE Project

Sybil Hosek 1, Marne Castillo 2, Anna Hotton 3, Christopher Balthazar 1, Bevin Gwiazdowski 2, Richard Laboy 2, Kortez Davis 1, Diana Lemos 4, Gary W Harper 5, Margo Bell 6
PMCID: PMC7531774  NIHMSID: NIHMS1543913  PMID: 33013233

Abstract

For many Black/African American gay, bisexual, and other young men who have sex with men (B-GBMSM), the House/Ball Community (HBC) offers a social network where they can be free to express diverse sexual and gender identities, but HIV prevalence and stigma are high. The POSSE project is an effectiveness-implementation trial of a popular opinion leader intervention designed to address HIV prevention in the Chicago and Philadelphia HBCs. In June 2016 baseline behavioral data were collected along with HIV, gonorrhea and Chlamydia testing. Eligible participants were sexually-active YMSM or transgender women (TGW), between the ages of 15–24, who self-identified as Black. One-third participants (32.5%) met or exceeded the clinical cut-off for depressive symptoms. Approximately 18% of the participants across both cities reported that they were HIV-positive. Overall, the baseline data establishes the need for HIV and STI prevention interventions across both cities, as well as interventions to address other co-occurring epidemics.

Keywords: HIV Prevention, Adolescents/Young Adults, House Ball Community

INTRODUCTION

Black/African American gay, bisexual, and other men who have sex with men (B-GBMSM) are more affected by HIV than any other group in the United States. In 2016, B-GBMSM accounted for 26% of new HIV diagnoses in the United States and 36% of those new diagnoses were among young B-GBMSM ages 13–24 (CDC, 2017). Black transgender women (B-TW; those assigned male sex at birth who now identify as a woman) have disproportionately high rates of HIV, with current estimates suggesting that more than half (56%) of Black/African American transgender women are living with HIV in the United States (CDC, 2018).

There are many complex factors driving the HIV epidemic among young B-GBMSM and B-TW such as high background HIV prevalence in the community, lack of awareness of HIV status, high levels of HIV stigma, the influence of peer/social norms, and high rates of STIs among racially assortative sexual networks (Bauermeister et al., 2016; Harper & Riplinger, 2013; Millett et al., 2012; Millett et al., 2007; Maulsby et al., 2014; Tieu et al., 2010; Harper, 2007). In addition, young B-GBMSM and B-TW have often been rejected by their families of origin, religious institutions, and society at large (Garofalo et al., 2006). These vulnerabilities are exacerbated by co-epidemics of poverty and violence as well as the syndemic of mental health problems, drug abuse and victimization (Kuhns et al., 2016; Wong et al., 2014; Singer, 2009). Among young B-GBMSM and B-TW, there are multiple distinct communities and social networks, including the House Ball Community (HBC) and the Family or Kiki scene (Dickson-Gomez et al., 2014; Arnold & Bailey, 2009; Kraft et al., 2000).

House and Ball Community

The HBC is an underground affiliative community consisting of primarily Black gay, bisexual, and transgender people that began in Harlem in the early 1900s and flourished during the 1960s, yet has recently gained increased attention in popular culture movies (e.g., Leave it on the Floor, Kiki) and television (e.g., Pose, My House). The HBC consists of two primary features: family-like structures called “houses” and competitive performance-based “balls”. The “houses” adopt a family structure in which a House Father and Mother mentor the remaining members (“children”) as they compete against other houses (“walk”) at balls in various categories related to performance, appearance, and/or attitude for status within the community. The progressive hierarchical status structure of this community (i.e., Stars, Legends, Icons) and the family-like structure of the Houses (i.e., Mothers, Fathers, children) allow for fluid blending of ages which encourages multi-generational mentorship, communication, and socialization within the community (Levitt et al., 2017; Holloway et al., 2014).

In recent years, a newer structure within the HBC, called either the “Kiki” or “Family”, scene has emerged, with younger leaders and members. The Kiki scene follows the same house structure as the HBC (referred to as “mainstream” by Kiki members), but has less rigorous criteria for advancement in the hierarchy. This structure arose from the desire of younger participants to hone their vogueing skills without the added pressure of competing with season ballroom performers. As a result of developing talent that eventually competes on the grand scale of ballroom, the Kiki scene has become an integral component in the ballroom scene. There are many who participate in both groups, perhaps as a Kiki leader and as a HBC member (Castillo & Hosek, 2018).

