African Americans comprised 52% of new HIV cases among adults and adolescents diagnosed in 2009(Center for Disease Control and Prevention, 2011) in the United States (US), but only 14% of the US population(Humes, Jones, & Ramirez, 2011). Between 2005 and 2008, African Americans made up two-thirds of all heterosexually acquired HIV/AIDS cases(Center for Disease Control and Prevention, 2011). In New York City (NYC), African American men, who comprise an estimated 22.2% of the city's population(New York City Department of City Planning - Population Division, 2011), made up 51% of heterosexually acquired HIV/AIDS cases among men(New York City Department of Health and Mental Hygiene, 2011). In NYC, heterosexually transmitted HIV is geographically concentrated in poor and racial/ethnic minority neighborhoods, with Central Harlem (in Manhattan) and the South Bronx having the greatest number of residents with HIV/AIDS in 2009(New York City Department of Health and Mental Hygiene, 2006).

Decreasing the prevalence of HIV among African Americans living in urban areas is a critical public health goal, with public health leaders and others calling for concerted and effective efforts to interrupt HIV transmission among African Americans(Black AIDS Institute, 2011). Most behavioral HIV prevention interventions for heterosexuals focus on women, injection drug users and men seeking treatment for sexually transmitted infections (STIs)(Johnson et al., 2009; Darbes, Crepaz, Lyles, Kennedy, & Rutherford, 2008). Few interventions have been designed specifically for heterosexual African American men who are not bisexually active, seeking STI treatment or partnered with an HIV-positive female partner(Johnson et al., 2009; Darbes et al., 2008). Here we report results of a theory-based, HIV prevention intervention designed for African American heterosexual men living in high HIV prevalence neighborhoods in NYC, using a single-arm intervention design with pre- and post-test assessments.

The four-session, group intervention was designed for and tailored to the needs of African American heterosexual men through a rigorous formative research phase that included focus groups, in-depth interviews, component testing of the intervention modules, and a pilot of the intervention among men in the target population. The intervention design process, content and approach are described in detail elsewhere(Frye et al., 2011), as are the primary results of the formative research(Bond et al., 2011). In brief, the resultant intervention integrated empowerment (Zimmerman, 1995; Carli, 1999; Rappaport J, 1984), social identity (Tajfel & Turner, 1979; Tajfel & Turner, 1986; Turner, 1982), and rational choice theories(Hechter & Kanazawa, 1997; McCarthy, 2002) and focused on four major content areas: HIV/AIDS education; condom application and skills training; key relational and behavioral turning points; and masculinity and fatherhood. The intervention also incorporated readings from the anthology Brotherman, The Odyssey of Black Men in America – An Anthology(Boyd & Allen, 1996). Entitled “Straight Talk”, the intervention sought to provide African American heterosexual men the knowledge, skills and opportunity to consider, practice and adopt new practices to increase their well-being and promote sexual health. The focal population for this study was heterosexually active African American men living in two high HIV prevalence neighborhoods in New York City: Harlem and the South Bronx.

We tested the hypothesis that compared to baseline, participants reported a statistically significant reduction in the number of female sex partners, occurrence of unprotected sex and engagement in concurrent partnering at the follow up visit. Differences between baseline and the 3-month visit were calculated for behavioral outcomes and compared using contingency tables and exact tests. Changes in outcomes between baseline and three month follow-up were assessed using McNemar discordant pairs exact test (binary variables) or paired t-tests (continuous variables) and Wilcoxon rank sign test. To consider potential biases resulting from those who discontinued participation, dropouts were compared to completers with respect to baseline behavior and other characteristics. Various analyses of within and between cohort variability in select outcome and key sociodemographic measures were conducted to assess evidence of clustering by cohort (teaching class), and none was found (data not shown).

