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Human immunodeficiency virus (HIV) disproportionately affects black men who have sex with men (MSM), yet there are few evidence-based interventions specifically designed for black MSM communities. In response, the authors created Real Talk, a technology-delivered, sexual health program for black MSM.
The objective of our study was to determine whether Real Talk positively affected risk reduction intentions, disclosure practices, condom use, and overall risk reduction sexual practices.
The study used a quasi-experimental, 2-arm methodology. During the first session, participants completed a baseline assessment, used Real Talk (intervention condition) or reviewed 4 sexual health brochures (the standard of care control condition), and completed a 10-minute user-satisfaction survey. Six months later, participants from both conditions returned to complete the follow-up assessment.
A total of 226 participants were enrolled in the study, and 144 completed the 6-month follow-up. Real Talk participants were more likely to disagree that they had intended in the last 6 months to bottom without a condom with a partner of unknown status (mean difference=−0.608,
Our findings suggest that Real Talk supports engagement on HIV prevention issues. The lack of behavior findings may relate to insufficient study power or the fact that a 2-hour, standalone intervention may be insufficient to motivate behavioral change. In conclusion, we argue that Real Talk’s modular format facilitates its utilization within a broader array of prevention activities and may contribute to higher PReP utilization in black MSM communities.
Human immunodeficiency virus (HIV) has disproportionately affected black men who have sex with men (MSM) since the beginning of the epidemic. Today, nearly 40% of individuals living with HIV in the United States are African American, even though African Americans represent only 12% of the US population [
Despite the devastating impact of HIV on black MSM, there are relatively few evidence-based HIV prevention interventions designed specifically for black MSM [
Seeking to offer additional evidence-based HIV prevention options for black MSM and the providers who serve them, the investigators developed Real Talk in both face-to-face and computer or tablet-delivered formats, the latter of which is the focus of this study (see [
In adapting the SISTA/SiHLE/WiLLOW trilogy for black MSM, Real Talk positions HIV prevention within a growing gay health movement that defines sexual health as more than safer sex practices or the absence of disease [
We created both the computer and face-to-face versions of Real Talk using an iterative agile product development process that included the following: (1) a Web-based needs assessment of national practitioners recruited through the National Minority AIDS Council in 2012, focus groups with black MSM in Atlanta and San Francisco in 2012-2013, and interviews with HIV prevention providers in these same cities in 2012-2013, (2) prototype testing of 2 activity components of the computer/tablet-delivered program with black MSM in 2013, (3) a run-through of the complete 12-hour face-to-face program in early 2014, and (4) input on design, activity format, and storyboards from a community panel of 6 black MSM throughout programming of the computer/tablet-delivered version in the second half of 2014. The final technology-delivered version of Real Talk plays on PC and Mac computers and Android mobile tablets, with WiFi necessary for optimal user experience. The program’s 6 modules take users approximately 2 hours to complete, in comparison to 12 hours for the face-to-face format (
Real Talk’s content builds on the three central themes identified in our formative research: (1) stigma, discrimination, and intersectionalities in the lives of black MSM, (2) the need for safe spaces and community, and (3) the need for sexual harm reduction approaches in HIV prevention programming [
This study aimed to determine whether a culturally tailored, computer/tablet-delivered, sexual health program can engage black MSM on sexual health issues, promote HIV risk reduction practices, and produce improvements in psychosocial factors linked to sexual risk behaviors. We hypothesized that, relative to the control condition, men in the Real Talk condition at follow-up would report the following: (1) higher levels of intention to reduce HIV risk, (2) increased HIV disclosure with partners, (3) higher levels of condom use for insertive and receptive anal sex, and (4) less risky sexual practices overall. These findings would provide preliminary support for the efficacy of Real Talk and offer organizations a technologically contemporary and easily scalable evidence-based HIV program for black gay men/MSM.
