Description
Core Elements, Key Characteristics, and Procedures
Adapting
Resource requirements
Recruitment
Policies and Standards
Quality Assurance
Monitoring and Evaluation
Key Articles and Resources
References

Description

Many Men, Many Voices (3MV) is a 7-session group-level intervention program to prevent HIV and sexually transmitted diseases among black men who have sex with men (MSM) who may or may not identify themselves as gay. The intervention addresses factors that influence the behavior of black MSM: cultural, social, and religious norms; interactions between HIV and other sexually transmitted diseases; sexual relationship dynamics; and the social influences that racism and homophobia have on HIV risk behaviors

3MV has been packaged by CDC's Diffusion of Effective Behavioral Interventions project; information on obtaining the intervention training and materials is available at The Diffusion of Effective Behavioral Interventions (DEBI) website.

Goals

3MV sessions aim to foster positive self-identity, educate clients about their risk for HIV and sexually transmitted diseases, and teach assertiveness skills.

How It Works

3MV consists of distributing educational materials, (which may be used to recruit persons at risk into the group), conducting outreach (by project staff) for recruitment, and holding the intervention sessions. The intervention addresses factors that influence the behavior of black MSM, such as values, perceived risk, cultural and social norms, and sexual relationship dynamics. It is delivered in 7 highly interactive group sessions, 2 to 3 hours each. The sessions are facilitated by a peer and contain 6 to 12 clients. Clients who are unaware of their HIV status are told the benefits of knowing their status and are referred for counseling and testing, if appropriate. 3MV uses behavioral skills practice, group exercises, facilitated discussions, role-playing, and lectures.

Theory behind the Intervention

3MV was adapted from the Behavioral Self-Management and Assertion Skills intervention¹ (now called Partners in Prevention), developed by the Center for AIDS Intervention Research in the Department of Psychiatry and Behavioral Medicine at the Medical College of Wisconsin.

Research Findings

In the original intervention, gay men who participated reduced their frequency of unprotected anal intercourse and increased their use of condoms significantly more than those who did not participate. The original intervention contained 12 sessions lasting 1.5 hours each; the intervention has been condensed to 7 sessions lasting 2.5 to 3 hours each. It has been adapted to address the factors that influence behavior of black MSM. The adaptation and implementation of this intervention were done through a partnership of Men of Color Health Awareness, Inc.; People of Color in Crisis, Inc.; and the Center for Health and Behavioral Training of the University of Rochester .

Back to top

Core Elements, Key Characteristics, and Procedures

Core Elements

Core elements are those parts of an intervention that must be done and cannot be changed. They come from the behavioral theory upon which the intervention or strategy is based; they are thought to be responsible for the intervention's effectiveness. Core elements are essential and cannot be ignored, added to, or changed.

3MV has the following 9 core elements:

• Enhance self-esteem related to racial identity and sexual behavior.
• Educate clients about HIV risk and sensitize to personal risk.
• Educate clients about interactions between HIV and other sexually transmitted diseases and sensitize to personal risk.
• Develop risk-reduction strategies.
• Build a menu of behavioral options for HIV and other sexually transmitted diseases risk reduction, including those that one can act on individually and those that require partner involvement.
• Train in risk-reduction behavioral skills.
• Enhance self-efficacy related to behavioral skills.
• Train in partner communication and negotiation.
• Provide social support and relapse prevention.

Key Characteristics

Key characteristics are those parts of an intervention (activities and delivery methods) that can be adapted to meet the needs of the CBO or target population.

3MV has the following key characteristics:

• Foster positive identity development and self-esteem for black MSM by
• exploring the dual identity culture of black MSM
• addressing social influences and family, religious, and cultural norms within the black community
• exploring the concept of internalized racism and homophobia
• Discuss sexual relationship roles and risks, addressing knowledge of interactions between HIV and other sexually transmitted diseases and transmission risk, and exploring beliefs about those risks.
• Address perceived personal risk and personal susceptibility for infection with HIV and other sexually transmitted diseases as well as perceived barriers to remaining HIV negative.
• Increase skills, self-efficacy, and intentions with regard to protective behaviors.
• Explore the dynamics of sexual relationships, including the dynamics of power and the concept of “tops” and “bottoms” for black MSM.
• Address the importance of peer support and social influence on maintaining healthy behaviors.

Procedures

Procedures are detailed descriptions of some of the above-listed elements and characteristics.

Procedures for 3MV are as follows:

Holding the Sessions

The 7 sessions address specific influencing factors in a purposeful sequence.

