Project Strength Through Youth Livin' Empowered (STYLE) 2.0

Project Strength Through Youth Livin’ Empowered (STYLE) 2.0 is a multi-component intervention designed to help reduce stigma and social isolation for Black gay, bisexual, and other men who have sex with men (MSM). The intervention relies on health care navigators who facilitate linkage and engagement activities. They also connect clients to behavioral health providers who conduct motivational interviewing, as well as to a mobile application (app) that supports all intervention activities. As part of the Ryan White HIV/AIDS Program (RWHAP) Part F Special Projects of National Significance (SPNS) Implementation of Evidence-Informed Behavioral Health Models to Improve HIV Health Outcomes for Black Men who have Sex with Men initiative, researchers at Duke University’s Center for Health Policy and Inequalities Research adapted STYLE to create STYLE 2.0 for young Black MSM (ages 18-35) living in North and South Carolina. STYLE 2.0 participation has been associated with positive trends across HIV care continuum outcomes, including retention in care and increased viral suppression.

Durham, Orange, and Wake Counties, NC

Columbia, SC

Implementation Guide
True
Evidence-Informed Intervention
Icon for Intervention Type
Clinical service delivery model; Outreach and reengagement activities
Icon for HIV Care Continuum
Retention in HIV medical care; Viral suppression
Icon for Ending the HIV Epidemic in the U.S. Strategy
Treat
Icon for Focus Population
Gay, bisexual, and other men who have sex with men (MSM); Black gay and bisexual men
Icon for Priority Funding
RWHAP Part F SPNS
Icon for Setting
Community-based organization/non-clinical setting; RWHAP-funded clinic or organization
Need Addressed

STYLE, originally developed by the University of North Carolina at Chapel Hill, used a social marketing campaign that focused on youth and members of their sexual and social networks, conducted testing and outreach on college campuses and within the broader community, and offered a tightly linked medical–social support system to engage and retain Black and Latino young MSM with HIV into HIV care.1,2 Because young Black MSM are disproportionally affected by HIV and experience gaps in the HIV care continuum as a result of mental health issues, including depression, anxiety, substance use, and trauma-related disorders,3,4 Duke University’s Center for Health Policy and Inequalities Research adapted STYLE to incorporate behavioral health services, calling the adaptation STYLE 2.0. With this adaptation and supported by peer health care navigators, providers addressed treatment barriers and improved HIV care continuum outcomes among Black MSM with HIV.

Core Elements
Social marketing campaign and outreach

A young adult advisory board (YAB) of Black MSM assisted with social marketing campaign adaptations from the original STYLE as well as with overall program implementation, evaluation, and dissemination. The YAB provided input on the imagery and content of social media recruitment ads and identified appropriate sites for engaging young Black MSM. In-person social marketing included outreach and distribution of materials to locations frequented by young Black MSM. Social marketing resources were dedicated to advertising the project on social networking sites popular among young Black MSM such as Facebook, Instagram, and Twitter.

Peer health care navigator

Health care navigators were chosen because of their involvement in Black lesbian, gay, bisexual, transgender, questioning, and HIV-centered communities. They provided culturally responsive services to all STYLE 2.0 participants over the phone or through the STYLE 2.0 app.

After participants enrolled, a health care navigator outlined the various STYLE 2.0 components—one-on-one sessions, behavioral health services, a virtual support group, and the STYLE 2.0 app—and participants then decided upon their level of participation. Support groups and app engagement were not mandatory. Similarly, one-on-one sessions with a navigator were not mandatory, but they were highly encouraged. Navigators used a Centers for Disease Control and Prevention (CDC)-adapted program, Choosing Life: Empowerment, Actions, Results (CLEAR)5 and met with participants once a week or biweekly to determine which key skills were the most important to work on. Sessions were held on topics such as communication, problem solving, adherence, and creating a vision for the future, all of which were intended to help participants make healthy life choices. Navigators also linked participants to supportive services (e.g., housing, education, and employment) and additional clinical and behavioral health care, as needed.

Once enrolled, the STYLE 2.0 intervention period lasted 12 months for participants. The first six months included intense collaboration with the navigators followed by a six-month transition period during which navigators were available as needed, but no prescribed outreach or sessions occurred.

