Members of our partnership strive to reduce health disparities from positive, ecological perspectives; equalize power among partners; harness the strengths and resources of each partner; promote co-learning; and integrate knowledge acquisition and intervention.^13,15 The pilot of the Impact Triad intervention was guided by a 15-person study-specific steering committee, comprised of local community members and representatives from community organizations.¹³ Sixty-seven percent of the committee self-identified as GBQMSM and 27% as transgender women; 60% self-identified as African American/Black and 27% as Latine.

Throughout this study, we adhered to characteristics of effective community engagement¹² including non-token representation of the impacted community in the study; agreement among steering committee members and the study team on the goals of the study; ongoing commitment and negotiation among steering committee members and the study team to work towards goals; transparent processes and open communication among all committee members and the study team; a focus on community empowerment and an assets-based orientation to health promotion and disease prevention; ongoing reflection to ensure adherence to values and goals; and shared power and resources among committee members and the study team. Each committee member received a $25 Visa card and a meal at each meeting.

Impact Triad is based on the HoMBReS¹⁶ and HOLA¹⁷ interventions that our partnership developed and tested previously using CBPR. They are included in the Compendium of Evidence-Based Interventions and Best Practices for HIV Prevention, compiled by the CDC (https://www.cdc.gov/hiv/research/interventionresearch/compendium/). These interventions leverage existing social networks within Spanish-speaking Latine communities. HoMBReS harnesses the social networks within recreational soccer leagues, and HOLA harnesses informal social networks among GBQMSM and transgender women.

Impact Triad includes three primary multilevel strategies: community-based peer navigation, use of social media, and antidiscrimination videos for service provider staff. The intervention aims to increase: awareness of the magnitude and impact of STIs and HIV on GBQMSM and transgender communities; knowledge of different types of STIs and HIV, their modes of transmission, prevention, signs and symptoms, and local screening, testing, and treatment options; correct and consistent use of condoms and PrEP; understanding of how social determinants of health influence health outcomes including STIs and HIV; and use of available community resources that address STIs, HIV, and prioritized social determinants of health among young African American/Black and Latine GBQMSM and transgender women. The intervention also aims to reduce discrimination experienced by young African American/Black and Latine GBQMSM and transgender women when accessing local resources.

The intervention is based on social cognitive¹⁸ and empowerment¹⁹ theories and uses natural helping.^16,20,21 Natural helping refers to the spontaneous, informal style of social support provided by individuals or groups to others in their social networks or communities. Community leaders are trained and supported to use their personal relationships to support the needs of their social network members and help them engage with services. Natural helping has advantages over other strategies because, with carefully personalized messaging and support, these leaders can reach community members who are considered “hard-to-reach.” Because they are trusted community members, these leaders are turned to for assistance and are effective because they are part of the networks in which they work, in terms of self-identity, socioeconomic status, values, and lived experience; understand community needs and strengths and what is meaningful to members; communicate in the language of social network members; and incorporate culture to promote health.^16,20,21

In this pilot, we recruited 15 African American/Black and Latine GBQMSM and transgender women who were informal community leaders to serve as community-based peer navigators, known as “community navigators” in English and “navegantes comunitarios” in Spanish. Because the reputation of each navigator as a leader within existing social networks is critical to the success of interventions that harness natural helping,^16,20,21 we recruited navigator candidates primarily through word-of-mouth and conducted individual interviews to assess and select them. Selection of navigators focused on three domains of primary characteristics that our CBPR partnership identified as essential to Impact Triad navigator success: personal, performance, and situational characteristics (Table 1).

Mean navigator age was 31 years. Navigators identified as African American/Black (n=7), Latine (n=5), multiracial/multiethnic (n=2), and Asian American (n=1); cisgender men (n=10), transgender women (n=4), and nonbinary (n=1); gay (n=10), heterosexual (n=4), and bisexual (n=1). All navigators reported sex with men.