Session 1 The Dual Identity Culture of black MSM

Session 2 HIV Prevention for black MSM: Sexual Roles and Risks

Session 3 HIV Risk Assessment and Prevention Options

Session 4 Intentions to Act and Capacity to Change

Session 5 Partner Selection, Communication, and Negotiation

Session 6 Social Support and Problem Solving to Maintain Change

Session 7 Building Bridges and Community. This session links clients to

• other prevention services within the CBO (e.g., behavioral counseling, HIV counseling and testing, screening for sexually transmitted diseases)
• related services within the community (e.g., mental health and substance abuse treatment)
• community building activities for black MSM

Information on the specific content of the sessions is provided during facilitator training sessions. Sessions are more interactive (i.e., allowing clients to learn through experience, such as educational games and exercises) and less didactic (i.e., containing very little presentation of information).

Determining Duration of Sessions

CBOs that have adapted the intervention found that the African American gay and bisexual men that they served were more inclined to attend 7 sessions of 2 to 3 hours each than 12 shorter sessions of 1.5 hours each. A CBO may conduct its own formative evaluation to determine the optimum number and length of sessions according to client needs and convenience. For example, the intervention may be condensed into a weekend retreat, covering the 18 to 21 hours of intervention materials in a single weekend.

Back to top

Adapting

Adapting means modifying the intervention to appropriately fit the local context in a way that does not violate the core elements of the intervention. Although 3MV was not specifically designed for members of other racial and ethnic groups who may identify themselves as being “of color,” (e.g., Asians/Pacific Islanders, Latinos, and Native Americans), the intervention could be adapted for these special populations.

Back to top

Resource requirements

People

3MV needs

• 1 or 2 facilitators
• The facilitators are responsible for coordinating all activities and organizing all aspects of the intervention.
• At least 1 must work full time.
• At least 1 must be a gay or bisexual black man.
• Both must be skilled in leading groups.
• Both must be trained in the specific content of each group session (2 training sessions, 3 days each).
• Facilitators are encouraged to satisfactorily complete trainings offered by their regional STD/HIV Prevention Training Center: “Group Facilitation,” and “Bridging Theory and Practice,” and “STD Overview for Community Providers.”
• Neither should run more than 2 concurrent groups.
• an administrative employee of the CBO (to supervise the facilitators)
• project staff (to recruit black MSM at risk into the intervention)

Space

3MV needs meeting space, which can usually be found at the CBO. It must be

• large enough for 6 to 14 people
• safe, with comfortable seating
• easy to get to using public transportation and near where black MSM live, work, and socialize
• private and secure, so that confidentiality can be maintained
• quiet and without interruptions (such as people entering and exiting the room or outside noise)

Supplies

3MV needs

• VCR, TV, overhead projector
• markers, easels and paper, masking tape, poster boards, clothespins
• Outreach materials (poster, flyers)

Back to top

Recruitment

The population recruited for 3MV is black men who are gay, bisexual, or same-gender–loving and black men who may not identify themselves as gay or bisexual but who do have sexual or emotional attraction to other men (men on the down-low). 3MV is not appropriate for other MSM such as inmates who have “situational sex,” those who have sex for money or drugs who do not have sexual or emotional attraction for other men, or heterosexual men.

Note: In relation to 3MV, black refers to black race, including African American, African, Caribbean/West Indian, and black Latino or Hispanic.

Clients are usually recruited by the group facilitators. If potential clients are referred from other programs, the facilitators should interview them to be sure they are appropriate for the group. Printed materials may be distributed to help with recruiting.

Back to top

Policies and Standards

Before a CBO attempts to implement 3MV, the following policies and standards should be in place to protect clients, the CBO, and the 3MV program team:

Confidentiality

A system must be in place to ensure that confidentiality is maintained for all participants in the program. Before sharing any information with another agency to which a client is referred, signed informed consent from the client or his or her legal guardian must be obtained.

Cultural Competence

CBOs must strive to offer culturally competent services by being aware of the demographic, cultural, and epidemiologic profile of their communities. CBOs should hire, promote, and train all staff to be representative of and sensitive to these different cultures. In addition, they should offer materials and services in the preferred language of clients, if possible, or make translation available, if appropriate. CBOs should facilitate community and client involvement in designing and implementing prevention services to ensure that important cultural issues are incorporated. The Office of Minority Health of the Department of Health and Human Services has published the National Standards for Culturally and Linguistically Appropriate Services in Health Care, which should be used as a guide for ensuring cultural competence in programs and services . (Please see Ensuring Cultural Competence in the Introduction of this document for standards for developing culturally and linguistically competent programs and services.)