HIV and stigma in the House Ball Community

High HIV prevalence coupled with estimates that less than 6% of HIV-infected youth achieve sustained viral suppression (Zanoni & Mayer, 2014), create extraordinary risk for HIV acquisition within the HBC, as well as among sexual partners outside of the HBC (Hosek et al., 2015; Castillo et al., 2012). Long histories of stigma experienced by many members of the HBC has increased rates of sex work and drug use within the community, which increases HIV risk (Levitt et al., 2017; Traube et al., 2014; Hwahng & Nuttbrock, 2007). While the balls create a safe space of affirmation and celebration, the importance placed on image and status in the HBC can actually increase HIV-related stigma (Levitt et al., 2017; Galindo, 2013) and cause HBC members to avoid HIV testing and medical care facilities for fear of being seen (Lightfoot, 2012; Rowan et al., 2014). In fact, due to negative effects of stigma, HBC members may be more reluctant to seek medical services than other B-GBMSM (Rowan et al., 2014). Qualitative work by our research team supports the connection between image and HIV stigma within the HBC. As one previous participant stated, “you can still be fierce when you’re poor, but you can’t be fierce with AIDS” (Telander et al., 2017). Strong histories of stigma and rejection from those outside the community, coupled with stigma, fear, and secrecy from within the community make young B-GBMSM and B-TW in the HBC at particularly high risk for new infections and onward transmission of HIV, thus warranting urgent delivery of primary and secondary prevention interventions.

The POSSE Project

The POSSE Project is a community-level HIV prevention intervention based on Diffusion of Innovation theory (Rogers, 2010) and popular opinion leader (POL) models (Kelly et al., 1991; Jones et al., 2008) of HIV prevention and was previously tailored for the HBC (Hosek et al., 2015). The intervention works in a collaborative manner with House mothers/fathers and members of the HBC and Kiki scene to identify opinion leaders who are then educated and trained in delivering HIV/STI prevention and treatment messages to other members of the HBC/Kiki scene through formal and informal gatherings and events. The current study is using an Effectiveness-Implementation Hybrid trial design to test the effectiveness and implementation of the POSSE intervention across two cities with similar HBCs, Chicago and Philadelphia. These two large cities were chosen because they have HBCs that are similar in size and history, but geographically distinct communities, which addresses concerns about intervention contamination. While HBC members tend to travel frequently to other cities to compete, they tend to stay within the region of their primary residence – the Philadelphia HBC travels to other East coast cities (i.e., Washington, DC, New York) while the Chicago HBC travels primarily within the Midwest (i.e., Detroit, St. Louis). The purpose of this article is to describe the baseline demographic and risk characteristics as well as HIV and STI rates among participants enrolled in both cities.

METHODS

Participants

Eligible participants for the baseline assessment 1) self-identified as Black, 2) were between the ages of 15 – 24 (with the exception of opinion leaders identified for the intervention trial, who could be older), and 3) were in attendance at a HBC event at the time of the POSSE assessment. HBC events included balls, vogue schools, and fashion/talent shows.

Procedures

Baseline assessments occurred over a one-month period in both Chicago and Philadelphia during June 2016. The assessment events were planned and coordinated through partnerships with our Community Advisory Boards (CAB) and collaborating community agencies. Youth were approached as they entered POSSE assessment events and the study was explained to them by research staff. If interested and eligible via a brief screener, then participants completed written informed consent and a unique participant identification number (PID) was assigned to each participant. Participants were then brought to a private assessment area with tablet computers and the PID was entered into the computer-assisted self-interview (CASI). Staff members remained in the vicinity to answer questions or to provide additional instructions as needed. If a participant was unable to read the CASI, it was administered to them privately by a staff member. The research team for this study is led by one clinical community/adolescent psychologist, one doctor of public health (one white, one Latina) and a Black adolescent medicine physician, all with many years’ experience working with Black GBT youth involved in the HBC. Research team members include project directors and research assistants who predominantly identify as Black and gay, who have extensive experience working with the HBC, and some of whom are part of the HBC.

