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CDC promotes plan to improve HIV testing and prevention among African Americans
Increasing available interventions is chief challenge
AIDS and African Americans: Special series on meeting the challenge of HIV epidemic in the black community
This is the first part in a series about the HIV/AIDS epidemic among African Americans and how the Centers for Disease Control and Prevention, researchers, and others are addressing the problem. The cover story is about the CDC's new initiative aimed at reducing HIV infection among African Americans; there is also a story on how Florida has made progress in the HIV epidemic through community partnerships, and a listing of the CDC's commitments to improving HIV prevention among African Americans. In July, more stories about the epidemic, how black churches respond, and prevention work.
About half of the nation's HIV/AIDS epidemic now involves African Americans, a reality that has prompted the Centers of Disease Control and Prevention (CDC) of Atlanta, GA, to launch a new campaign to address this health disparity.
As part of the new effort, the CDC recently published a report, titled, "A Heightened National Response to the HIV/AIDS Crisis among African Americans," which outlines the CDC's plans and commitments.
"One of the key things we're encouraging, especially for health care providers, is increasing the opportunities for diagnosis and treatment," says Robert Janssen, director of the CDC's Division of HIV/AIDS Prevention.
"We hope there will be money appropriated in 2008 for HIV testing, and we really want to use that to implement the new recommendations of routine HIV testing in health care settings, particularly in high-rate areas," Janssen says. "As part of the African American heightened response, we're encouraging all African Americans, ages 16 to 64, to get tested."
One of the CDC's commitments is to expand the number of available risk-reduction interventions that are tailored toward African Americans.
This is a commitment that may be more challenging because of the lengthy amount of time it takes to bring an intervention idea to public use, Janssen acknowledges.
In recent years, the CDC has required organizations receiving HIV prevention funding to use one of the evidence-based interventions on a list called the Diffusion of Effective Behavioral Interventions (DEBI). However, there are 13 interventions on this list, and only a few were designed for prevention in the African American community.
Setting high standards for HIV prevention interventions is a worthwhile goal, but it makes for a difficult situation, says Nancy Glick, MD, an attending physician in infectious diseases and the HIV medical director at Mount Sinai Hospital Medical Center in Chicago, IL.
"In the past people have used interventions that were never fully tested, so having outcomes of these studies is very helpful, even though it takes a long time to do that," Glick says.
There are dozens, maybe even hundreds of HIV prevention interventions designed for African Americans that have been studied, peer-reviewed, and published, but most of them will never make it to the DEBI list.
One of these new proven interventions is the REAL (Responsible, Empowered, Aware, Living) men intervention, designed for fathers and adolescents, and studied in a cohort that was primarily African American.
The REAL men intervention's findings showed that it works in delaying the onset of sexual intercourse and increasing the use of condoms among those adolescents who were sexually active, says Colleen DiIorio, PhD, professor at the Rollins School of Public Health at Emory University in Atlanta, GA.
But it's not on the DEBI list, and it might be a long time before it is. The DEBI lists 13 interventions, which is only one more than it had 2 years ago.
"If the CDC is interested in it and wants to add it to their list, I would welcome that," DiIorio says. "I can see the possibility of this intervention being included because it's the only one that is focused on fathers and sons."
Janssen says the CDC plans to add 2 or 3 interventions to the DEBI list each year.
While it's a good idea to put HIV prevention money into evidence-based programs, the drawback is that adding a new intervention to the DEBI list is difficult, and by the time some interventions make the list, they may be outdated, DiIorio notes.
"Times change, so something that was developed in the mid-1990s may no longer meet the requirements of today," she says.
CDC officials are aware of this problem, Janssen says.
"There are a number of effective interventions published, and we have evidence of their effectiveness, but because of resource limitations we can only package so many interventions into the DEBI process each year," Janssen says. "We're actually beginning conversations and talking with folks at the National Institutes of Health to look at how we can work together to streamline that process."
Also, the CDC has been looking at the earlier interventions and updating them as needed, Janssen notes.