From June 2015 to May 2016, we conducted a quasi-experimental, 2-arm outcome study at 4 sites to test the preliminary efficacy of the computer/tablet-delivered version of Real Talk in reducing sexual health risks and improving psychosocial factors associated with sexual health (Portland State University IRB Protocol #153352). Two study sites were located in Florida, and one each in Georgia and New Jersey, and all sites have long histories of providing prevention and care services to black MSM. Due to the endogamous structures of black MSM communities [
Sites recruited men through their existing client base, venue-based outreach, social media spaces, and snowball sampling. To be eligible, men were required to self-identity as black/African-American, be between the ages of 18 and 49 years, and report having had sex with a man in the past 3 months. We decided on a cutoff age of 49 years because of the following reasons: (1) the intervention does not include any specific content on aging and sexual health issues, (2) program aesthetics and role-play scenarios were directed toward the 20s to 40s age range, and (3) individuals in the 18 to 49 age range are on average more likely to be sexually active than their older counterparts. During the first session, participants completed a baseline assessment using a computer or tablet administered SurveyMonkey instrument, used Real Talk (intervention condition) or reviewed 4 sexual health brochures (the standard of care control condition), and completed a 10-minute user-satisfaction survey on their impressions of their respective study condition. Six months later, participants from both conditions returned to complete the follow-up assessment. The baseline and follow-up assessments were identical and assessed demographic characteristics; mental health and social support; HIV/STI (sexually transmitted infection) knowledge and prevention atittudes; partner communication; HIV/STI history; race, identities, and sexuality (intersectionalities); alcohol and drug use; and sexual behavior/risk reduction strategies.
Over the period of June to October 2015, 226 participants were enrolled in the study and completed the baseline assessment and their particular condition, with 106 men in the Real Talk arm and 120 men in the control (
Risk reduction intentions over the past 6 months were assessed using 22, 1-5 scale, Likert items addressing risk reduction strategies (eg, condom use, serosorting, strategic positioning, pulling out, and not using condoms when positive partner is on ART or has an undetectable viral low) [
Condom use and other risk reduction practices were assessed through questions addressing the following: (1) the number of times participants had engaged in particular risk reduction strategies for insertive and receptive anal sex, with separate sections for positive, negative, and unknown status male partners (8 questions per partner HIV status type) and (2) a 24-question examination on each of the participants’ last 3 sexual partners, including partner characteristics, discussion of HIV status, risk reduction practices for insertive and receptive anal sex, and reasons for not using condoms for topping and bottoming if applicable [
Men’s HIV/STI history was assessed using self-reports of gonorrhea, chlamydia, syphilis, and human papillomavirus diagnoses in the past 6 months, date of last HIV test, result of last HIV test, PrEP use in self-reported HIV-negative men, and ART and viral load testing among self-reported HIV-positive men.
We derived psychosocial mediators from the intervention’s underlying social cognitive and gender and power theoretical framework and the literature discussed in the introduction section of this study, with the goal of capturing potential changes in mental health, social support, and other factors that may mediate an individual’s HIV risk and risk reduction practices. All constructs were assessed using scales with satisfactory psychometric properties developed in evaluations of the face-to-face and computer-delivered versions of the SiSTA/SiHLE/WiLLOW trilogy [
Self-esteem was assessed using the 10-item Rosenberg Self-Esteem Scale (alpha=.885) [
Six true/false questions addressed HIV transmission risk knowledge (eg, “HIV is only transmitted through anal sex,” “STIs put people at a greater risk of HIV infection,” and “sheepskin condoms are better than latex condoms for preventing HIV transmission”). A 5-item index assessed negative attitudes to condom use (alpha=.585) [
Fourteen yes/no questions compared the experiences of black men to gay men, women, and heterosexual men of different race/ethnicities. Two open-ended questions and 3 ranking questions examined experiences of discrimination. Nine questions asked where respondents socialize and meet partners, 4 questions measured the number of people who know they have sex with men (ie, friends, family, work, and overall), and the 45-item Aspects of Identity Questionnaire IV (alpha=.971) [
Two questions addressed alcohol consumption frequency (days used) and intensity (number of drinks per day) in the past 30 days. Four questions addressed substance use just before or during sex in the past 30 days (alcohol, poppers, downers, and painkillers), and 10 questions covered non-prescription substance use in the past 30 days for marijuana, hallucinogens, ecstasy, ketamine, GHB, methamphetamine, crack, powder cocaine, heroin, and erectile dysfunction medications.
Participants completed a 22-item user satisfaction survey immediately after viewing Real Talk (intervention) or reviewing the sexual health brochures (control). The user satisfaction included Likert-like scale questions on experience with the program or brochures (ie, enjoyment, presentation, held attention, and clarity) and intervention/material quality (ie, overall design, ease of use, usefulness of information, and potential to help people lower their sexual health risks). Open-ended questions addressed overall impressions, likes and dislikes, new information learned, and suggestions for improving Real Talk or the sexual health brochures.
