Focus on Men Who Have Sex With Men (MSM) This month, NASTAD focuses on HIV prevention for men who have sex with men (MSM), particularly Black MSM.    Through 2003, CDC estimates that 67% of all men and 54% of all people who had received a diagnosis of AIDS were MSM.1   A recent CDC Fact Sheet notes that "MSM, as a group, continue to be the most affected by HIV/AIDS." 2   And among MSM, Black MSM are disproportionately impacted by HIV/AIDS; 32 percent of MSM living with HIV/AIDS at the end of 2003 were African American.3   A sustained effort, with resources and an expanded arsenal of effective strategies to address HIV/AIDS among MSM are clearly needed.  The following stories highlight significant national activities and local efforts to make an impact, including NASTAD's response to the disproportionate impact of HIV/AIDS on MSM.  References: 1. CDC. HIV/AIDS Fact Sheet: HIV/AIDS Among Men Who Have Sex With Men, July 2005. Downloaded 3/27/06 from: www.cdc.gov/hiv/PUBS/Facts/msm.htm 2. ibid. page 5 3. ibid, page 2     Focusing on Black MSM The tremendous impact of HIV/AIDS among men who have sex with men (MSM) and in particular, Black MSM, is well documented.  Data released by the CDC at the 2005 National HIV Prevention Conference in Atlanta, GA further illustrates the HIV epidemic's disproportionate impact on Black MSM.  A study of MSM conducted in five U.S. cities (Baltimore, Los Angeles, Miami, New York City, and San Francisco) from June 2004 to April 2005, showed that 46 percent of Black MSM tested were HIV-positive, and 67 percent of these men were unaware of their status.1  In response to this alarming data, CDC convened a Black MSM consultation in August 2005 at which health care providers, policymakers, scientists, researchers, and community leaders discussed current HIV prevention programs and research activities targeted for Black MSM.  While much more research needs to be done on effectively reaching MSM, particularly Black MSM, there are some key elements that must be included in effective care and prevention programs for MSM, including addressing testing barriers, intervening in social networks, mobilizing communities, and focusing on comprehensive health and wellness and evidence-based behavioral interventions.2  Moreover, the intersection of HIV/AIDS with issues of sexuality, particularly among Black MSM, creates a powerful dynamic.  Black MSM navigate many cultural, social, spiritual, sexual, racial, and economic issues.  When combined, these issues pose a unique set of challenges for this population. References: 1. CDC. HIV Prevalence, Unrecognized Infection, and HIV Testing Among Men Who have Sex with Men – Five U.S. Cities, June 2004-April 2005.  MMWR 2005; 54 (24): 597-601. 2. NASTAD. Black MSM Issue Brief No.1: Black Men Who Have Sex With Men (MSM), February 2006. NASTAD's Response Recently, NASTAD has urged health departments to examine effective strategies and resources to prevent transmission among Black MSM, while considering the many nuances, social constraints, and homophobia (both internal and external) that define the realities of Black MSM.  In February 2006, NASTAD published an issue brief entitled, Black Men Who Have Sex with Men (MSM): Standing at the Crossroad of the HIV/AIDS Epidemic in the United States.  The issue brief examines the HIV/AIDS crisis among Black MSM and provides an overview of recent CDC data, while seeking to frame issues related to the identity of Black MSM.  Additionally, the issue brief addresses the core components of effective prevention and care strategies for Black MSM and provides recommendations that health departments can follow in designing programs and implementing strategies to address the significant needs of this population. NASTAD has supported Black MSM community mobilization efforts and participates in the National Black Gay Men's Advocacy Coalition, a group of Black gay men formed in response to the alarming data which underscores the HIV epidemic's disproportionate impact on Black MSM.  The Coalition has presented recommendations to assist CDC and other HHS agencies in crafting a comprehensive response to drastically reduce rates of HIV/AIDS among Black MSM.  NASTAD has also released a call to action entitled, A Turning Point:  Confronting HIV/AIDS in African American Communities, which urges state and local health departments, African American leaders, federal agencies, and policy makers to strengthen their responses within African American communities as a whole; specific recommendations to address the epidemic among Black MSM are included. NASTAD is also conducting an assessment of health department activities related to Black MSM.  In order to mount a comprehensive response, NASTAD is working with both leaders within the African American MSM community and with the CDC to develop an understanding of the level of investment by various jurisdictions in prevention activities directed toward this population.  