After participants completed the CASI assessment, they met with a certified HIV tester in a private space for HIV testing. Certified HIV testers come from community-based organizations and are predominantly Black-identified. The tester then provided them with a swab for rectal gonorrhea (GC) and Chlamydia testing and explained self-administration procedures. All participants with preliminary positive HIV test results, as well as any previously diagnosed patients not in care, received immediate post-test counseling and a specific appointment at their choice of ambulatory HIV clinics collaborating with the project, all of which offer care regardless of patient’s ability to pay. Participants found to be HIV negative, but testing positive for GC/Chlamydia were contacted by the investigative team and scheduled for a treatment appointment. Assessment procedures (testing & CASI) took approximately 1 hour and participants received $50 for participation. The protocol was approved by the Institutional Review Boards of both study sites.

Measures

The assessment battery took approximately 30 minutes to complete and included the measures listed below. All assessments were conducted using computer-assisted self-interviews (CASI) programmed into a secure web application software (i.e., RedCap) and deployed via tablet computers. All of these measures have been used previously within the HBC.

Demographics

Age, gender, race/ethnicity, housing status, HBC affiliation, education, employment, and sexual orientation

Sexual Risk Factors

Condom/barrier protected and unprotected oral, vaginal, and anal sexual activity with HIV+, HIV-, and unknown status partners in the past six months.

Other Risk Factors

Substance Use

The Alcohol Smoking and Substance Involvement Screening Test (ASSIST; WHO, 2002) was used to assess the frequency of use for tobacco, alcohol, cannabis, cocaine, amphetamine-type stimulants, inhalants, sedatives, hallucinogens, opioids and ‘other drugs’ (e.g., “In the past 3 months, how often have you used __________?”). Responses are never, once or twice, monthly, weekly, or daily/almost daily. Depression: Depressive symptomatology was assessed using the 10-item Center for Epidemiologic Studies Depression Scale (CES-D 10; Andresen, 1994), a screening tool that has been used and validated with adolescent and young adult populations (Bradley, Bagnell & Brannen, 2010; Reisner et al., 2016; Van Voorhees, et al., 2009). Participants were asked to indicate how often in the past week they felt or behaved certain ways on a response scale ranging from 0 “rarely/never” to 3 “all the time” (e.g., “During the past week, I was bothered by things that usually do not bother me”). Scores range from 0 to 30, with higher scores indicating more depressive distress. A clinical cut point of ≥10 was used to categorize clinically significant depressive distress. Internal consistency of the CES-D 10 was strong (alpha = 0.80). Partner Violence: The intimate partner violence questionnaire developed for a multi-national study (Garcia-Moreno et al., 2006) consists of 4 questions that assess physical, emotional and sexual harm experienced by the participant in the past year (e.g. “In the past year, has your current or most recent partner punched, slapped, kicked, or bit you, or caused you any type of physical harm?). Responses are yes, no or refuse to answer.

HIV/AIDS Stigma

This measure (Molina & Ramirez-Valles, 2013) assessed three dimensions of HIV/AIDS stigma: enacted (15 items), perceived (15 items), and internalized stigma (8 items) (e.g., “People believe that having HIV/AIDS is a punishment for being gay.”) Responses were rated in a Likert-type scale from 1=Strongly Disagree to 4=Strongly Agree. Summary scores indicate greater stigma with higher scores. Reliability using Chronbach’s alpha for each subscale was high: Enacted stigma = 0.91, Perceived stigma = 0.94, and Internalized stigma =0 .93.

HIV and STI testing

HIV infection was assessed using the INSTI rapid HIV test (bioLytical Laboratories; Moshgabadi et al., 2015) which delivers results within 1 minute. Rectal GC/Chlamydia testing was conducted using self-administered swabs (APTIMA Unisex Swab Specimen Collection Kit; Gen-Probe Inc).

Analyses

Participant characteristics were summarized overall and by city using frequencies for categorical variables and means and medians for continuous variables. Differences between cities were assessed using Pearson chi-square tests for categorical and Wilcoxon rank-sum tests for continuous variables. Data were analyzed using SAS software version 9.4 (SAS Institute, Cary, NC).

RESULTS

A total of 236 unique participants completed the baseline assessment (126 Philadelphia, 110 Chicago) (see Table 1.). The average age of participants was 21.7 years. Most participants were assigned male sex at birth (98.3%), currently identified their gender as man (86.4%) and considered their sexual orientation to be gay (73.8%). Approximately half of participants in both cities had completed high school or received a GED and about half had received public aid of some type in their lifetime. There were slight demographic differences identified between participants in the two cities. For example, participants from Philadelphia were less likely to identify their racial/cultural background as African-American compared to Chicago participants. Participants in Philadelphia were more likely to belong to a formal house within the HBC (p<.001) and more likely to be currently employed (<.001) than Chicago participants.

