HIV treatment as prevention promotion Detroit18
HIV treatment as prevention promotion program in Detroit, Michigan
Tracy Liichow
Concordia University, Nebraska
Principles of Health Behavior
MPH 515
Instructor: Dr. Kimberly B. Brodie, CHES, ACSM-HFS
August 2014
HIV treatment as prevention promotion Detroit18
Table of Contents
HIV treatment as prevention promotion program in Detroit, Michigan 3
Previous HIV prevention as treatment programs 5
Epidemiological, behavioral and environmental assessment 9
Educational and ecological assessment 10
Administrative and policy assessment and intervention alignment 10
Implementation and Evaluation 11
HIV treatment as prevention promotion program in Detroit, Michigan
According to the Centers for Disease Control and Prevention (CDC) (2013b), it could be estimated that “1,144,500 persons aged 13 years and older are living with HIV infection, including 180,900 (15.8%) who are unaware of their infection.” HIV (human immunodeficiency virus) has been a national public health epidemic for a long time and continues to be a public health priority well into the twenty-first century. The aim of this paper is to present a feasible HIV prevention strategy.
If HIV-positive individuals (newly diagnosed) are linked to care and start taking antiretroviral drugs (ARVs) and adhere to their prescribed regimen, then they are engaging in an HIV prevention activity. The goal of this HIV treatment as prevention promotion program is to increase the number of HIV-positive individuals taking and adhering to ARVs thereby promoting HIV prevention. Hopes have been raised that combining existing prevention efforts with HIV treatment as prevention can now end the spread of HIV infection around the world (J. Cohen, 2011). However, reaching the world is beyond the scope of this particular health promotion. The population of interest for this health promotion is the African American community residing on the eastside of Detroit, Michigan.
HIV treatment as p revention
It is exhilarating and challenging to contemplate the significance of the evidence resulting from the study entitled, “Prevention of HIV-1 infection with early antiretroviral therapy,” commonly known as the HPTN 052 study, conducted principally by M. S. Cohen. The conclusion of the study was “The early initiation of antiretroviral therapy reduced rates of sexual transmission of HIV-1 and clinical events, indication both personal and public health benefits from such therapy” (M. S. Cohen et al., 2011, p. 493).
It is established that the “probability of sexual transmission of HIV is strongly correlated with concentrations of HIV in blood and genital fluids” (Rayment, 2012, p. 193). Antiretroviral therapy (ART) consists of administering antiretroviral medications, which are intended to inhibit HIV replication preserving vital CD4 cells (Shechter, Bailey, Schaefer, & Roberts, 2008). Furthermore, sustained and prolonged suppression of HIV replication in blood and genital fluids occurs with effective ART (Rayment, 2012).
HIV and African Americans
HIV has become a chronic disease, and the number of people living with the virus continues to grow. The CDC (2013b) reports that African Americans are continuing to severely experience the affliction of HIV, compared with other races and ethnicities. According to the Henry J. Kaiser Family Foundation (2014, p. 1), “a number of challenges contribute to the epidemic among Blacks, including poverty, lack of access to health care, higher rates of some sexually transmitted infections, lack of awareness of HIV status, and stigma.” An HIV prevention strategy designed to target African Americans is challenging.
In the designing of the prevention program, it must acknowledge that African Americans generally have a different culture. The prevention program will be culturally sensitive along with taking an ecological approach that incorporates a health behavior change theory. “Culture and ethnicity are critical to consider when applying theory to a health problem” (Glanz & Rimer, 1997, p. 7). Furthermore, Airhihenbuwa and Obregon (2000, p. 6) argue “A critical point in this debate about relevant health communication theories/models is the recognition of culture as central to planning, implementation, and evaluation of health communication and health promotion programs in general. . . and HIV/AIDS prevention and care in particular.”
Treatment as p revention
According to the CDC (2013a), public health professionals in particular should realize the full prevention benefit of treating HIV infection and be mindful of importance HIV testing and early identification. “Early identification of infection empowers individuals to take action that benefits both their own health and the public health” (Centers for Disease Control and Prevention, 2013a). Subsequently, infected persons substantially decrease their risk of transmitting HIV when they are engaged in early treatment (Centers for Disease Control and Prevention, 2013a). Effective treatment requires adherence to ART and linkage to and retention in care.