This assessment seeks to determine the baseline for our country's future response to this growing epidemic.  Several members of NASTAD's Executive Committee and African American Advisory Committee met with representatives of the National Black Gay Men's Advocacy Coalition in Washington, D.C. in November 2005 to gather input on NASTAD's health department assessment tool and discuss ways in which to work together to reduce the disproportionate number of infections among Black MSM.  The assessment will be used to determine resources and activities focused on Black MSM and will serve as a springboard for future efforts to determine policies and programs which focus on this population.  If you would like to share information about your prevention activities focused on Black MSM, or for more information on NASTAD's Black MSM activities, please contact Terrance Moore. Maryland's RISE (Rewriting Inner Scripts) Project for African American MSM By Kip Castner, Acting Deputy Chief, Center for Prevention, Maryland AIDS Administration The Maryland AIDS Administration is launching a new intervention for same-gender-loving African American men designed to serve as a precursor or bridge into the state's other health projects for men who have sex with men (MSM.) The AIDS Administration is partnering with Baltimore's African-American LGBT community center, the Portal/Empowering New Concepts on the RISE project.  Executive Director and Portal Founder Rickie Green provided critical feedback throughout the development process on the cultural competence of the draft intervention, and is now serving as lead on project implementation—recruiting clients, managing the process, and participating in the evaluation design.  RISE takes direct aim at shame—as a tool of oppression, and as a barrier to African American men who have sex with men's (AAMSM) pursuit of health care and other services.  RISE retreats are a full-day intervention taking place on Saturdays.  The retreat format avoids the challenge that multi-session health education/risk reduction interventions commonly face: retaining participants over several weeks of weekly sessions.  Half the day's activities identify the sources of internalized oppression (in the dimensions of race, gender and sexual orientation).  The balance of the day involves reframing and rebuilding exercises which empower participants to interrupt negative self-talk and reframe internal decisions.  The retreat concludes with the distribution of a local MSM Resource Guide, including referrals to MSM-friendly HIV care providers. The premise of RISE is that providers' expectations of health-seeking behaviors are not realistic for some members of highly oppressed communities.  Health-seeking behaviors result when individuals place value on their own health and exert effort or incur costs on its behalf.  Some same-gender-loving African American men have been so impacted by oppression that they do not value themselves enough to participate in health programs such as HIV prevention, substance abuse, mental health, and / or HIV treatment.  RISE explores the shame associated with being gay.  RISE helps participants to perceive that their sexual orientation does not make them a failure.  Rather, others have failed to value their sexual orientation.  RISE intends that after they achieve this shift in perspective, participants will be more self-accepting and better prepared to perceive health-seeking behaviors as meaningful. The RISE curriculum is part of the AIDS Administration's response to the local findings of the National HIV Behavioral Surveillance study.  One-third of local study participants were found to be infected with HIV.  Almost half of the African American men who participated in the study were diagnosed HIV positive. During behavioral surveillance data collection, the Maryland AIDS Administration convened a team to pool resources and inform the programmatic response.  The MSM Response Team is comprised of representatives of other funding agents such as Ryan White CARE Act Titles I and II, and local MSM providers and consumers.  In the summer of 2005 the AIDS Administration conducted a series of open meetings to share the behavioral surveillance findings and to collect input regarding why Baltimore had such alarming results.  Participants consistently responded by identifying the multiple stigmas confronting the population, related to their race and sexual orientation.  This local input dovetailed with published literature about the challenges faced by same-gender-loving African American men. Rewriting Inner Scripts (RISE) is based on three behavioral theories: Social Learning, Health Belief, and Transtheoretical.  The intervention is led by a self-identified member of the community of same-gender-loving African-American men, who is conscious of the role of internalized oppression in his own life.  Informed by the Social Learning model, participants observe how much progress it is possible to make in overcoming oppression when the intervention is led by such a peer.  