HIV/AIDS prevention gets back on track

A year into Gov. Deval Patrick's tenure in the corner office HIV/AIDS advocates say the administration, bolstered by the appointment of John Auerbach as commissioner of the Department of Public Health (DPH), has begun to reverse the damage done to the state's HIV prevention efforts under Patrick's predecessor, Mitt Romney. But much work remains to deal with vastly disproportionate rates of HIV in communities of color, the impact of crystal methamphetamine addiction in HIV transmission and general prevention fatigue among gay men.

Joe McKee, executive director of AIDS Project Worcester and a member of the Massachusetts HIV Prevention Planning Group (MPPG), which advises DPH on prevention policy, said that under Romney HIV prevention efforts were decimated both by budget cuts and by the governor's politicization of public health issues, which led to DPH reversing its stand on programs for providing IV drug users with clean needles and stalling on the development of updated HIV prevention materials and outreach programs aimed at gay and bi men. After Auerbach assumed his post at DPH he began touring the state and speaking to health providers to get a sense of their needs, and when Auerbach came to Worcester McKee said he let them know that the days of politicizing public health were over.

"One of the things that was incredibly encouraging that John did here in Worcester in May 2007 was John opened his remarks [by saying] that he realized, understood and has made a commitment to depoliticize public health issues. ... That was for me as an AIDS service provider since 1984 an incredible message to hear after coming out of the Romney administration," said McKee.

Yet other advocates say it is too soon to tell how effective the Patrick administration will be at translating its rhetoric into action. Cynthia Harris, director of prevention programs at the Multicultural AIDS Coalition (MAC) and another member of the MPPG, said that she is hopeful but that it is too soon to give a verdict on the administration's efforts.

"I know that [Auerbach] definitely is cutting edge and willing to go with what works best for the people we're trying to serve. So I'm expecting to see some of the same. ... I'd love to see what providers said to him [during his tour of the state] in some report given back to us, so we can hold him accountable, but I'm very hopeful," said Harris.

Another MPPG member, greg-eugene, an HIV outreach worker and past chair and member of the Bayard Rustin Breakfast Committee, said that the state is moving in the right direction.

"The rhetoric is there. There's lots of rhetoric in that direction. ... Monies are there, funding is back in place, people are optimistic, I'm optimistic. But we don't really get results for another year or two," said greg-eugene.

Let's talk about sex (and drugs)
Auerbach told Bay Windows that the Patrick administration is committed to reversing the politicized approach to public health taken by Romney and returning the focus to scientifically sound prevention programs, regardless of whether they might be seen as controversial.

"The perspective of the current [administration] ... is that our HIV prevention efforts should reflect what we know works in terms of reaching the populations at risk with clear and effective messages or interventions, and it's not concerned with whether those messages are edgy or are about issues that make some people uncomfortable to talk about, namely issues of sex and substance abuse," said Auerbach.

As an example of the administration's new approach he cited the implementation of the pharmacy access bill, a piece of legislation passed in 2006 when the legislature overrode Romney's veto. The bill, which took effect in September, allows the over-the-counter sale of syringes, and proponents say evidence shows that the availability of clean needles significantly reduces HIV transmission among IV drug users.

In the run-up to the vote on the needle access bill then-Lt. Gov. Kerry Healey stated that one of the reasons the Romney administration opposed the legislation was that it would lead to increased disposal of used needles in parks and other public places. Yet Auerbach said once the bill passed the Romney-era DPH failed to set up a program for the safe disposal of used needles, one of the provisions of the legislation. The disposal program was intended both to safeguard the public from exposure to discarded needles as well as to assuage the fears of communities hesitant about the effects of legalizing needle sales. Auerbach said under Patrick DPH has since implemented the disposal program, distributing needle disposal kiosks across the state and paying for regular pickups to collect the discarded needles.

Another initiative DPH has undertaken since Patrick took office is increasing support for programs aimed at the gay and bi male community. Auerbach said the administration has been able to "allow [providers] to do the particular programs that they knew worked, which were also very grassroots work through outreach workers that knew how to work in different parts of the communities where gay men would socialize and to adapt the message in a way that it was more likely to be received."

