An Innovative Adaptation of an HIV Status-Neutral,Community-Informed,Socioemotional Asset-Building Intervention With the House Ball Community

Background and Assessment of Need

Black men who have sex with men (MSM) continue to have the highest incidence of new HIV diagnoses despite reporting fewer sexual partners and less substance use than their White counterparts (Millett et al., 2012). Black MSM also face multiple stigmas, though some have found refuge in the House Ball Community (HBC)—a national network of Black lesbian, gay, bisexual, and transgender persons (LGBT) kinship commitments (families) that affirm gender expression(s) and sexualities and provide skills-building for its members (Arnold & Bailey, 2009). While structural factors (e.g., poverty, racism) impact vulnerability to HIV for many Black MSM, internal and external (socioemotional) assets influence the health of young Black sexual and gender minorities (Ginwright & James, 2002; Millett et al., 2012). Internal assets include skills and personal values such as self-esteem, sense of purpose, positive identity, planning, and decision-making capacities. External assets include relationships, support systems, and opportunities such as positive peer influence and creative activities. Building internal and external assets in the HBC is critical to facilitating engagement in health-promoting behaviors (Ginwright & James, 2002). Limited research has addressed the impact of the HBC, such as asset-based skills-building as a community-clinical intervention approach.

House Ball Community (HBC)

The HBC was born from the need for social solidarity and mentoring in a society largely hostile to sexual and gender expression differences (Arnold & Bailey, 2009). The term “houses” refers to familial networks, which are generally not localized in any one place or residence. The “Ballroom scene” or “ballroom” are the common terms for competitive dance and performance events that celebrate gender and sexual identities and display fashion, form, and physical attributes (Arnold & Bailey, 2009). Each House structure has leaders who assume the traditional roles performed by parents of origin regardless of gender, sex, or age (most commonly a “father” and/or a “mother”), and act as surrogate parents to the House “children,” primarily LGBT adolescents, young adults, and/or persons who have less experience within the HBC (Arnold & Bailey, 2009). House families provide a safe haven and source of support for its members, LGBT youth of color, as some have been rejected by their families of origin or other social institutions (Arnold & Bailey, 2009).

HBC and Clinical Partnership

Since 1992, Health & Education Alternatives for Teens (HEAT) Clinic has been providing comprehensive outreach, HIV testing and linkage to care for youth (13–29) at-risk for, or living with, HIV. HEAT provides age-appropriate, culturally competent HIV care for LGBT youth, most of whom are Black and Latinx. For over 20 years, HEAT has collaborated with community-based partners, including the HBC, throughout Brooklyn and New York City. Specific partnerships include The Federation, House Lives Matter, and Union Theological Seminary.

For over a decade, HEAT has been implementing Many Men, Many Voices (3MV), a best-evidence, group-level retreat-based intervention originally developed for HIV-negative Black MSM (Wilton et al., 2009). 3MV addresses factors that influence the behavior of Black MSM: cultural, social, and religious norms; interactions between HIV and other STIs; sexual relationship dynamics; and the influences that racism and homophobia have on vulnerability to HIV. Over time, HEAT allowed repeat 3MV participants as well as Black MSM living with HIV and transgender participants from the HBC. These occurrences highlighted gaps in much-needed services for diverse HBC members and were the catalyst for this adaptation.

Description of Community-Informed Adaptation Strategy

To increase and maintain trust in the 3MV adaptation as well as gain the perspective of the HBC, Community Advisory Board (CAB) meetings occurred with national HBC experts and leaders from 2020 to 2022. CAB feedback and input for the adaptation occurred throughout the project timeline, demonstrating effective partnership between the research team and HBC members, and addressing the needs of the HBC. CAB members, several of whom were prior 3MV participants who later became public health professionals, advocated for the inclusion of prior 3MV participants as a programmatic asset. The CAB was adamant that the adapted intervention identify and strengthen assets to support resilience to hardships that can undermine the effects of HIV interventions.

Six focus group discussions (FGDs) were also conducted with national parental and leadership figures in the Ballroom scene to delve into 3MV components and recommend adaptations for the HBC. While 3MV was developed specifically for HIV-negative Black MSM, the HBC includes gender-diverse family members, leaders, and members living with HIV. Important design adaptations recommended by FGDs included having an HIV status-neutral intervention, inclusive of all genders, to represent the HBC more accurately. Examples of intervention-specific changes included discussing mental health and substance use as an intervention component (especially crystal methamphetamine); integrating peer-based approaches to promote HIV and pre-exposure prophylaxis (PrEP) care by House parents, who would accompany individuals to health care visits and facilitate treatment adherence; and including health literacy into the adapted curriculum. Finally, a key adaptation recommendation was to allow repeat engagement in the adapted intervention for past 3MV participants. Indeed, repeated exposure to intervention components may boost protective factors and increase self-efficacy of HBC members to impact positive change.

The resulting 3MV community-informed adaptation is Our Family, Our Voices (OFOV), a status-neutral, retreat-based intervention focusing on asset-building for Black MSM within HBC families. The OFOV study team includes HBC members and leaders and centers the family unit as the focus of the intervention. OFOV builds on Hosek et al.’s (2015) groundbreaking scientific contributions by co-anchoring a risk-reduction intervention to an asset-building framework that promotes identifying, activating, and leveraging existing assets; and building new assets that can optimize HIV prevention and care. Biomedical outcomes for OFOV are increased HIV testing and PrEP uptake for HIV-negative HBC members and engagement in HIV care and improved viral suppression for members living with HIV. OFOV is currently in the field.

Implications for Practice

HEAT and the HBC’s collaboration, resulting in OFOV, is an important model for researchers and clinicians to consider when adapting evidence-based interventions for priority populations. Based on our experience, we recommend developing and maintaining transparent community relationships and involving community leaders in joint decision-making.