Data Security

To ensure data security and client confidentiality, data must be collected and reported according to CDC requirements.

Informed Consent

CBOs must have a consent form that carefully and clearly explains (in appropriate language) the CBO's responsibility and the clients' rights. Individual state laws apply to consent procedures for minors; but at a minimum, consent should be obtained from each client and, if appropriate, a legal guardian if the client is a minor or unable to give legal consent. Participation must always be voluntary, and documentation of this informed consent must be maintained in the client's record.

Legal and Ethical Policies

CBOs must know their state laws regarding disclosure of HIV status to sex partners and needle-sharing partners; CBOs are obligated to inform clients of the organization's responsibilities if a client receives a positive HIV test result and the organization's potential duty to warn. CBOs also must inform clients about state laws regarding the reporting of domestic violence, child abuse, sexual abuse of minors, and elder abuse.

Linkage of Services

Recruitment and health education and risk reduction must link clients whose HIV status is unknown to counseling, testing, and referral services and persons living with HIV to care and prevention services. CBOs must develop ways to assess whether and how frequently the referrals made by their staff members were completed.

Personnel Policies

CBOs conducting recruitment, outreach, and health education and risk reduction must establish a code of conduct. This code should include, but not be limited to, the following: do not use drugs or alcohol, do use appropriate behavior with clients, and do not loan or borrow money.

Referrals

CBOs must be prepared to refer clients as needed. For clients who need additional assistance in decreasing risk behavior, providers must know about referral sources for prevention interventions and counseling, such as partner counseling and referral services and other health department and CBO prevention programs.

Safety

CBO policies must exist for maintaining safety of workers and clients. Plans for dealing with medical or psychological emergencies must be documented.

Selection of Target Populations

CBOs must establish criteria for, and justify the selection of, the target populations. Selection of target populations must be based on epidemiologic data, behavioral and clinical surveillance data, and the state or local HIV prevention plan created with input from state or local community planning groups.

Volunteers

If the CBO uses volunteers to assist with or conduct this intervention, then the CBO should know and disclose how their liability insurance and worker's compensation applies to volunteers. All training should be documented. CBOs must also ensure that volunteers sign and adhere to a confidentiality statement.

Back to top

Quality Assurance

The following quality assurance activities should be in place when implementing 3MV:

Facilitators

Training for facilitators should address

• completion of a training workshop, including review of the intervention theory and materials
• participation in practice sessions
• observed cofacilitation of groups, including practice of mock intervention sessions

CBOs implementing 3MV are encouraged to complete and use the Many Men, Many Voices implementation planning tool to plan, document, and guide their project.

CBOs should have in place a mechanism to ensure that all session protocols are followed as written. For quality assurance, key staff can observe and rate the sessions in terms of adherence to session content and group facilitation skills.

Selected intervention record reviews should focus on assuring that consent forms (signed either by the client, if older than 18 or emancipated, or by a legal guardian) are included for all participants when required and that session notes are of sufficient detail to assure that clients are participating actively. The entire content of the sessions constitutes the core elements of this intervention, so the entire content must be covered to implement the intervention with fidelity.

Clients

Clients' satisfaction with the intervention and their comfort should be assessed at the end of the 7th session. Process monitoring systems should also track the number of sessions each client attends as well as reasons for not attending.

Back to top

Monitoring and Evaluation

Specific guidance on the collection and reporting of program information, client-level data, and the program performance indicators will be distributed to agencies after notification of award.

General monitoring and evaluation reporting requirements for the programs listed in the procedural guidance will include the collection of standardized process and outcome measures. Specific data reporting requirements will be provided to agencies after notification of award. For their convenience, grantees may utilize PEMS software for data management and reporting. PEMS is a national data reporting system that includes a standardized set of HIV prevention data variables, web-based software for data entry and management. CDC will also provide data collection and evaluation guidance and training and PEMS implementation support services.

Funded agencies will be required to enter, manage, and submit data to CDC by using PEMS or other software that transmits data to CDC according to data requirements. Furthermore, agencies may be requested to collaborate with CDC in the implementation of special studies designed to assess the effect of HIV prevention activities on at-risk populations.

Back to top

References

1. Kelly JA, St. Lawrence JS, Hood HV, Brasfield TL. Behavioral intervention to reduce AIDS risk activities. Journal of Consulting and Clinical Psychology. 1989;57:60–67.

Mpowerment