Additionally, each of 14 navigators recruited five members of their social networks who were not already participating through enrollment with another navigator; one navigator, however, recruited only four social network members. Other inclusion criteria for social network members were self-identifying as an African American/Black or Latine man or transgender women and reporting any sexual activity with men since the age of 16. Inclusion was assessed through an interviewer-administered screener. Although each navigator would work with more than five social network members, we wanted to collect data from a sample of their social network members to evaluate the pilot implementation of the intervention.

After navigators were consented, they were trained on how to explain details of the study to their social network members. After enrollment and collection of baseline data from social network members, navigators were trained in the Impact Triad intervention by a Latino cisgender gay man, a White cisgender heterosexual woman, and a White cisgender gay man during four sessions of four hours each in private meeting rooms within conveniently located community organizations. Sessions were held over four sequential weeks. The training sessions and activities are outlined in Table 2.

Training sessions were bilingual and interactive, and included opportunities for navigators to role play and practice informal helping. Each navigator received a satchel with the intervention logo embroidered on it that contained materials to distribute to their social network members as warranted, including all presentations used during the training and an instructional penis model. They also received pocket-sized cards outlining the locations of STI screening and HIV testing sites and depicting how to correctly use a condom, condoms, water-based lubricants, and brochures about STIs, HIV, and PrEP to share within their social networks. Navigators also received t-shirts and identification badges with the project logo. At the final training session, navigators participated in a graduation ceremony, and each received a framed signed certificate of training completion. Navigators then met monthly for 12 months as a group with the intervention coordinator to obtain additional support, restock satchels with materials to distribute to social network members, submit Activity Logs (which provided a mechanism for navigators to document their helping activities), share successes and problem-solve challenges, and build a sense of community among navigators. During this period, navigators promoted STI screening, HIV testing, and condom and PrEP use, and use of available resources (i.e., education, job training, and job-finding resources) to address social determinants of health among their social network members, using skills gained through the training.

There were no prescribed activities; rather, navigators informally provided personalized information to meet social network member individual and group needs and priorities related to prevention behaviors and social determinants of health, offered guidance on where and how to access local available services, reframed unhealthy and bolstered healthy norms and expectations related to sexual health, and brought the voices of young GBQMSM and transgender women of color to local community organizations. Each navigator received a $50 stipend per month and was reimbursed for travel.

The steering committee, navigators, and study team also produced six brief online videos in English and Spanish presenting testimonials designed to raise consciousness among service providers about the challenges and barriers young African American/Black and Latine GBQMSM and transgender women face when seeking resources related to STIs and HIV and social determinants of health, and how providers can facilitate access. The videos were designed to not require a large commitment of time to watch and to meet the learning needs of service providers at all levels, with a particular focus on frontline staff. These videos were broadly disseminated by community partners, steering committee, navigators, and study team to providers of local services (e.g., health departments, libraries, Goodwill, and other social service organizations). They were also distributed by the project Facebook and Instagram accounts. Videos are available at: https://www.youtube.com/channel/UCd7gOGhBerT0w1CTq5BwMcQ.

The Triad Impact intervention was tested using a single-group pretest-posttest design. Our partnership chose this design because we wanted to obtain early evidence of the efficacy of the intervention.

Data were collected from enrolled social network participants at baseline and at immediate post-intervention, after 12 months of intervention. The assessment contained 48 items with both predefined and open-ended response categories and was completed in about 10 minutes. The assessment was read aloud by trained study team members in the language preferred by the participant (English or Spanish). Participants were reimbursed $5 for their participation in each assessment.

Baseline demographic data, including age in years, race/ethnicity, country of origin, sexual orientation, gender identity, educational attainment, employment, and monthly income, were collected using measures that have been validated among English- and Spanish-speaking sexual and gender minorities.^17,22

We assessed STI screening and HIV testing during the past 12 months, condom use at most recent sex, and current PrEP use.