Table 1.

Demographic characteristics by city

Total (N=236) n (%) Philadelphia (N=126) n (%) Chicago (N=110) n (%) p-value
Age, Mean (SD); Median 21.7 (4.5); 21 22.4 (5.4); 21 20.6 (2.5); 21 0.134
 <20 74 (38.0) 40 (35.7) 34 (41.0) 0.455
 ≥20 121 (62.0) 72 (64.3) 49 (59.0)
Sex at birth
 Male 229 (98.3) 120 (96.8) 109 (100.0) 0.125
 Female 4 (1.7) 4 (3.2) 0 (0.0)
Current gender identity
 Male 203 (86.4) 110 (88.0) 93 (84.6) 0.558
 Female 1 (0.4) 0 (0.0) 1 (0.9)
 Trans male/Trans man 3 (1.3) 2 (1.6) 1 (0.9)
 Trans female/Trans woman 27 (11.5) 12 (9.6) 15 (13.6)
 Genderqueer or non-binary/non-conforming/other 1 (0.4) 1 (0.8) 0 (0.0)
Sexual orientation
 Gay 172 (73.8) 96 (77.4) 76 (69.7) 0.495
 Bisexual 30 (12.9) 14 (11.3) 16 (14.7)
 Straight 20 (8.6) 8 (6.5) 12 (11.0)
 Other 11 (4.7) 6 (4.8) 5 (4.6)
Ethnic/cultural background
 African American 200 (85.5) 98 (79.0) 102 (92.7) 0.031
 Black Latino 15 (6.4) 11 (8.9) 4 (3.6)
 Caribbean/West Indian 9 (3.9) 7 (5.7) 2 (1.8)
 Other 10 (4.3) 8 (6.5) 2 (1.8)
Currently working
 No 112 (48.3) 43 (34.7) 69 (63.9) <0.001
 Yes, full-time 59 (25.4) 39 (31.5) 20 (18.5)
 Yes, part-time 61 (26.3) 42 (33.9) 19 (17.6)
Highest grade completed
 <High school 51 (22.1) 24 (19.5) 27 (25.0) 0.516
 High school graduate or GED 116 (50.2) 62 (50.4) 54 (50.0)
 >High school 64 (27.7) 37 (30.1) 27 (25.0)
Ever received public aid
 Yes 115 (50.2) 64 (51.2) 51 (49.0) 0.745
 No 114 (49.8) 61 (48.8) 53 (51.0)
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Participants in both cities had experienced housing instability, with 19.7% reporting being homeless in their lifetime and 21.4% reporting they had been kicked out of their home due to their sexual orientation. Similarly, 22.7% acknowledged having to exchange sex for a place to stay in their lifetime. A small proportion of participants used alcohol daily (2.7%) compared to 22.4% who used marijuana daily. With regard to depression, 32.5% of participants met or exceeded the clinical cut-off on the CES-D 10 indicative of depressive distress. These vulnerabilities were consistent across both cities with no statistically significant differences (see Table 2). The perception of HIV-related stigma was common and similar across cities. For example, the majority of participants in both cities endorsed the perception that people don’t want to date those living with HIV, want their children around someone with HIV, and that gay men are responsible for the spread of HIV (Table 3).

Table 2.