Auerbach said starting in 2001 cuts to the DPH budget gutted much of the state's HIV prevention funding. State surveillance data shows that the number of new HIV infections decreased over the past several years, from 1326 new cases in 1999 to 884 in 2005, the last year for which complete data is available. But Auerbach said there are also indications that there has been a marked increase in recent years in risky behavior, particularly among gay and bi men. He said a few years ago advocates and health officials saw new HIV diagnoses in patients addicted to crystal meth and believed the drug was contributing to people engaging in unprotected sex. Increased cases of syphilis in gay and bi men also suggest that there is an increase in unprotected sex, said Auerbach.

Auerbach's concerns are bolstered by a study conducted by Fenway Community Health that was presented this month at the National HIV Prevention Conference in Atlanta (see "CDC Won't Release HIV Stats Showing Higher Rates Of Infection"). The study found that among a sample of HIV-positive men in Boston, more than a third reported engaging in unprotected anal sex within the past three months. While about 40 percent of those did so with partners who were also HIV-positive, another 23 percent did so with HIV-negative partners, and about a third did so with partners of unknown HIV status. The study found that the men who had unprotected sex were four times as likely as their peers to be diagnosed with another STD, frequently syphilis, and that those who used meth were three times more likely than their peers to have an STD.

"What we saw in Massachusetts is that when the cuts occurred in HIV funding after 2001, many of the prevention initiatives in Massachusetts were cut, and we began to see increases in certain populations with regard to either HIV or high risk behavior," said Auerbach. He said by working to restore those programs he hopes to reverse that trend.

McKee said already there are efforts underway to restore some of the prevention programs that had been cut under Romney.

"I know the Department of Public Health has been updating its prevention literature," said McKee, saying that in particular the prevention materials aimed at gay and bi men will be significantly updated to reflect the current reality of the epidemic. "That's all going to be rolling out. Also they're making attempts to further increase access to HIV counseling and testing by rolling out more broad-based rapid testing."

greg-eugene, who facilitates HIV prevention outreach programs for multiple agencies in the Boston area, said he has seen programs receive new funding for prevention programs aimed at black men who have sex with men (MSM).

"I happen to have just gotten a go-ahead at the MAC for continuing some work. ... There's new monies, and people are revving up on how to reach the black community. ... Is it effective? We don't know. But there's a dialogue," said greg-eugene.

Challenges on the ground
In 2007 HIV prevention is about much more than just passing out condoms in bars and in the Fens. Jon Vincent, manager of prevention and education for Fenway Community Health, said that while condom distribution as well as counseling and testing are still key to Fenway's prevention work, the health center has also worked to find new ways to reach people with prevention messages, particularly those who have been bombarded with safe-sex messages for years and who may be feeling prevention fatigue.
"With anything else, like a computer or automobile, we have to update our technology for the 21st century," said Vincent.

For Fenway one of those innovations is the Health Navigator program, in which Fenway staff members work one-on-one with people at high risk for HIV infection to connect them to services above and beyond prevention counseling and testing. The theory behind the program is that gay and bi men who are at high risk for contracting HIV, including those who are homeless, who are addicted to crystal meth, who are dealing with mental health issues, who have no health care, or who are transgender, may not be able to focus on protecting themselves from HIV unless they can resolve some of the other issues that put them at risk.

"The HIV for these folks is sometime not their largest problem. Our Health Navigators go out and really try to triage the most important problems for them," said Vincent.

He said the Navigators refer clients to services both inside and outside the Fenway so they can get a roof over their head, get access to a bed in a treatment facility, apply for health insurance, find a trans-friendly healthcare provider, or take care of any of the other issues in their life that put them at high risk for infection. With those needs met, the Navigators can then get the clients to focus on HIV prevention. The program, which is in its second year, is a collaboration between Fenway, the MAC, AIDS Action's Male Center, and the Latino Health Institute.

McKee said AIDS Project Worcester has had great success using prevention programs that recruit people who are considered leaders in their community, whether that community consists of a subset of gay men, people of color, drug users, different age groups, or other types of groups. The agency trains those leaders to be HIV/AIDS prevention advocates and sends them back to spread the message in their own community.