The Health Belief model is applied in that RISE aims to increase participants' health-seeking behaviors by raising their own awareness of self and the importance of mental, emotional, and physical health.  Drawing from the Transtheoretical model, RISE aims to move men to act on their own behalf by seeking health services and/or engaging in protective behaviors. RISE draws on the work of Kaufman and Raphael, psychologists and educators who help gay men overcome oppression, and help children and adolescents confront bullying.  RISE also draws on "Reclaiming Your Life: The Gay Man's Guide to Love, Self-Acceptance, and Trust," by Rik Isensee.  RISE defines a script as the words an actor says in a play or a television show.  A screenplay is the script of a movie.  An "inner" script, then, is the words we have in our head.  It's our story.  It's the lines we tell ourselves and the roles we have inherited.  The purpose of RISE is to assist participants in articulating the past and writing themselves a new script.  While the format, target, and goals of the project are new, the need it addresses is shared across oppressed groups.  Decades ago Gloria Steinem described the challenge of recruiting women to the cause of their own equality: "...it is difficult to fight an enemy that has outposts in your own head."  RISE aims to interrupt the negative scripting that African American MSM internalize, thereby breaking the cycle of oppression.  One can also understand the title in terms of HIV viral replication.  RISE intends to act as a psychosocial protease inhibitor, interrupting the replication of oppressive messages inside the host. If RISE is successful in raising awareness about internalized oppression, and increasing health services utilization among AAMSM, Maryland will develop and pilot a non-racially specific version for sexual minority youth.  A pre-SISTA version for African American women is also under consideration. For more information contact RISE author Kip Castner (410) 767-5290. Oregon Tri-County Initiative to Address HIV/AIDS among MSM  By Kimberly Toevs, HIV Coordinator, Clackamas County Public Health Department In an effort to reach Oregonians at highest risk of HIV infection with evidenced-based prevention, the state HIV Prevention Program facilitated the development of collaborative programs between counties to maximize the effectiveness of these efforts. One of these collaborations affects men who have sex with men (MSM) in the Portland metropolitan area, who live between three counties--Clackamas, Multnomah, and Washington Counties.  These three Oregon counties are collaborating across county lines to implement Community PROMISE, one of CDC's Diffusion of Effective Behavioral Interventions (DEBIs).  Community PROMISE stands for "Peers Reaching Out and Modeling Intervention Strategies" and is a community-level STD/HIV prevention intervention that utilizes peer advocates from target communities to deliver role model stories to members of the target population.  This intervention has been adapted for use by a wide variety of high risk populations including MSM. Similar to the rest of Oregon, most new HIV infections in Clackamas, Multnomah, and Washington counties are among MSM. Although many MSM live in Multnomah County, which encompasses most of the urban center of Portland proper, MSM living in the surrounding suburban and rural areas of Clackamas and Washington counties travel into downtown Portland to work, socialize, and meet other men for sex, with no regard to the boundary of the county lines. The collaboration is currently in the latter part of the "community identification" process which includes discovering which subpopulations are at greatest risk for HIV infection, what the highest risk behaviors are, what the motivations are for continuing risky behavior and how to make protective behavior change, and in identifying a baseline stage of change for the most high-risk members of the community.   A working group has been established in order to carry out this initiative.  This group consists of a core of seven HIV prevention staff from the three local health departments who meet bi-monthly. The group has chosen to divide out work by skill set rather than by county affiliation. This collaborative effort has allowed the group to implement a community level intervention in two counties with less than two fulltime HIV prevention staff each. The collaboration also allows the group to serve a broad and diverse geographic area, targeting the highest risk subpopulations of MSM with very specific messages coming from the local communities themselves.  With Portland being the most metropolitan and resource-rich area of Oregon, the three counties involved in this initiative are able to share skills, data analysis methods, and interview tools with other counties in Oregon who have less-funding and fewer-staff. For more information, contact Mitch Zahn, HIV Prevention Manager, Oregon Department of Human Services.   