Sexual and Other Risk Factors by City

Total (N=236) n (%) Philadelphia (N=126) n (%) Chicago (N=110) n (%) p-value
Ever kicked out due to sexual orientation
 Yes 49 (21.4) 25 (20.5) 24 (22.4) 0.721
 No 180 (78.6) 97 (79.5) 83 (77.6)
Ever homeless
 Yes 45 (19.7) 29 (23.4) 16 (15.4) 0.131
 No 183 (80.3) 95 (76.6) 88 (84.6)
# nights without housing (n=43), Median (Q1-Q3) 20 (4–90) 20 (4–90) 30 (3–116) 0.600
Ever exchanged sex
 Yes 53 (22.7) 29 (23.0) 24 (22.2) 0.885
 No 181 (77.4) 97 (77.0) 84 (77.8)
# times sex exchange in past month (n=17), Median (Q1-Q3) 5.0 (3.0–11.0) 5.0 (2.0–11.0) 5.0 (4.0–20.5) 0.419
Ever taken PrEP
 Yes 44 (18.9) 28 (22.4) 16 (14.8) 0.140
 No 189 (81.1) 97 (77.6) 92 (85.2)
HIV status of primary partnerc
 Negative 117 (77.5) 66 (79.5) 51 (75.0) 0.633
 Positive 16 (10.6) 9 (10.8) 7 (10.3)
 Unknown 18 (11.9) 8 (9.6) 10 (14.7)
Condomless anal sex last month
 Yes 60 (43.8) 36 (48.0) 24 (38.7) 0.275
 No 77 (56.2) 39 (52.0) 38 (61.3)
Condomless vaginal sex last month
 Yes 33 (24.3) 18 (25.0) 15 (23.4) 0.832
 No 103 (75.7) 54 (75.0) 49 (76.6)
Alcohol use frequency in past 3m
 Never 82 (37.1) 36 (30.0) 46 (45.5) 0.100
 Once or twice 64 (29.0) 38 (31.7) 26 (25.7)
 Monthly 24 (10.9) 16 (13.3) 8 (7.9)
 Weekly 45 (20.4) 25 (20.8) 20 (19.8)
 Daily or almost daily 6 (2.7) 5 (4.2) 1 (1.0)
Marijuana use frequency past 3m
 Never 101 (46.1) 46 (39.3) 55 (53.9) 0.208
 Once or twice 25 (11.4) 16 (13.7) 9 (8.8)
 Monthly 12 (5.5) 6 (5.1) 6 (5.9)
 Weekly 32 (14.6) 21 (18.0) 11 (10.8)
 Daily or almost daily 49 (22.4) 28 (23.9) 21 (20.6)
Any cocaine or other amphetamine used, past 3m
 Yes 26 (12.0) 15 (12.8) 11 (11.1) 0.701
 No 190 (88.0) 102 (87.2) 88 (88.9)
CESD-10 binary score
 ≥10 62 (32.5) 37 (34.9) 25 (29.4) 0.420
 <10 129 (67.5) 69 (65.1) 60 (70.6)
Partner violence
Physical harm
 Yes 34 (15.7) 18 (15.4) 16 (16.2) 0.876
 No 182 (84.3) 99 (84.6) 83 (83.8)
Emotional harm
 Yes 51 (23.5) 33 (28.0) 18 (18.2) 0.090
 No 166 (76.5) 85 (72.0) 81 (81.8)
Sexual harm
 Yes 14 (6.4) 9 (7.6) 5 (5.1) 0.463
 No 203 (93.6) 110 (92.4) 93 (94.9)
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Table 3.

Perceived HIV Stigma by City

Total (N=236) n (%) Philadelphia (N=126) n (%) Chicago (N=110) n (%) p-value
Total score, Median (Q1-Q3) 6 (1–10) 6 (2–10) 5.5 (1–10) 0.552
Individual items:
People believe those with HIV/AIDS should be isolated from society
 Agree/Strongly agree 56 (26.1) 28 (24.1) 28 (28.3)
 Disagree/Strongly disagree 159 (74.0) 88 (75.9) 71 (71.7)
People don’t want to hug/kiss/touch people with HIV/AIDS
 Agree/Strongly agree 83 (39.2) 43 (37.1) 40 (41.7)
 Disagree/Strongly disagree 129 (60.9) 73 (62.9) 56 (58.3)
People don’t want to be friends with someone with HIV/AIDS
 Agree/Strongly agree 63 (29.3) 34 (29.1) 29 (29.6)
 Disagree/Strongly disagree 152 (70.7) 83 (70.9) 69 (70.4)
People don’t want to date someone with HIV/AIDS
 Agree/Strongly agree 129 (60.6) 73 (64.0) 56 (56.6)
 Disagree/Strongly disagree 84 (39.4) 41 (36.0) 43 (43.4)
People will end a relationship if the partner has HIV/AIDS
 Agree/Strongly agree 122 (58.7) 64 (56.6) 58 (61.1)
 Disagree/Strongly disagree 86 (41.4) 49 (43.4) 37 (39.0)
People don’t want to live with someone with HIV/AIDS
 Agree/Strongly agree 74 (35.8) 38 (33.6) 36 (38.3)
 Disagree/Strongly disagree 133 (64.3) 75 (66.4) 58 (61.7)
People don’t want their children around someone with HIV/AIDS
 Agree/Strongly agree 108 (53.7) 57 (52.8) 51 (54.8)
 Disagree/Strongly disagree 93 (46.3) 51 (47.2) 42 (45.2)
People believe workers/volunteers in HIV service have HIV/AIDS
 Agree/Strongly agree 82 (39.6) 46 (40.0) 36 (39.1)
 Disagree/Strongly disagree 125 (60.4) 69 (60.0) 56 (60.9)
Employers don’t want an employee with HIV/AIDS
 Agree/Strongly agree 65 (31.7) 34 (30.1) 31 (33.7)
 Disagree/Strongly disagree 140 (68.3) 79 (69.9) 61 (66.3)
People don’t want to work with someone who has HIV/AIDS
 Agree/Strongly agree 74 (35.9) 40 (35.4) 34 (36.6)
 Disagree/Strongly disagree 132 (64.1) 73 (64.6) 59 (63.4)
People believe those with HIV/AIDS are promiscuous/drug users
 Agree/Strongly agree 76 (37.1) 47 (41.6) 29 (31.5)
 Disagree/Strongly disagree 129 (62.9) 66 (58.4) 63 (68.5)
People believe having HIV/AIDS is a punishment for being gay
 Agree/Strongly agree 111 (53.4) 69 (59.0) 42 (46.2)
 Disagree/Strongly disagree 97 (46.6) 48 (41.0) 49 (53.9)
People believe gays are to blame for the spread of HIV/AIDS
 Agree/Strongly agree 131 (63.6) 82 (71.9) 49 (53.3)
 Disagree/Strongly disagree 75 (36.4) 32 (28.1) 43 (46.7)
People believe that those with HIV/AIDS are a burden to society
 Agree/Strongly agree 104 (51.5) 63 (56.3) 41 (45.6)
 Disagree/Strongly disagree 98 (48.5) 49 (43.8) 49 (54.4)
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Perceived HIV stigma based on 14 items measured on a 4-point scale from strongly disagree to strongly agree; items were dichotomized as strongly disagree or disagree=0 and agree or strongly agree=1 and summed, with higher scores reflecting higher perceived stigma (range=0–14). Individual item frequencies are also presented.

