A key strategy for reducing HIV in African American communities: Promoting HIV testing

In this journal’s publication, “HIV/AIDS Disparities: The Mounting Epidemic Plaguing US Blacks,” Oramasionwu, et al. highlight the alarming rates of HIV/ADDS in African American communities and bring attention to one perhaps underemphasized strategy that may have a profound impact on ending the epidemic: HIV testing.¹ There is a need to urgently promote HIV testing and develop effective strategies that will address barriers to testing in African American communities. World AIDS Day on December 1, 2010 reminds us of the need to address the epidemic plaguing our own backyards. While making up only 12% of the U.S. population, African Americans account for nearly 50% of the HIV/AIDS cases.² While a multi-faceted approach is required to effectively prevent the continued spread of HIV in African American communities, HIV testing is a key strategy.

It is estimated that the people infected with HIV but unaware of their status are contributing to more than 50% of new infections.³ As highlighted by Oramasionwu, et al, this means people infected, but unaware, are unknowingly passing on HIV to others. We know that when they find out they are infected with HIV, many people will change their behaviors to protect their partners from being infected.⁴ Additionally, awareness of HIV status affords the opportunity to begin HIV treatment to lower viral load, the main biologic predictor of HIV transmission. Modeling studies indicate that increasing awareness of seropositivity can reduce new HIV infections; furthermore, coupling universal testing with universal treatment could theoretically put an end to the pandemic.^5,6 Daniels and Wimberly in this journal emphasize that “African Americans must start to believe that knowing their HIV status can save lives and reduce the infection rates.”⁷ In February 2010, during his speech on National Black HIV/AIDS Awareness Day, the Director of the National Institute of Allergy and Infectious Disease, Dr. Anthony Fauci noted, “One of the fundamental ways black men and women can reduce the spread of HIV in their communities and preserve their health is by getting tested for the virus during routine medical care, as recommended by the Centers for Disease Control and Prevention and the American College of Physicians. Identifying HIV infection early in its course is critical.”⁸

Getting tested for HIV is a step in ending the epidemic for African Americans, yet many barriers exist to getting tested. In a 2009 Kaiser Family Foundation national survey, nearly 1 out of 3 African Americans were “not at all concerned” about becoming infected with HIV.⁹ While some African Americans are not at risk for HIV infection, this lack of concern may also highlight a lack of awareness of the prevalence of HIV in the community, a potential barrier to getting tested. In fact, 1 out of 3 African Americans report never having had an HIV test.¹⁰ Of those reporting no prior testing, 1 out of 2 report not being tested because of low risk perception and 1 out of 4 report not being tested because a doctor never recommended it.¹⁰ Oramasionwu, et al.,¹ and Daniels and Wimberly,⁷ have highlighted fear and stigma as additional barriers that will need to be overcome in order for testing to be an effective weapon to mitigate the epidemic.

Unfortunately, when African Americans are diagnosed with HIV, nearly 50% are diagnosed with HIV within 3 years of an AIDS-defining condition, highlighting a significant delay in testing and lost opportunities for life-saving treatment and prevention counseling to prevent further spread of HIV in the community.¹¹ Increasing testing – and testing early – may have a profound impact on the epidemic in African American communities.

In a study of African American women in a high HIV prevalence neighborhood in Boston, MA, women stated the message of “Get Tested” needed to be more widely promoted in the community.¹² Women believed that the severity of HIV/AIDS in the African American community is not accurately perceived, highlighting a known barrier for HIV testing. One woman stated, “I think people is still not getting the picture…it [HIV] doesn’t discriminate. ‘Get tested.’” Women in Boston noted that even when HIV information is available, the community may not be heeding it. As one participant stated, “We know where to get tested and the information is so out there. It’s just the fact that our people rarely use the information…What you’re doing with the information makes a difference.” HIV testing messages need to be promoted in a way that will effectively reach and influence the behaviors of African Americans.

In an effort to increase HIV testing, in 2006 the U.S. Centers for Disease Control and Prevention (CDC), issued new recommendations to encourage that everyone ages 13–64 -- regardless of risk factors – be tested for HIV in healthcare settings. Healthcare providers are to routinely offer HIV testing and patients would need to specifically decline or “opt-out” of testing. In a 2009 national survey (3 years after the CDC recommendations on testing), 70% of African Americans reported that their doctors had never suggested HIV testing.¹⁰ Studies done in healthcare settings since this paradigm shift in testing indicate that HIV testing is still not universally accepted even when offered. Up to 65% of patients offered testing in healthcare settings still opt-out of testing.^13–15 While solutions to the ongoing challenges to HIV testing in healthcare settings are needed – addressing both physician and patient barriers to testing -- strategies are also needed to encourage HIV testing for those without access to or not engaging in health care settings.

Media campaigns are a cost-effective strategy to promote HIV prevention messages and are a strategy shown to be effective to promote HIV testing and testing knowledge, including in African American communities.^16–18 Limited research indicates that mass media sources such as television, newspaper, radio, and the internet are prominent and preferred sources of HIV information for African Americans.^19–25 African Americans want more information about HIV testing. In a 2009 national survey, nearly 50% of African Americans wanted to know if they should get tested for HIV or not and 40% wanted to know where to get tested.¹⁰ The National Medical Association’s HIV/AIDS Consensus Panel highlighted the importance of the media as a strategy to address the HIV/ADDS crisis in the African American community.²⁶ In the report, “A heightened national response to the HIV/AIDS crisis among African Americans,” the CDC emphasized a need to develop campaigns that encourage HIV testing in African American communities as a major strategy to end the epidemic.²⁷ Little is known about the preferences for message format (e.g., fear appeals, narratives, exemplars), message framing (gain-framed versus loss-framed), and media sources that will most effectively deliver HIV testing messages and impact testing behaviors in African American communities. Attention to these executional elements of campaigns, as well as campaigns based on behavior change models, can lead to success.^{18, 28–30} A research agenda is needed to guide successful HIV testing campaign development and evaluation in African American communities.

While HIV testing promotion can be pursued by many strategies including the use of social networks, popular opinion leaders, church leaders, and civic groups, media campaigns may have a prominent role for African Americans who cite the media as an important source of HIV/AIDS information. As Freimuth and Quinn noted, “eliminating health disparities requires that public health professionals expand their use of health communication strategies in comprehensive interventions aimed at affecting individual, community, organizational, and policy change” and “we must work collaboratively with communities of color to…create meaningful effective health communication interventions.”³¹ As the African American women in the Boston study noted when discussing the design of campaigns for HIV prevention in their community, “People want to feel like they’re a part of something, and people want to feel like they’re involved.” Campaigns should be developed with the input of those the message is intending to impact.

It is encouraging that the CDC has recently launched major national media campaigns, such as the “Greater Than” campaign, targeting African Americans with HIV testing messages.³² On World AIDS Day 2010 as we reflect on the toll AIDS has had on many neighborhoods in the world, and on the successes of antiretroviral therapy and evidence- and community- based prevention programs, we must be mindful that our fight is not over. Every 9½ minutes, someone in the U.S. is infected with HIV.³³ We must engage African Americans, healthcare providers, and public health leaders to continue to develop innovative methods to address barriers to HIV testing in the African American community. Effectively promoting HIV testing may turn the tide in this epidemic.