Programs for Rural MSM Programs intended to reach MSM in urban and suburban settings are not always appropriate for rural gay men/MSM, who often face additional barriers related to geography and resources, as well as significant homophobia and stigma.  Recent NASTAD HIV Prevention Bulletins profiled two programs designed specifically to reach rural gay men/MSM.  The March 2006 HIV Prevention Bulletin profiled the Wyoming Rural AIDS Prevention Projects (WRAPP) internet-based program, and the September 2005 HIV Prevention Bulletin profiled the Colorado Department of Public Health and Environment STD/HIV Section's Mpowerment-based intervention for rural gay men called ManReach.  In both cases, reaching MSM in settings and venues that "meet them where they are" by being relevant, accessible and appropriate for the local cultural contexts in which gay men live are important.  Link to these Bulletins for the profiles.  For more information on HIV prevention in rural settings, visit the Rural Center for AIDS/STD Prevention (RCAP).   Special Projects of National Significance Young MSM of Color Initiatives Of HIV infection cases reported in 2001 among men ages 13 to 19, 46 percent occurred in young MSM (YMSM), and among men ages 20 to 24, 49 percent occurred in YMSM.1   Research indicates that African American and Latino YMSM have disproportionately high rates of HIV infection. The U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA) is addressing the challenges facing these populations through the Special Projects of National Significance (SPNS) YMSM of Color Initiative.2  The initiative consists of eight five-year demonstration projects targeting YMSM of color between ages 13-24.3 The projects are designed to reach members of the target population who are not currently in care and link them with ongoing primary care, support, and prevention services and will be evaluated through an evaluation center at George Washington University.4 Following are profiles from two SPNS YMSM of Color Initiative demonstration sites. References: 1. Advocates for Youth. The Facts: Adolescents and HIV. January 2003.  Retrieved March 22, 2006 from: www.advocatesforyouth.org/publications/factsheet/fshivaid.pdf#search=\'2001%2C%20YMSM%2C%20HIV%20infection%20rates\' 2. U.S. Department of Health and Human Services, HRSA.  What's Going on at SPNS: An Update from the RWCA SPNS Program, HRSA HIV/AIDS Bureau.  February 2006. 3. ibid Profile: Working for Togetherness, Chicago, IL Interview with George J. Greene, Principal investigator and Program Evaluator Working for Togetherness (WFT) was founded in 1999 as a minority-controlled, not-for-profit organization committed to addressing high rates of HIV infection among African-Americans through HIV testing and STI screening.  WFT targets those considered at highest risk for HIV, including the homeless, injection drug users, and low-income women.  In September 2004 the organization began implementing the Chicago Area Priority Access Project (CAPA) as part of the SPNS YMSM of Color Initiative.  The main objective of the CAPA Project is to decrease fragmentation (and increase integration) of services within the HIV/AIDS healthcare delivery system for young African American men who have sex with men (YAAMSM) by creating seamless rapid referral and mutually supportive linkages between HIV/AIDS prevention programs, social service providers, and primary care providers.  From outreach to initiation and retention in primary care, the CAPA Project aims to assess the effectiveness of an innovative Continuum of Care Model. The CAPA Project Continuum of Care Model features: Innovative Mobile Tech outreach in community areas hardest hit by the HIV epidemic and which are underserved by traditional HIV service providers. HIV and STD counseling, testing, and referral on site at the outreach venue. Linkages with medical and social service providers which will facilitate YAAMSM initial entry (or re-entry for clients lost to care) into primary care.  Youth Empowerment Center, which consists of an integrated client maintenance and retention program developed with their primary care partner, The CORE Center.  WFT designed a creative Mobile Tech approach to street outreach and interventions.  In Mobile Tech outreach, vehicles are equipped with state-of-the-art audio-video equipment (TV monitors, DVD players, and video game systems) and travel from neighborhood-to-neighborhood conducting both mobile and fixed-site outreach, counseling, HIV testing and sexually-transmitted infection (STI) screening, and prevention education. Rather than utilizing traditional outreach vans, WFT uses vehicles including a Hummer and a GMC Sierra, replete with shiny rims and booming stereo systems, designed to appeal to the audience they are trying to reach. While many community members have been reluctant to approach traditional mobile health units, these vehicles have made tapping into HIV prevention services more attractive to the target audience. This strategy has allowed for an innovative method of service delivery that addresses cultural barriers to health seeking behaviors in the African American community and facilitates the organization's ability to conduct HIV/AIDS prevention services.  