Previous HIV prevention as treatment programs
Uganda
Current literature discusses HIV prevention and the various means utilized in the field of public to address the pandemic. One identified implemented health promotion program that addressed HIV prevention and the impact of ART was the “Changes in sexual behavior and risk of HIV transmission after antiretroviral therapy and prevention interventions in rural Uganda” conducted by Bunnell, Ekwaru, Solberg, Wamai, Bikaako-Kajura, Were, Coutinho, Liechty, Madraa, Rutherford, and Jonathan Mermin in 2006. The health behavior theory used was the ecological perspective or approach. The objective was to “assess changes in risky sexual behavior and estimated HIV transmission from HIV-infected adults after 6 months of ART” (Bunnell et al., 2006, p. 85). The design was set up as a prospective cohort study, which was performed in rural Uganda. The results were positive. “Six months after initiating ART, risky sexual behavior reduced by 70% . . . Estimated risk of HIV transmission from cohort members declined by 98%, from 45.7 to 0.9 per 1000 person years” (Bunnell et al., 2006, p. 85).
HIV/AIDS Complacency
Another identified implemented health promotion program that addressed HIV prevention and the impact of ART was the “HIV/AIDS complacency and HIV infection among young men who have sex with men, and the race-specific influence of underlying HAART beliefs” funded by the CDC. In this author’s opinion, the health behavior theory used was social cognitive theory (SCT). “SCT is predicated on the concept that the social environment is a central influence on behavior, making personal characteristics alone an inadequate explanation of health behaviors” (DiClemente, Salazar, & Crosby, 2013, p. 165).
The method used was an analysis of data from a two year “cross-sectional 6-city survey of 1575 MSM aged 23 to 29 years who had never tested for HIV or had last tested HIV-negative” (MacKellar et al., 2011, p. 755). The researchers assessed the data for plausible influences overall and by race/ethnicity. The results produced were anticipated. “Young MSM who are complacent about HIV/AIDS because of HAART may be more likely to engage in risk behavior and acquire HIV. Programs that target HIV/AIDS complacency as a means to reduce HIV incidence among young MSM should consider that both the prevalence of strong HAART-efficacy beliefs and the effects of these beliefs on HIV-infection risk might differ considerably by race/ethnicity” (MacKellar et al., 2011, p. 755).
The HPTN 052 study
Another identified implemented health promotion program that addressed HIV prevention and the impact of ART was the above mentioned HPTN 052 study. The ecological perspective or approach was the overarching health behavior theory used. The participants were from nine countries. The researchers enrolled “1763 couples in which one partner was HIV-1–positive and the other was HIV-1–negative” (M. S. Cohen et al., 2011, p. 493). The results were impressive with a small number of HIV-1 transmissions observed.
Objective
The HIV treatment as prevention promotion program will provide crucial health information and education, which will lead to a change in health behavior among African American HIV-positive residents of Detroit. At the end of the first year of the program, 80% of HIV-positive individuals residing in on the eastside of Detroit will have begun adhering to their HIV ARV regimen, and a decrease in HIV infection will be demonstrated.
Health Behavior Theory
Using a health behavior theory to promote health protective behaviors is of upmost importance. According to Fishbein (2000, p. 273), “it has become increasingly clear that preventing the transmission and the acquisition of HIV must focus upon behaviour and behaviour change.”
Furthermore, planning is crucial to the development of public health promotion endeavors. One of the best planning instruments available for public health professionals is the PRECEDE-PROCEED Model.
PRECEDE-PROCEED Model
As a logic model the PRECEDE-PROCEED Model (PPM) is effective in changing health behaviors, and it is an effective planning tool as well (Crosby, Salazar, & DiClemente, 2011). According to Glanz and Rimer (1997, p. 40), “Planning systems, such as social marketing and PRECEDE-PROCEED, facilitate the process of developing successful programs because they lead practitioners through a step-by-step process of examining health and behavior at multiple levels.”
PPM is “valuable to health promotion planning because it provides a format for identifying factors related to health problems, behaviours and program implementation” (The Health Communication Unit, 2001, p. 3). “PRECEDE stands for Predisposing, Reinforcing, Enabling Constructs in Educational/ Environmental Diagnosis and Evaluation . . . PROCEED, on the other hand, stands for Policy, Regulatory, and Organizational Constructs in Educational and Environmental Development” (Crosby et al., 2011, p. 48). One of the primary beneficial aspect of the PPM is its community level approach. It is adaptable and utilizes monitoring and adjusting methods. Figure 1 displays the PRECEDE-PROCEED Model.