Medical-social support network

Health care navigators facilitated linkages for identified clients and provided warm handoffs versus simple referrals to physicians for HIV medical care, behavioral health services, as well as for support services, such as housing, case management services, and other services to reduce barriers to linkage and regular engagement in HIV care.

Virtual support groups

STYLE 2.0 offered a virtual support group for participants through videoconferencing. This weekly support group, facilitated by the health care navigators, provided a space for participants to build community, and offer one another support, as well as to hear educational presentations.

STYLE 2.0 app

A mobile app, developed specifically for STYLE 2.0 through adaptations of the healthMpowerment app,6 provided information about the importance of linkage and regular engagement in HIV care, facilitated scheduling appointments or messaging with their health care navigators, and allowed users to access the online support groups and engage in peer-to-peer sharing designed to reduce stigma and social isolation.

Behavioral health interventions

STYLE 2.0 includes several behavioral health components, including the use of the Substance Abuse and Mental Illness Screener (SAMISS)7 at intake and at six months. Health care navigators were trained in administering and scoring the screener for substance use and mental illness. For a participant who screened positive for behavioral health needs, navigators provided a warm handoff to the behavioral health provider who facilitated four virtual motivational interviewing sessions via videoconferencing on the STYLE 2.0 app. During these sessions, the provider helped the participant find the inner confidence and motivation necessary to make specific positive life changes.

Outcomes

Sixty-six young Black MSM between the ages of 17 and 35 enrolled in STYLE 2.0 from November 2019 through December 2020. HIV care continuum outcomes improved from baseline to 12-month follow-up, including receipt of HIV care, retention in HIV care, prescription of antiretroviral therapy (ART), and reaching viral suppression, although none were statistically significant.

Category Information
Evaluation data
  • Electronic medical record data and client surveys at baseline, 6 months, and 12 months
Measures
  • Receipt of HIV medical care, defined as clients who had two or more routine HIV medical care visits in the past year
  • Retention in HIV medical care, defined as clients who had at least one routine HIV medical care visit in the past 12 months, with a second visit at least 90 days after
  • Prescribed ART, defined as clients prescribed ART in the past 12 months
  • Viral suppression, defined as clients with a HIV viral load <200 copies/mL at last HIV viral load test in the past 12 months
Results
  • Receipt of HIV medical care increased from 79% to 85%
  • Retention in HIV medical care increased from 76% to 88%
  • Prescribed ART increased from 97% to 99%
  • Viral suppression increased from 82%–91%

Source: LeGrand SH, Davis DA, Parnell HE, et al. Integrating HIV and mental health services for Black gay, bisexual, and other men who have sex with men living with HIV: Findings from the STYLE 2.0 intervention. AIDS Patient Care STDS. 2022;36(S1):S74–S85.

Planning & Implementation

Adaptation of the original STYLE intervention. The STYLE 2.0 adaptation was informed by extensive guidance from the YAB, which consisted of young Black MSM with HIV from the intervention regions, that met monthly throughout the intervention development. Although the YAB did not develop intervention activities, they were able to offer feedback and opinions on recruitment approaches and timing, and language around warm hand-offs to behavioral health providers. The YAB also worked with STYLE 2.0 staff to review all of the original STYLE materials (e.g., logos and advertising materials) to determine which of these should be used, or modified, for STYLE 2.0. YAB members provided input on intervention implementation, evaluation, and dissemination throughout the project and were reimbursed for their time with e-gift cards after each meeting.

Recruitment. STYLE 2.0 recruited for participants using several methods: in-person at clinics, following up on referrals from current participants and community members, and through posting on social media. Medical care providers, nurses, social workers, and other clinic staff were trained in referring potential participants for screening to one of two navigators or to the online pre-screener. Flyers and palm cards were placed at clinics that referred potential participants to the online screener for eligibility screening. 

Incentives. STYLE 2.0 participants were compensated with a $50 e-gift card for completing the baseline evaluation survey and $35 e-gift card for each follow-up evaluation survey.