A total of 362 men were screened to participate in the study; 64 (5.7%) met the eligibility criteria and 53 of these men (82.8%) completed an ACASI survey. Forty-seven men (88.7%) were enrolled in the intervention. Men who did not enroll in the intervention, but completed the ACASI, were more likely at baseline to report being a current student than were men who did enroll (50.0% vs. 6.4%; p<.05). No other significant differences in select outcome and key sociodemographic measures were found. Completion of the intervention sessions was high with 179 of a possible 188 sessions completed (95%); 81% of men completed all 4 sessions and 96% completed at least 3 sessions. Men who completed three or fewer intervention sessions were more likely to report HIV testing in the 3 months prior to baseline (100% vs. 57%; p<.05) No other significant differences in select outcome and key sociodemographic measures were found. The three-month visit was completed by 83% of participants; 6 of the 8 men who could not be interviewed at the three-month visit were incarcerated during the follow-up interview window period. Men lost to follow-up were less likely to report an income of more than $10,000 per year (0% vs. 45.7%; p<.05) and were less likely to have children (37.5% vs. 76.3%; p<.05) at baseline. They were more likely to have been on parole at baseline (87.5% vs. 31.0%; p<.05). Men lost to follow-up were also more likely to have reported concurrency with their non-primary female partners at baseline (100% vs. 51.4%; p<.05).

Risk-reduction interventions have been developed for African American sero-discordant couples, African American or Latino men seeking treatment at STI clinics, and men who inject drugs(Johnson et al., 2009; Darbes et al., 2008). We know of no published studies reporting interventions developed specifically for African American heterosexual men, engaged in high-risk sexual activities and living in high prevalence areas, who are not bisexually active, seeking STI treatment or partnered with a known HIV-positive woman. We found promising preliminary evidence that the intervention was efficacious, with intervention participation associated with a statistically significant reduction in the number of total, new and unprotected female sex partners, as well as partner concurrency in the context of both primary and non-primary sexual partnerships. Although the proportion of men who had been tested for HIV increased between baseline and the 3-month follow-up assessment, this difference was not statistically significant, perhaps because the baseline level of testing was so high.

There are several limitations to this study that must be acknowledged. First, this single-arm study design did not include a control condition. Second, we were only able to assess short-term effects of the intervention; thus whether the effects are lasting or not is unknown. Third, because of our small sample size only bivariate analyses were conducted; a larger trial would enable multivariable analyses. Finally, we lost 17% of the sample to follow-up, due primarily to men being incarcerated during the follow-up window. This could have resulted in a bias towards finding a positive intervention effect, however there were no statistically significant differences in mean number of female sex partners, new female sex partners or unprotected female sex partners at baseline between men who had been incarcerated for any amount of time in the three months prior to baseline and men who had not. Future tests of this and similar HIV prevention interventions must build in procedures for following incarcerated men and include an attention control arm.

The results of this trial are encouraging, particularly the finding around sex partner concurrency, a sexual behavior that is thought to be driving the heterosexual epidemic among African Americans in particular(Adimora, Schoenbach, & Doherty, 2007). Interventions for heterosexual men generally focus on decreasing unprotected sex and number of sex partners(Johnson et al., 2009; Darbes et al., 2008). The Straight Talk intervention focused specifically on concurrency, with interactive modules that illustrated how concurrency propagates HIV, as well as analysis of how social structures relate to sexual health outcomes. Although not a structural intervention, the session content reflected and analyzed the structured positions of African American men in society. For example, participants examined how African American men's social roles and identities, as fathers and men, economic realities and life experiences relate to concurrency.

The National HIV/AIDS Strategy for the United States (The White House, 2010) focuses specifically on reducing disparities in HIV infections through prevention efforts focused in communities where HIV is most heavily concentrated and applying evidence-based prevention approaches. The Straight Talk intervention was designed specifically for African American heterosexual men; analyses reported here demonstrate preliminary evidence of efficacy, however it is important to test the intervention using a more rigorous study design. The results reported here represent a promising step forward in the effort to reduce HIV prevalence in the African American community, via a culturally congruent HIV prevention intervention focused on inconsistent condom use, partner concurrency and unknown HIV status, and reflecting the structured life experiences of heterosexual, African American men.