Health Belief Mode l
When designing a health promotion focusing on HIV prevention a multi-level approach should be adopted. The multi-level approach to health behavior change that this paper is addressing includes PPM and the Health Belief Model. According to Kaufman (2014, p. S250), “HIV risk and AIDS care involve complex behaviors influenced from multiple levels, from an individual’s knowledge, attitudes, emotions, and risk perception, to power dynamics between partners, accessibility of services, economic inequalities, criminalization of vulnerable groups, and policies that make HIV a priority health issue.”
Initially developed in the 1950s by social psychologists the Health Belief Model (HBM) is a widely used psychosocial approach to explaining health behaviors (Rosenstock, Strecher, & Becker, 1994). Several primary concepts are contained within HBM. These concepts “predict why people will take action to prevent, to screen for, or to control illness conditions; these include susceptibility, seriousness, benefits and barriers to a behavior, cues to action, and most recently, self-efficacy” (Glanz, Rimer, & Viswanath, 2008, pp. 46–47).
Social a ssessment
Community p articipation and r elevance
Community participation is essential to the project. Community involvement will be highly stressed and valued. Planning for community participation will be one of the first items undertaken. Monthly meetings will be set up with community-based organizations (CBO) in the Detroit area. Focus groups will be developed from established partnerships with CBO in the Detroit area. A partnership will be established with a Federally Qualified Health Center (FQHC) in the area, namely Detroit Community Health Connection. A peer network will be developed as well as existing support groups will be strengthened and enhanced. Additionally, a multimedia sexual health media campaign will be developed. A city-wide kick-off event coordinated with the CBOs and FQHC will be held before the media campaign takes place. HIV counseling and testing will be made available at the kick-off event.
The following is a list of the CBOs who will be contacted:
· AIDS Partnership Michigan (APM)
· Community Health Awareness Group (CHAG)
· Health Emergency Lifeline Program (HELP)
Epidemiological, b ehavioral and e nvironmental a ssessment
Current data on HIV infection
“HIV among African Americans in Detroit is rising at an alarming rate” (James, 2014, p. 1). In the city of Detroit, African Americans comprise up to 72% of the HIV-positive population. See Table 1 for Michigan Department of Community Health’s July 2014 annual HIV surveillance analysis of Detroit. The contributing factors leading to HIV infection in the city of Detroit include, poverty, lack of access to health care, higher rates of sexually transmitted infections (currently particularly syphilis), lack of awareness of HIV status, and stigma (The Henry J. Kaiser Family Foundation, 2014, p. 1).
Educational and e cological a ssessment
The educational and ecological assessment will identify preceding (predisposing or cognitive), reinforcing, and enabling factors that must be in place to initiate and sustain change (Crosby et al., 2011; Glanz & Rimer, 1997). This is the place where the HBM will be used. During the educational and ecological assessment, all three levels (individual, interpersonal, and community) of change theories can apply and are relevant.
The predisposing factors will be dealt with using a health education initiative that will coincide with the peer networks and peer support groups. “Health education remains the front-line method of changing predisposing factors in public health” (Crosby et al., 2011, p. 54). The reinforcing factors, which are rewards or incentives, will be included in the media campaign, the kick-off event, and support group meetings. The incentives will include the most-common ones, such as gas cards and bus tickets. The participants will have to be praise and reassured during the program in various ways. The enabling factors will be addressed by advocating HIV social work case management services for all participants.
Administrative and p olicy a ssessment and intervention alignment
In the administrative and policy assessment phase, the capacity and available resources will be identified. A determination will be made to identify any additional resources that may be needed. Subsequently, after the assessment has been made then the intervention alignment can begin. “Intervention alignment is the point where [the] formative work (PRECEDE) ends and [the] action (PROCEED) begins” (Crosby et al., 2011, p. 53). The intervention alignment has a policy changing element that is daunting. The difficulties of accessibility (mass transit is not good in Detroit), affordability (the main outreach is to individuals who are low income or no income), availability (logistics involved in having services available during convenient hours), and acceptability (entrenched attitudes concerning HIV) have long been issues public health has dealt with in Detroit. Therefore, there will have to be several meetings with partners to address the current environment and all structural barriers.
Implementation and Evaluation
Implementation indicates the initiation of the program. The timeframe will be one year. The responsible party will be the Detroit Health Department working in collaboration with the Michigan Department of Community Health. The health departments will be responsible for the implementation plan. Resources will be mobilized, and partners (CBOs and FQHC) will be assigned duties.