Sustainability
  • Peer navigation services, as well as medical and behavioral health services, are funded through the RWHAP. 
  • STYLE has been shown to be replicable in many settings. In addition to the original STYLE intervention success,1 CDC funded the University of California-San Francisco Prevention Research Center to collaborate with the AIDS Project of the East Bay in Oakland, California, to adapt and replicate STYLE. Replication materials for this adaptation, called M+ Oakland STYLE are available at: style.ucsf.edu. STYLE 2.0 participation is still available to young Black MSM with HIV in North Carolina through support from Duke University. See stylenc.org for more information.
Lessons Learned
  • Health care navigators spend a significant amount of time networking and building relationships with local organizations. They need to establish a robust network before enrolling clients, maintain connections through regular emails or phone calls, and always be actively looking for new resources to support their clients.
  • There were two main barriers to recruitment and enrollment. The first was securing physician buy-in to support the intervention, given their already busy schedules. Second, some of the participating clinics stopped advertising STYLE 2.0, as they were unclear if it was ongoing or because the turnover of knowledgeable clinical staff was proving to be challenging. 
  • During the enrollment process, every participant said that had the health care navigator not been of the same race, they would not have enrolled. Some participants also stressed the importance of representation, that is, seeing clinic staff who looked like them and/or could understand the experiences they were living through.
  • Several steps facilitated participant retention and engagement. First, the health care navigator told potential participants that achieving their health goals would always be a team effort. The second step was building trust between a participant and navigator by: addressing head-on that although the navigator was not a person with HIV, they knew a lot about the virus and could help connect the participant to services; and, showing empathy without pity. The third step was letting participants know that navigators were part of the same community, meant to be considered peers and not providers. Even though this was stated, some participants still referred to the navigators as case workers. The last step was changing the language from “study” to “project,” reassuring participants that the project needed them and was also focused on building network and community support systems. Many participants remained in the project because they were interested in building a support system.
  • The project recognized the importance of self-care for staff. The health care navigators had personal assistant services available to them whenever they felt stressed out and needed support. The project leader and manager also made sure that health care navigators did not overwork, as they knew the importance of a balanced work life. They also held weekly team meetings, providing an opportunity for navigators to discuss things that happened during the week personally or with participants.
  • Cultural responsiveness played a significant role in behavioral health-seeking behaviors. Some clients stressed that many of the behavioral health specialists they had previously encountered could not relate to their experiences because they did not have the cultural background to understand their circumstances. Some participants recalled their interactions with a behavioral specialist before STYLE 2.0, which consisted of being prescribed medication and barely discussing other possible treatment and/or support.
Contact
Duke University, Center for Health Policy and Inequalities Research
Sara LeGrand, PhD
References
  1. Hightow-Weidman LB, Smith JC, Valera E, et al. Keeping them in "STYLE": Finding, linking, and retaining young HIV-positive black and Latino men who have sex with men in care. AIDS Patient Care STDS. 2011;25(1):37–45. doi:10.1089/apc.2010.0192
  2. Center for Innovation and Engagement (CIE): Project STYLE (Strength Through Youth Livin’ Empowered). TargetHIV.org.
  3. Hussen SA, Easley KA, Smith JC, et al. Social capital, depressive symptoms, and HIV viral suppression among young Black, gay, bisexual and other men who have sex with men living with HIV. AIDS Behav. 2018;22(9):3024–3032. doi:10.1007/s10461-018-2105-6
  4. Hussen SA, Camp DM, Wondmeneh SB, et al. Mental health service utilization among young Black gay, bisexual, and other men who have sex with men in HIV care: A retrospective cohort study. AIDS Patient Care STDS. 2021;35(1):9–14. doi:10.1089/apc.2020.0202
  5. University of California, Los Angeles Center for Community Health Semel Institute for Neuroscience and Human Behavior. CLEAR: Choosing Life: Empowerment, Action, Results!—A one-on-one intervention with youth and adults living with HIV/AIDS or at High Risk 
  6. Muessig KE, Baltierra NB, Pike EC, LeGrand S, Hightow-Weidman LB. Achieving HIV risk reduction through HealthMpowerment.org, a user-driven eHealth intervention for young Black men who have sex with men and transgender women who have sex with men. Digit Cult Educ. 2014;6(3):164–182.
  7. Whetten K, Reif S, Swartz M, et al. A brief mental health and substance abuse screener for persons with HIV. AIDS Patient Care STDS. 2005;19(2):89–99. doi:10.1089/apc.2005.19.89

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