We also assessed knowledge of PrEP using a single item: “On a scale from 0 to 5, with 0 being knowing nothing at all and 5 being a lot, how much would you say you know about PrEP?”. Knowledge of resources associated with prioritized social determinants of health was operationalized using these items: “If a friend of yours wanted to get help related to education, where would you send them?”; “If a friend of yours wanted to get help related to job training, where would you send them?”; and “If a friend of yours wanted to get help related to finding a job, where would you send them?” Response options were open ended and included “Don’t know.” The open-ended responses were adjudicated to confirm whether the responses were locations that offered the resource.

We assessed perceived social support using an abbreviated and revised version of the 3-item social support subscale (α = 0.74) from The Coping Self Efficacy Scale.²³ We also assessed perceived discrimination (α = 0.89) using items that we adapted from a study of unfairness.²⁴ Of the 6 items, sample items include: “I often have the feeling that I am being treated unfairly because of my ethnicity or race”; “I have experienced violence due to my ethnicity or race”; and “I have experienced discrimination due to my ethnicity or race.” Response options range from “Strongly disagree” (1) to “Strongly agree” (4).

While partnership members were aware of other important constructs associated with STI screening, HIV testing, and sexual protective and risk factors (e.g., adherence to traditional notions of masculinity, homonegativity, transphobia, and community attachment), we strived to ensure low participant burden and focused on measuring variables that the steering committee and study team perceived to be most proximal to STIs, HIV, and social determinants of health.

We used descriptive statistical analyses to summarize participant demographics at baseline and for prevalence of primary and intermediate outcomes at both baseline and immediate post-intervention follow-up. Bivariate and multivariate regression modeling were used to assess the change in primary and intermediate outcomes between baseline and follow-up with random intercept for the individual participant and navigator. We used mixed effect linear and logistic regression modeling for continuous and ordinal and binary outcomes, respectively, and multivariate models adjusted for baseline score, age, education, employment, country of origin, and clustering by social network group to obtain adjusted odds ratios (AORs) and corresponding P values. We fit models using PROC MIXED procedure for continuous and ordinal outcomes and PROC GLIMMIX procedure for all other binary outcomes. All analyses were conducted in SAS V9.4.

Human subject oversight was provided by the Institutional Review Board of Wake Forest University School of Medicine.

At immediate post-intervention, participant STI screening, HIV testing, condom use, and PrEP use increased significantly (Table 4). After adjusting for baseline outcome score, age, education, employment, country of origin, and clustering by social network group, at 12-month follow-up, participants were: 34.1 times as likely to report past 12-month STI screening (P=.001), 12.6 times as likely to report past 12-month HIV testing (P=.001), 2.6 times as likely to report condom use at most recent sex (P=.03), and 28.2 times as likely to report current PrEP use (P=.02).

We also observed marked differences in most intermediate outcomes. Participants also significantly increased knowledge of PrEP (P<.0001) and of community-based educational (P=.047), job-training (P=.002), and job-finding resources (P=.02). However, knowledge of STI screening and HIV testing did not increase significantly. Social support increased (P<.0001) and perceived discrimination decreased (P<.01).

Limitations of this pilot include its reliance on self-reported measures, which may be subject to social desirability biases. However, participants were provided motivating instructions that assured confidentiality of responses and explained the importance of truthful answers to guide future efforts, which has been shown to increase honesty in self-reports.³⁰ Further, the single-group design without a comparison or control group limits the ability to establish causality and rule out alternative explanations for the observed outcomes. Future research should incorporate designs that can strengthen causal inference and further evaluate the intervention.

Improved knowledge of educational and employment resources is an initial, but insufficient, step to addressing upstream social determinants of health. Future research should explore whether the use of resources increases and should expand the social determinants of health addressed by interventions such as Impact Triad. Since this pilot was conceptualized, additional social determinants of health have become increasingly relevant within our community, including food insecurity, housing access, and immigration policy.

Important gaps exist in the current intervention arsenal for reducing STI and HIV risk among minoritized populations. Impact Triad represents a promising approach to addressing the complex interplay of individual, interpersonal, societal, and structural factors driving STI and HIV disparities among young GBQMSM and transgender women of color and can serve as a foundation for interventions designed to reduce STI and HIV risk and address social determinants of health among other populations.