Approximately 18% of the participants across both cities reported that they were HIV-positive and most stated that they were actively receiving medical care. Of participants who completed HIV testing at baseline, 11% of Chicago participants tested positive whereas there were no new positive results in Philadelphia discovered through screenings at baseline assessments (p=.056). Positive GC results were found in 4% of Philadelphia participants and 13.9% of Chicago participants (p=.029). Chlamydia infections were found in 10.7% of Philadelphia participants and 18.8% of Chicago participants. Overall, 43.8% of participants reported condomless anal sex in the past month and 24.3% reported condomless vaginal sex in the past month (see Table 4).

Table 4:

STI and HIV positivity at baseline by city

Total (N=236), n (%) Philadelphia (N=126), n (%) Chicago (N=110), n (%) p-value
Ever diagnosed with HIV (by self-report)
 Yes 38 (17.8) 23 (19.8) 15 (15.5) 0.407
 No 175 (82.2) 93 (80.2) 82 (84.5)
HIV resultsa
 n tested 119 37 82
 Positive 9 (7.6) 0 (0.0) 9 (11.0) 0.056
STI resultsa, b
 n tested 176 75 101
 Gonorrhea positive 17 (9.7) 3 (4.0) 14 (13.9) 0.029
 Chlamydia positive 27 (15.3) 8 (10.7) 19 (18.8) 0.138
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a.

Among those who tested

b.

Excludes 2 positive APTIMA but no NG or CT results, 5 indeterminate. 7 were dually diagnosed with NG and CT; 37 had either infection

DISCUSSION

The data in this paper describe baseline demographics, sexual and other risk factors, and HIV and STI rates among young Black people enrolled in the POSSE Project, an intervention effectiveness and implementation study among the HBC in Chicago and Philadelphia. These data demonstrate the range of socio-ecological factors that may negatively impact the physical and mental health of Black young people involved in the HBC. Such forces may put these youth at greater risk for the acquisition of HIV/STIs, as well as impair their ability to engage in both preventive and treatment-related behaviors (e.g., PrEP, ARVs).

The HIV and STI testing results from this baseline assessment period identify two communities with high rates of prevalent infection. Almost 18% of participants overall self-identified as living with HIV and 7% of those who tested were found to be HIV-positive. Rates of rectal gonorrhea and chlamydia infections, which are often asymptomatic, were also very high. These data are consistent with the steep increase in national trends in the identification of STIs among GBMSM (CDC, 2017). Of note, many participants in the baseline assessment reported that they had never been tested for STIs via a rectal swab.