Statistical analyses occurred in 3 phases. We first calculated descriptive statistics for sociodemographic variables, hypothesized mediators, and sexual behaviors. We then conducted bivariate analyses to assess differences between conditions, using
A total of 140 participants completed the baseline assessment, study condition, and 6-month post assessment. At baseline, participants had a mean age of 33 years. A total of 66 men (47%) reported being HIV-positive and 57 (41%) being HIV-negative, with the remainder not reporting their HIV status. Sixty-two men (44%) described their sexual identity as gay, 40 (29%) homosexual, 9 (6%) same-gender loving, 15 (11%) bisexual, and 4 (3%) heterosexual. For the sample as a whole, 65% of people in the men’s lives knew that they have sex with other men. In terms of the highest level of education, 12 men (9%) reported having less than a high school degree, 46 (33%) a high school diploma, 42 (30%) some college degree, 18 (13%) a 2-year or technical degree, 17 (12%) a 4-year degree, and 4 (3%) having completed graduate work beyond a 4-year degree. Participants’ incomes were below national averages, with 34 men (24%) reporting less than $6000/year, 24 (17%) between $6000 and $12,000/year, 33 (24%) between $12,000 and 24,000/year, 33 (24%) between $24,000 and 48,000/year, and 12 (9)% earning over $48,000/year.
Participants reported relatively low levels of stress (mean=2.4 on a 1 to 5 scale, with 5=a great deal of stress, SD=0.84251), high levels of self-esteem (mean=4.2 on a 1 to 5 scale, with 5=highest self-esteem, SD=0.80244), moderately high levels of self-efficacy (mean=3.9 on a 1 to 5 scale, with 5=highest self-efficacy, SD=0.76667), and moderate levels of coping skills (mean=3.26 on a 1 to 5 scale, with 5=the highest level of coping, SD=0.55940). A total of 94 men (67%) also said they had a healthy relationship with their families. Only 51 (36%) men felt that the black community accepts black gay men, whereas 85 men (61%) thought that the white gay community accepts black gay men. In terms of where men socialize, 105 (75%) men reported hanging out and meeting men online, 94 (67%) at gay bars, 92 (66%) at dance clubs, 78 (58%) at community organizations, 77 (55%) at coffee shops and restaurants, 71 (51%) at professional networks, 64 (46%) at the gym, 49 (35%) at church, and 30 (21%) at bathhouses.
Regarding sexual behaviors and risk reduction strategies, 100 of 140 men (71%) reported being single at baseline. The median number of male sex partners in the past 6 months was 2, with a mean of 6 and a mode of 1 (SD=14.064). Of 59 men who reported having insertive anal sex with their last male partner, 25 (42%) said they used a condom the whole time, whereas 35 (58%) of the 60 men who reported having receptive anal sex with their last male partner said they used a condom the whole time. Moreover, 89 of the 125 (71%) men reporting a male sex partner in the past 6 months said that they discussed HIV status with their last male sexual partner. Respondents reported an average of 4.1 on a 1-5 Likert scale (4=agree and 5=strongly agree) for both condom use with different status partners and condom use with unknown status partners. Regarding intentions to use risk reduction strategies other than condoms in the past 6 months, on a 1-5 Likert scale, baseline respondents reported a 3.5 average on serosorting (3=neutral and 4=agree), 2.6 on negotiated safety agreements (2=somewhat disagree and 3=neutral), and 2.5 pulling out when topping. Only 3 men stated they were on PrEP at baseline.
We found statistically significant differences (
Intentions and Disclosure
In comparision with the control group condition, Real Talk participants were more likely to disagree that they had intended in the last 6 months to bottom without a condom with a partner of unknown status (mean difference=−0.608, 95% CI=−1.23 to −0.09,
There were no significant differences between Real Talk and control participants regarding condom use for insertive or receptive anal sex at last sexual encounter and the number of partners in the past 6 months with whom they always used condoms for insertive and receptive anal sex. Nor were there any signficant differences regarding use of non-condom-based risk reduction practices, although there were insufficient data to support detailed analyses of the number of times respondents used risk reduction strategies by partner HIV status and type.
