Missing the HIV message (American Public Health Assn. annual meeting)

After decades, efforts toward AIDS prevention may seem tired and worn. But people are still getting sick, as new at-risk populations are being identified.

By Susan J. Landers — Posted Dec. 17, 2007

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Although the HIV/AIDS epidemic is decades old and preventive measures have been widely promoted, another 40,000 people become infected each year. And, despite considerable progress in reducing the disease's impact among populations hardest hit initially -- gay men and intravenous drug users -- other populations, especially racial and ethnic minorities, continue to bear a disproportionate burden, according to a recent report from the Centers for Disease Control and Prevention.

That's why researchers are crafting prevention messages to reach these vulnerable people. Several presenters at the American Public Health Assn.'s 135th annual meeting, held Nov. 3-7 in Washington, D.C., provided examples of effective programs.

Some researchers zeroed in on young minority students at colleges and universities, a group not traditionally thought of as at high risk for contracting the AIDS virus.

Young, female, Hispanic college students were the focus of research done at Florida International University in Miami. Hispanic women ages 16 to 24 are one of the fastest-growing groups for getting HIV infection, said Robert Malow, PhD, professor of public health and director of FIU's AIDS Prevention Project.

These women, who may have been born in Latin American nations such as Cuba, Panama, Honduras, Guatemala and Columbia, are often caught in a cultural crunch. While focusing on the importance of remaining virgins for marriage, they are also intent upon not chasing men away. They may practice oral and anal sex in order to maintain their virginity, but are unaware of the HIV risks those options involve, he said.

The need to educate this often-sheltered population led to the formation of the university's peer education program, SENORITAS -- Student Education Needed in Order to Reduce Infection and Transmission of AIDS/HIV and STIs.

Spreading the word

The situation is similar for African-American college students, noted CDC medical epidemiologist Madeline Sutton, MD, MPH. She led surveys on student attitudes and behaviors about HIV and AIDS and found a difference between perceived and actual risk.

Of 1,172 students surveyed at historically black colleges and universities, 79% said they were at low risk for acquiring the virus, but only 55% had used condoms during their last sexual encounter. In addition, many of the students, both males and females, reported encounters with multiple partners during the previous 12 months.

On the plus side, many said they would be willing to have an HIV test. And those who said they already had been tested said they had done so after a talk with a doctor or other health professional, said Dr. Sutton. She urged physicians to take advantage of their persuasive powers. "Students take it to heart when we sit down and discuss with them getting an HIV test."

Physicians and other health professionals were also found to be believers in packaging the prevention message with medical care, according to a survey sent to 136 physicians, nurse practitioners and physician assistants by the AIDS Activities Coordinating Office in Philadelphia.

The surveyors thought physicians and others might be too time-strapped by patient care to think about prevention, said Marlene Matosky, MPH, RN, a member of the research team. But that wasn't the case.

Although nearly everyone who responded thought prevention was important, almost half said they would like to be more effective at communicating the message to patients. The physicians particularly needed materials to distribute to those already infected. As a result, the city is now gearing up to supply such handouts as well as information on bleach kits to use when cleaning needles, needle-exchange programs and condom distribution sites, Matosky said.

Another session focused on reaching Hispanic men who have sex with men. These men do not necessarily consider themselves to be gay and so are often missed by the messages that began going out to that group decades ago, said Ana Martinez-Donate, PhD, assistant professor of health promotion and behavioral sciences at San Diego State University's Graduate School of Public Health.

She led a research team in a campaign called Hombres Sanos, or "healthy men." It promotes condom use and HIV testing among this high-risk group. Researchers distributed materials at nightspots and barbershops and aired radio promos. The effort has produced good results, she said. Condom use increased, as did the men's perception of their risk.

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How AIDS is spreading

Adolescent girls and young adult women have been identified as being at high risk for HIV infection. From 2001 to 2005, the majority of AIDS cases diagnosed among these groups were attributed to high-risk heterosexual contact.

Mode of transmission 13- to 19 year-olds 20- to 24-year-olds
Injection drug use 333 800
High-risk heterosexual contact 2,086 4,740
Other/not identified 22 47
Total 2,441 5,587

Note: Based on cases reported in 33 states.

Source: Centers for Disease Control and Prevention

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Disproportionate burden

Hispanics made up about 14% of the U.S. population in 2005, but accounted for 19% of the AIDS cases reported to the CDC that year. Similarly, blacks made up about 13% of the U.S. population but 40% of total AIDS cases. Of the 956,019 AIDS cases reported to the CDC through 2005, the disease burden for these two ethnic groups breaks out as follows:

Hispanics Blacks
Total cases 19% 40%
Women with AIDS 19% 60%
Heterosexual people at high risk 22% 59%
Children younger than 13 23% 59%
Adults and adolescents* 20% 48%

* Note: Percentage of total new cases reported in 2005

Source: Centers for Disease Control and Prevention

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CDC, states at odds on HIV testing

State laws often stand in the way of implementing a 2006 Centers for Disease Control and Prevention recommendation to offer HIV testing routinely to most patients, said a study presented at the APHA's annual meeting last month.

Many state laws require specific consent for an HIV test rather than the CDC-recommended "opt out" procedure in which a physician notifies patients that HIV testing will be conducted and offers them an opportunity to decline. Pre- and posttest counseling also is required by many states.

Robert Wood Johnson Foundation clinical scholar and researcher Anish Mahajan, MD, MPH, and others found that 22 states have laws that are incompatible with the federal outline.

Their search of state health department Web sites also found that few provide guidance about the CDC approach. "Our contention is that proper and responsible implementation of the recommendations will depend on providers being well informed and well educated on how best to ensure patient autonomy, and how best to recognize when a patient really needs a referral to counseling and getting them there," Dr. Mahajan said.

A separate presentation detailed how the California Medical Assn. and state AIDS advocacy groups worked together to change that state's law to facilitate routine screening in all health care settings. The bill, signed into law in October, simplifies the consent necessary for the test. It takes effect Jan. 1.

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External links

Details about the 2007 American Public Health Assn. annual meeting (link)

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