Studies with LGBT youth outside of the HBC have found that family acceptance of sexual orientation provides a protective health effect (Ryan et al., 2010). As has been seen in other studies of gay and transgender adolescents, high rates of unemployment, housing instability and experiences with rejection from family due to sexual orientation or gender identity may force young people in the HBC to engage in behavior, such as transactional sexual encounters or alcohol/drug use, that increases their risk of HIV infection (Boyer et al., 2017; Wolitski et al., 2007). Such experiences with rejection and inconsistent housing were far too common among our participants, but similar across cities. When working with this population, facilitating referrals for housing services and case management is critical. In fact, studies have demonstrated a direct link between being placed in supportive housing and decreased risk of new HIV infection (Lee et al., 2018) as well as an association between home eviction and increased viral load among individuals living with HIV (Kennedy et al., 2017).

One-third of participants from both HBC communities also reported levels of depressive symptomatology that may be commensurate with clinical diagnoses of depression. Mental health problems, including depression and suicidality, have frequently been seen among LGBT youth and occur at much higher rates than among their heterosexual peers (Kann et al., 2016). Furthermore, studies with diverse samples of LGBT youth and adults have found that high rates of psychosocial problems are correlated to greater HIV risk (Mustanski et al., 2007; Stall et al., 2008). Access to LGBTQ-competent mental health services must be a key component of any HIV prevention services that target B-GBMSM and B-TW. However, providers should acknowledge that the stigma surrounding mental health creates a barrier to successful service provision (Bauermeister et al., 2018). In addition, the perceptions of pervasive HIV-related stigma adds yet another layer of HIV and STI vulnerability to the HBC community.

Overall, the baseline data presented here clearly establishes the need for HIV and STI prevention interventions across both cities. Factors such as high unemployment, lack of consistent housing, the need to exchange sex for money, high rates of depression and being a part of a stigmatized community likely exacerbate HIV and STI vulnerability and could also lead to poor sexual health awareness and engagement with healthcare and social service providers. Experiences with stigma and ostracism from outside the HBC may make the implementation of an intervention delivered by community members, such as POSSE, particularly effective. Ultimately, interventions with the potential to successfully impact the HBC must be comprehensive in their approach to ameliorate the complex social and structural problems faced by these young people.

The data presented here highlight important targets for behavioral and structural HIV prevention interventions within the HBC and are strong in the inclusion of both self-report and objective measures of risk factors. However, there are limitations that must be noted. To begin with, this data provides only a cross-sectional snapshot of the HBCs in both Chicago and Philadelphia. Longitudinal data is needed to monitor trends over time and adjust for any temporal factors that may have impacted the community at the time of the baseline assessment. Additionally, because our assessments occurred in collaboration with other HBC events, only HBC members present at those events had an opportunity to participate. Finally, while the baseline data help to establish the similarities between the HBCs in these two US cities, generalizations to other HBCs or to all B-GBMSM or B-TW may not be appropriate.

ACKNOWLEDGEMENTS

We would like to thank the tireless efforts of our Chicago and Philadelphia Community Advisory Board members for their time and commitment to this study and their community. In Chicago: Icon Father Tommy Avant Garde, Legendary Overall Father Amari Christian, Legendary Father Mario Balenciaga, Mother ShaSha Golden/Lauren, Kweli Balenciaga, Legendary Kentrele Mizrahi/Father Rajah, Relic Mizrahi, Legendary Alonzo Balmain/Baldwin, Nate Baldwin, Jeff Omni, Rykko Herrera, Amya Khan/Baldwin, and Adonte Prodigy/Baldwin. In Philadelphia: (Legendary Mike Ebony, Ja’Nae Balenciaga, Legendary Bubby Revlon, Dippy 007, Legendary Season Lanvin, Shimmy Old Navy, Ike Ebony/Avalon, Jay Escada, Legendary Aamina Prodigy, Kemar /Old Navy/Mizrahi, Nick Prodigy/Avalon, Joshua Ninja, Legendary Fuzzy Blahnik, Icon Jay Blahnik, Tatyana Escada/Farragomo, Maurice West/Avalon, Tori Prodigy, Legendary Hakeem Balenciaga, Legendary Markise Prodigy, Kash Balenciaga, Dominique Ebony, and Will Blahnik. This study was funded through a grant from the National Institute of Mental Health (5 R01 MH104106).

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