"We refer to them as popular opinion leaders. So it could be someone in the gay community who's looked up to because he's very knowledgeable about artwork. So within his social network he's looked up to. ... He already has a level of trust and respect by community members," said McKee.

Harris said the MAC has found the social networking strategy particularly successful in doing outreach to different communities of color.

"Using people who are from the community who may be engaging or who used to engage in the same behavior has been quite effective for us, particularly because it gives people of color a way to participate," Harris said. She explained that when people approach the MAC looking to make a difference in their community, they can learn how to bring friends, family members, and other people within their sphere of influence into the agency for counseling, testing and other services.

Finding ways to reach communities of color with HIV prevention messages is a particularly pressing goal for advocates and health officials in Massachusetts. On Dec. 1 DPH released a report on the impact of the HIV/AIDS epidemic on communities of color. The report showed that the black and Hispanic communities bear a disproportionate brunt of new infections. While the last Census found that black and Hispanic people each make up six percent of the Bay State population, they account for 28 percent and 25 percent of the people living with HIV, respectively.

The report found that the state has been successful at adjusting its spending on HIV/AIDS services to match that reality, funding services in communities of color in proportion to those communities' representation in the epidemic. But adjusting spending has not been sufficient. The report found that there is particularly low utilization of HIV prevention and testing programs in the black community.

To address that disparity the report recommends a number of options, including increasing prevention resources to communities of color above and beyond those communities' representation in the epidemic, expanding the use of rapid HIV testing in healthcare and other settings within those communities, and expanding social network-based prevention programs used at agencies like the MAC and AIDS Project Worcester.

Harris said one of the challenges in reaching communities of color is changing the mindset of HIV service providers to get them to focus on reaching out to people in their own communities and environments. She said rapid testing is a potentially powerful tool for getting people tested, but most testing sites are located in hospitals or agency offices and are open only during business hours. She said the MAC does not have a contract to do rapid testing.

"I think with the technology of rapid, [you need] to really reach people in the places where they are. And that requires us as providers to sometimes work past five o'clock," said Harris.

She said many people may not feel comfortable going into a health center for a rapid test, and they may not be able to take time out of their workday to get tested. Rapid testing providers need to bring their testing operations directly to the clients they serve and offer testing in sites that people frequent regularly, such as churches, Harris said.

"It's possible. I think there are people who are ready, willing and able, and if we're strategic we can have testing offered once a month in places, and people will come," said Harris.

She said agencies should extend that same approach to case management services for people who are at risk. At the MAC she said case managers make themselves available to their clients "24/7," and she said that while some agencies have done the same, there is still a strong nine-to-five mindset in the HIV/AIDS field overall.

Harris said another effective strategy the MAC has found in reaching communities of color is to maximize resources by partnering with other organizations to collaborate on projects. She pointed to MAC's work on World AIDS Day, when the agency partnered with about eight other community organizations to hold a cultural showcase on HIV/AIDS at Hibernian Hall in Roxbury.

Yet greg-eugene said agencies targeting communities of color have not collaborated in designing much of their prevention programming, and they waste resources by running overlapping programs. He said he has seen clients attend an HIV prevention group at one agency, collect a check for participating, then go across town and attend a nearly identical group at another agency and collect another check, and then attend yet another similar group at another agency. Each of the agencies count the participant for funding purposes, greg-eugene said, but the chance to use the funding for those programs to reach a wider audience is squandered.

"If you can't sit down and figure out how your target group is overlapping with somebody else getting the same money, you're competing. ... If we're simply just trying to spend money that's coming down the pike, that's a different thing," said greg-eugene.

He said the contract-driven approach also makes it difficult for agencies to maintain long-term relationships with the people they are trying to reach with their prevention messages.

"I have brought I know at least 30, 40 men into the agencies that I work for, and those men come in and they have met the numbers that the agency needed to meet their contracts, and those boys are back in the streets," said greg-eugene.

He said agencies need to collaborate to create a stronger network of referrals, so that clients move between agencies to help address all of the issues that put them at risk, rather than collecting their stipend and disappearing.

"So then a person feels that he's being embraced by a community, rather than that these agencies are pitted against each other," said greg-eugene.