WFT contends that although going out into the streets, bars and clubs to distribute information is critical, one area that is often neglected is what to do after street outreach has been conducted.  This deficit is being addressed through the services and interventions offered at the Youth Empowerment Center.  For HIV-positive youth who were initially reluctant to enter care and those who have dropped out of care, the goal of the Youth Empowerment Center is to (re)connect them to HIV-specific primary care.  For those youth who are connected to care through comprehensive outreach and case-finding strategies, the goal of the Youth Empowerment Center is to retain them in care. Although WFT does not offer monetary incentives, a big draw for participants is the on-site barber who provides free hair cuts for youth on Mondays.  Participants are also provided a full meal every Monday, which has led to the evening being referred to as "Monday Night Social Club."   Twenty-seven youth are currently enrolled at the Youth Empowerment Center and the program sees roughly twenty-nine youth per week (Mondays, Wednesdays, and Fridays) as part of the SPNS project.  WFT identified several success stories. Foremost, WFT is proud to have successfully launched and maintained the Youth Empowerment Center for lesbian, gay, bisexual, transgender and questioning (LGBTQ) youth.  Additionally, after hosting an open house at the Youth Empowerment Center, the need for services for women of color was raised, which the organization has subsequently begun to address through a weekly "Girl's Only" program.  One of the major challenges is the Chicago weather, which has made street outreach difficult during a great part of the year and has forced them to examine the seasonal aspect of their work and to identify other avenues to reach young men.  Also, once youth have tested HIV positive, it has proven challenging to ensure that they take the steps needed to visit the doctor. For more information contact George Green. Profile: Men of Color Health Awareness Project (MOCHA) Rochester, NY Interview with Anita Marrero, Project Coordinator, Kraig Pannell, Program Director, and Dr. Sheldon Fields, Principal Investigator Men of Color Health Awareness (MOCHA) is a peer-driven initiative founded in 1996 to provide HIV/AIDS education, outreach, case management and community development for men of color who identify as gay, bisexual, or men who have sex with men. With offices in both Rochester (which has the highest HIV infection rate in N.Y. outside of New York City) and Buffalo, MOCHA is the only organization that specifically targets LGBTQ of color in western New York.  MOCHA is in the second year of implementing the Youth Empowerment Around HIV Project (YEAH) as part of the SPNS initiative. The primary activities of Project YEAH include: Intensify outreach services for young MSM of color ages 13-24, including traditional street, internet and peer- based outreach. Implement an adapted version of Many Men Many Voices (3MV) to be user- friendly to youth populations (to be pilot tested in summer 2006). Conduct an adapted version of the individual one on one stage-based behavioral counseling model, a technique that takes about ten minutes for counselors to assess the stage of a clients risk behavior to then begin to help them move along a continuum. Facilitate a testing initiative as part of a care collaborative with local community-based health care facilities.  MOCHA will conduct educational training for the staff of collaborating organizations to increase their cultural competence and understanding of youth issues. MOCHA recognized that although they already had clients coming in for youth activities prior to the SPNS Initiative, they needed to have more engagement, which has been realized through intensified outreach efforts, focus groups, and the formation of an after school program and Youth Advisory Council (YAC).   MOCHA started after school programming within their "safe zone" which meets once a week.  This program allows youth to gather in a structured environment yet is "informal enough for participants to raise topics ranging from transgender issues to domestic violence."  The after-school program does not provide incentives, however, retention and participation have been high due to the fact that there are no other facilities in the area where YMSM of color can congregate and feel comfortable.  Participants typically range in age from15-22 and stem from a variety of communities including "high school, college, transgender, femme queens, and the ball scene."   