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Battling AIDS In Its Worst-Hit Demographic

With African Americans disproportionately affected by HIV, we asked Donna Hubbard McCree to describe the culturally centered work being done to stem the infection. A interview.

The U.S. AIDS epidemic disproportionately affects African Americans — of the 1 million-plus HIV positive Americans, nearly half are black. And every year, about 25,000 African Americans become infected. The crisis is the focus of most of the articles in the June edition of the American Journal of Public Health. spoke with one of the issue's guest co-editors, Donna Hubbard McCree of the HIV/AIDS prevention division at the Centers for Disease Control and Prevention, about the nature of the problem and some research aimed at addressing it. Health disparities between racial groups exist across a range of diseases. Why is tackling HIV/AIDS different?

Donna Hubbard McCree: There are common causes for other disparities, such as the lack of access to care and poverty. But HIV is different because we're talking about a sexually transmitted disease. It's different because of how HIV is transmitted and acquired. Culture has a role in how people look at themselves as being at risk, and how they seek care in terms of disclosure. If you read the literature, particularly about some of the factors affecting HIV in African Americans, you see issues around stigma, things like homophobia and racism. With most other health disparities, stigma is not an issue.

The advances in treatment have also made it more of a chronic disease. We have to deal with treatment in terms of not just the individual who might be affected but also mothers or those of childbearing age.

M-M: In an editorial in this issue, you mentioned the CDC's first-of-its-kind collaborative research consultation on the topic in late 2007. As a leader of the event, what did you learn, and how is CDC applying it to research?

DHM: It was unique in that it was the first time we really brought researchers in. The consultations we've had in the past have brought in members of the African-American community, which is important. This time we were looking at a need to bring everybody to the table.

At the consultation, we found that it made sense to look more at the structural and contextual causes of HIV among African Americans and a focus on prevention research around those initiatives, maybe to look at a shift in the paradigm. That's something we're already doing — it's a shift from looking at individuals to looking more at groups and communities, where you can have broader effects.

M-M: Within the black community, HIV rates are extremely high among African-American men who have sex with men (MSM), but don't identify as gay or bisexual. What are the most promising prevention strategies among that group?

DHM: If you look at the data, African-American men who have sex with men make up the largest proportion of the U.S. population affected by HIV. But black women are second. Given those statistics, we have to look at the African-American community as a whole. You have to look more at the contextual factors, those that affect not just HIV but other diseases and disparities.

M-M: Is CDC funding parallel interventions targeted specifically toward that group?

DHM: We're doing that, too. D-up/Defend Yourself is one project. It's a community-level intervention based on previous work with other groups and adapted for black men who have sex with men.

We go into a community, find people who are popular or opinion leaders and train those individuals around HIV prevention behavior. Then we send them out to become agents of change within their communities. These men are recruited from settings where you can target men for an intervention study, like nightclubs. Those individuals who were trained went out and educated others. The whole premise is about what you can do to not only defend yourself but to defend your community. The activities are developed around skills-building and prevention.

We've also funded projects that looked at the use of different methodologies to identify men who have sex with men and women. We used respondent-driven sampling, a technique for finding hidden populations, as a strategy to locate them. We used the results of that method to design funding opportunities to develop interventions for bisexually active men who have sex with men and women. We funded three sites to conduct studies, and we're just beginning to design the studies.

We have a huge six-site study we call the Latino/African-American MSM project. The project researchers have already had preliminary evidence of interventions with effectiveness, and we're now funding rigorous evaluations of them.

M-M: One AJPH study led by Lisa W. Kimbrough uses a social network strategy that seems similar to D-up.

DHM: With D-up, it's about recruiting people in social networks to promote healthy sexual behavior. Kimbrough is talking about a mechanism for bringing individuals within a social network in for HIV testing. In traditional counseling, if someone tests positive, they'd bring in their sex or needle-sharing partner, as those people would be at risk. With a social network approach, you're not just asking people to bring in their partners, but also to bring in their friends. The point is to get within the network of people, assuming that whole network may be at high risk. We're funding evaluations of the traditional HIV counseling approach against the social networking approach to see which one is most effective.

M-M: Another paper proposes that interventions among African-American men and women should be very different. Is that a worthwhile strategy?

DHM: Yes, and I think they really did a great job of laying out the reasons why. There are so many differences based on the gender and sexual roles. For example, looking at the protection mechanism of the use of the male condom, which women have to negotiate. And there are different reasons, based on the gender of the individual, why it might be difficult to engage in those acts, so I definitely believe interventions need to be specific. There's also the gender dynamics of intimate partner violence, and economic reasons, different reasons why women and men may be having sex. This requires us to develop interventions differently.

M-M: Is there more government money than before to conduct interventions like that?

DHM: We're in a time of flat federal funding, and the majority of the money is going into treatment. As a nation, we're interested more in treatment than prevention. About 4 percent of the national HIV budget goes to prevention (with CDC providing about $750 million of that figure). That's a small amount, but we use those dollars to affect those who are most affected by the epidemic.

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