Men in the control condition were significantly more likely to agree that they had less concern about becoming HIV positive because of the availability of antiretroviral medications (mean difference=0.778, 95% CI=−1.47 to −0.08,
Real Talk participants provided higher satisfaction ratings on a 1 to 5 scale than control condition participants in the 4 principal user experience categories: enjoyment (4.25 vs 3.31,
Our study demonstrates that a technology-delivered sexual health promotion program (Real Talk) resonates with black gay men/MSM and supports self-reflection on sexual health and relationship issues. The data further support our first 2 study hypotheses, with Real Talk participants demonstrating, in comparison with the control condition, less intention to have risky forms of anal sex with unknown status partners and to lie about their status to their partners. These results suggest that despite a well-documented trend toward decreased concern about HIV infection and increased sexual risk behaviors in MSM communities [
Nonetheless, we found no significant differences between Real Talk and control participants regarding actual risk reduction practices in the past 6 months. There are several possible explanations as to why Real Talk did not generate lower sexual risks. It may be that a one-time, 2-hour intervention is insufficient to support behavioral change on its own, and that Real Talk might contribute more effectively to improved sexual behavioral outcomes if combined with other strategies, including treatment as prevention modalities [
This study has several limitations. One concern is the sample size. Despite monetary compensation and extensive recruitment and follow-up activities, we did not achieve our target sample size of 240, and our retention rate of 62% was substantially less than the 80% to 90% retention rates we have achieved in similar outcome studies of eHealth interventions in communities of color over the past 5 years. In addition, 20% of men reported having had no male sex partner partners in the past 6 months, and not all men had sex with positive, negative, and unknown status partner or practiced both receptive and insertive anal sex. As a result, our sample does not support detailed analyses of the number of times respondents utilized different risk reduction strategies according to partner HIV status, differences in risk reduction strategies based on relationship status and particular sexual acts (eg, insertive vs receptive anal sex), and the reasons men did not use condoms with their most recent sexual partners. It is possible that with greater power, we would have been able to detect more nuanced differences in sexual risk behaviors between the Real Talk and control groups.
A second concern is the study’s reliance on self-reported data for its outcomes measures—even with computer-administered instruments, such data may not always accurately capture respondents’ actual sexual behavior and may include inconsistent responses [
A third limitation is our focus on sexual behavior outcomes. We designed our study in this manner to obtain evidence to support Real Talk’s inclusion in CDC’s DEBI library. However, a growing literature demonstrates that black MSM, in comparison with MSM of other race/ethnicities, have higher rates of HIV infection due to structural factors (eg, health care access, culturally component care, and HIV/STI testing rates) rather than higher levels of sexual risk [
A fourth limitation relates to Real Talk’s technological specifications. Our decision to develop a relatively long and unidirectional program (ie, each module’s content directly builds on that of preceding modules), rather than a shorter and more flexible app for mobile phones, was based on the promising preliminary efficacy findings of the development team’s similar, 2-hour computer-delivered versions of the SiSTA/SiHLE/WiLLOW trilogy [
In recent years, researchers and policy makers have called for the expansion of culturally appropriate HIV-related programs, social marketing campaigns, and health care services to address the elevated HIV rates in black MSM communities [
Seeking to promote program utilization and longevity, we designed Real Talk to be a flexible tool focused on skills acquisition, self-reflection, and participant-generated content that enables men to address emerging sexual health issues without requiring a major reworking of the intervention. Real Talk’s modular format also facilitates its utilization in conjunction with a broader array of prevention activities, including HIV testing and counseling, online outreach, and community-level programs, and may help address the currently low levels of PrEP utilization in black MSM communities [
Our interest in identifying mediating variables and key intervention components [
Real Talk content.
Real Talk screenshot 1.
Real Talk screenshot 2.
Real Talk outcome study flowchart.
Real Talk outcome study findings.
antiretroviral therapy
Centers for Disease Control and Prevention
Diffusion of Effective Behavioral Interventions
gamma-hydroxybutyric acid
men who have sex with men
pre-exposure prophylaxis
Sisters Informing Healing Living and Empowering
Sisters Informing Sisters about Topics on AIDS
sexually transmitted infections
Women Involved in Life Learning from Other Women
Real Talk was made possible by Phase I (R43MD005812-0) and Phase II (R44 MD005812-02) Small Business Innovation Research (SBIR) grants from the National Institute on Minority Health and Health Disparities. The authors would like to thank Dr Gina Wingood and Dr Ralph DiClemente, whose SiSTA/SiHLE/WiLLOW trilogy was the starting point for the development of Real Talk, and the authors’ community partners in California, Florida, and Georgia who participated in the formative research, pilot testing, and outcome study. Finally, the authors would like to thank the many black gay men/MSM who shared their experiences and ideas—without them, there would be no Real Talk.
None declared.