"We've looked at ways to short-circuit the whole process, which can be 10 years to developing an idea to doing a clinical trial and then translating it to get it into a prevention program," Janssen says.
"We've looked at ways to adapt and tailor -- taking interventions known to be effective and modifying them to other populations and other types of venues," Janssen says. "That saves us from having to do a completely new clinical trial, and it can save several years off the process."
This translation process involves having principal investigators translate the materials they developed for investigative purposes into materials that can be used by community based organizations for prevention programs, Janssen says.
"It's not a simple process of just creating materials or Xeroxing materials," he says. "It actually requires a fair amount of effort, particularly on the part of the principal investigators."
Nonetheless, adapting and tailoring existing interventions is less time-consuming than starting a new intervention for study, and that's what makes it attractive to the CDC and researchers.
For instance, Glick's research involves the Treatment Advocacy Program at Mount Sinai Hospital. She and co-investigators used an intervention that had been tested in a population of white men who have sex with men (MSM) and changed it to work in a population of African Americans, including heterosexuals.
"I think that there are more and more interventions becoming available that can be effectively changed to work in different populations," Glick says. "That process won't take as long a period of time as it has in the past because the intervention is somewhat proven."
Researchers who adapt an existing intervention still will need to study the outcomes in the different communities, and each group has issues that will need to be addressed separately, Glick explains.
Then there is the issue of keeping an intervention fresh, even as the culture to which it is being adapted changes during the clinical trial process.
For instance, in the Treatment Advocacy Program, the tailored intervention included education that deflated some of the myths circulating about HIV in the black community, says Sheela Raja, PhD, a clinical psychologist in the HIV Program at Mount Sinai Hospital and a co-investigator on the study.
One myth that came out and couldn't be addressed because the study was underway was that the U.S. government had a cure for HIV, but was just not giving it to people because they were working with pharmaceutical companies to increase their profits, Raja says.
"The disturbing thing about it was that one of the peer educators whom I supervised weekly said that she believed that myth," Raja adds.
While the CDC report states that the government agency is committed to finding and translating more prevention interventions, most of its prevention and surveillance funding is directed towards increasing HIV testing.
"Half of the money we put into prevention programs provides services or support for services for African Americans," Janssen says. "Most of that will go toward supporting testing among African Americans."
The CDC is putting out $30 million to $35 million to state and local health departments to increase testing in their jurisdictions, and this money is going to areas where the HIV rate among blacks is highest, he adds.
The states with large cities that have high HIV rates among African Americans include New York, Florida, Texas, Virginia, the Carolinas, Tennessee, Alabama, Mississippi, Louisiana, California, Michigan, Ohio, Pennsylvania, and New Jersey, Janssen says.
Starting this summer, the CDC will hold 8 to 10 regional and local meetings in these areas, meeting with African American leaders and community health leaders, he adds.
"We want to work closely with local leaders and public health officials to link leaders with HIV prevention organizations and AIDS service organizations," Janssen says.
The state of Florida's Silence is Death initiative is a good example of state health officials working with the African American community to improve HIV testing and prevention, Janssen says.
Well before the CDC launched its initiative aimed at African Americans, the Florida Department of Health started its own campaign, trying to reach this population, says Tom Liberti, chief of the bureau of HIV/AIDS for the Florida Department of Health in Tallahassee, FL.
"Several components of the CDC plan are things that we're heavily engaged in," Liberti says. (See story about Florida's HIV prevention efforts, p. 65.)
"The first is a very large HIV counseling and testing program," Liberti adds. "We believe, like the CDC, that knowing your status is critical to reducing new infections in the United States."
Last year, the state of Florida tested more than 100,000 African Americans for HIV, which was one third of the state's 300,000 HIV tests in 2006, Liberti says.
"The second part of what the CDC likes is our mobilization efforts," he says. "We do believe that if you get people who are from the community and of the community and live in the community, especially the African American leadership, then you have a better chance of making an inroad into the African American community."