A Youth Advisory Council was formed which meets once a month to provide input and suggestions to Project YEAH, leadership development to youth participants of the after school program, and to conduct outreach.  Participants of the YAC are provided a stipend for their time.  The major success of Project YEAH has been the ability to bridge the gap between sub-populations by bringing participants together with positive role models - successful, well-adjusted, professional black gay men who provided them with hope for their futures.   One of the major challenges MOCHA faced in the implementation of the Project YEAH was identifying staff who were qualified, understood the vision of the project, and were reflective of the target population.  Since many of the staff members were in fact peers of program participants, it was imperative that staff receive training on maintaining boundaries.  In addition, identifying a youth-friendly space, or safe zone, also proved challenging.  For more information contact Anita Marrero or Kraig Pannell, or visit the website. Follow-up on TDH Story on IDU Outreach In March, NASTAD's HIV Prevention Bulletin profiled prevention outreach and recruitment in Texas.  NASTAD learned of an additional link to the Texas health department outreach information that may be helpful: www.tdh.state.tx.us/hivstd/fieldops/TA_Bulls/recruitment.pdf face="Arial">.   Capacity Building Calendar Information on CDC-sponsored Capacity Building Assistance trainings for April-June is now available. Meeting and Planning Calendar May 2-6, 2006 "Embracing Our Traditions, Values and Teaching: Native People of North America HIV/AIDS Conference," Anchorage, AK.  Presented by Inter-Tribal Council of Michigan, Inc. Currently accepting abstracts on Research, Mental Health, Prevention, Special Populations and Stigma, Spiritual Issues and Leadership, and Treatment, Care and Support. For more information, visit the conference website. May 8–11, 2006 National STD Prevention Conference, Jacksonville, FL.  "Beyond The Hidden Epidemic:  Evolution or Revolution?"  For more information, visit the conference website. May 19, 2006 National Asian and Pacific Islander HIV/AIDS Awareness Day. For more information, visit the event website. May 19 -20, 2006 ABA HIV/AIDS Law & Practice Conference, in Portland, Oregon. For more information, visit the conference website.    May 25-28, 2006 "HIV/AIDS 2006: The Social Work Response."  Eighteenth Annual National Conference on Social Work and HIV/AIDS, Miami, FL. Sponsored by the Boston College Graduate School of Social Work.   For more information, contact Vincent Lynch (617) 552-4038. June 4-7, 2006 HIV Prevention Leadership Summit (HPLS), Dallas, TX. For more information, visit the conference website. June 22-25, 2006 A National Symposium: Global Health Care Justice, Hiram, OH.  For more inforamtion, visit the symposium website. June 27, 2006 National HIV Testing Day.  Sponsored by the National Association of People With AIDS. For more information, visit the event website. August 13-18, 2006 XVI International AIDS Conference, Toronto, Canada. Abstract submissions due February 22, 2006.  For more information, visit the conference website. September 12-14, 2006 CDC's 2006 National Health Promotion Conference: Innovations in Health Promotion: New Avenues for Collaboration, Atlanta, GA.  For more information, visit the conference website. September 24-26, 2006 Note Correct Location United States Conference on AIDS (USCA), Hollywood, FL.  For more information, visit: the conference website. October 15, 2006 National Latino HIV/AIDS Awareness Day. For more information, visit the event website. November 4-8, 2006 "Public Health and Human Rights," American Public Health Association's 134th Annual Meeting, Boston, MA.  For more information, visit the conference website. November 9 – 12, 2006 Sixth National Harm Reduction Conference, Oakland, CA.  For more information, visit the conference website. December 1, 2006 World AIDS Day. For more information, visit the event website. April 5-7, 2007 "HIV/STD Prevention in Rural Communities: Sharing Successful Strategies V," the Rural Center for AIDS/STD Prevention national conference, Indiana University, Bloomington, IN.  A call for papers will be issued in Fall 2006. For more information, visit the RCAP website.               If you have an idea or program relative to any of these topics that you would like to include in the Bulletin, please contact Nyedra Booker (202/434-8090). The NASTAD HIV Prevention Bulletin is written and edited by NASTAD staff and participants of community planning and prevention efforts around the country.  NASTAD's production of the Bulletin is made possible through funding provided by CDC's Division of HIV/AIDS Prevention (DHAP) in the National Center for HIV, STD, and TB Prevention. LET US KNOW WHAT YOU THINK!  NASTAD welcomes feedback to issues presented in our newsletter.  To submit commentary, please e-mail us at NASTAD@NASTAD.org face="Arial">.