Contributions of Community-Based Organizations Funded by the Centers for Disease Control and Prevention's HIV Testing Program.

CONTEXT: HIV testing is a critically important first step in preventing and reducing HIV transmission. Community-based organizations (CBOs) are uniquely positioned to provide HIV testing and other prevention services to populations disproportionately affected by HIV infection. OBJECTIVE: The purpose of this analysis was to assess CDC-funded health department (HD) and CBO testing programs during 2012-2017, including the number of tests and HIV positivity. DESIGN: This is an analysis of National HIV Prevention Program Monitoring and Evaluation HIV testing data submitted between 2012 and 2017 to CDC. SETTING: Sixty-one CDC-funded state and local HDs in the United States, Puerto Rico, and the US Virgin Islands and between 122 and 175 CDC-funded CBOs, depending on the year. PARTICIPANTS: Persons who received HIV testing at CDC-funded CBOs and HDs. MAIN OUTCOME MEASURE: The number of HIV tests and positivity at CBOs were compared with HDs overall and to HDs in non-health care settings that, like CBOs, include HIV risk data and are in similar locations. RESULTS: CBOs accounted for 7625 (8%) new diagnoses but conducted only 3% of the almost 19 million CDC-funded HIV tests from 2012 to 2017. Newly diagnosed HIV positivity at CBOs (1.4%) was nearly 3 times the new positivity at HDs overall (0.5%) and twice that of new positivity at HDs in non-health care settings (0.7%). A higher proportion of tests at CBOs were conducted among groups at risk, and new HIV positivity was higher for most demographic and population groups than new HIV positivity at HDs in non-health care settings. CONCLUSION: These findings demonstrate the essential role CDC-funded CBOs have in reaching, testing, and diagnosing groups at high risk for acquiring HIV infection.

CDC's Community-Based Organization Behavioral Outcomes Project: Perspectives for Researchers, Implementers and Funders.

Behavioral interventions have been a crucial tool for the prevention of HIV transmission since early in the epidemic. The Centers for Disease Control and Prevention (CDC) has provided funding for evidence-based behavioral interventions (EBIs) at health departments and community-based organizations (CBOs) since 2004. From 2006 to 2015, CDC funded 25 CBOs to evaluate one or more of seven EBIs designed to prevent HIV through the Community-based Organization Behavioral Outcomes Project (CBOP) as implemented outside of a research setting. For each EBI, CBOP showed that most HIV risk behaviors improved after the intervention, and improvements were similar to those observed in research studies. Our findings show that behavioral interventions can be successfully implemented in real-world settings. Although the focus of HIV prevention has largely shifted toward biomedical interventions in recent years, successful implementation often depends on behavioral components. Lessons from CBOP can inform future efforts to develop and implement behavioral interventions for HIV and other areas of public health.

Evaluation of an HIV prevention intervention for women living with HIV.

It is estimated that 23% of the adults and adolescents living with HIV in the United States are female. The Division of HIV/AIDS Prevention at the Centers for Disease Control and Prevention (CDC) funds evidence-based interventions (EBIs) to reduce HIV risk behaviors, including HIV prevention programs for people living with HIV and their partners. While EBIs have been shown to be effective in controlled research environments, there are limited data on intervention implementation in real-world settings. Women Involved in Life Learning from Other Women (WILLOW) is a four-session small-group intervention that targets heterosexual women aged 18-50 who are living with HIV. This evaluation assessed changes in participants' HIV knowledge, attitudes, beliefs and risk behaviors. A repeated measures design was used to collect participant risk behaviors at baseline, and again at three and six months post-intervention. Changes in attitudes, beliefs, and risk behaviors were assessed using generalized estimating equations. After participation in WILLOW, participants reported increased HIV knowledge, attitudes and beliefs, being more supportive of condom use, and reduced prevalence of HIV risk behaviors. Findings suggest that the WILLOW intervention can be successfully delivered by community-based organizations to reduce HIV risk behaviors among members of this high-risk population.

HIV Diagnoses Through Partner Services in the United States in 2019 and Opportunities for Improvement.

HIV partner services (HIV PS) is an effective strategy for diagnosing HIV infection. Sex/needle-sharing partners of individuals diagnosed with HIV are notified about potential exposure and offered HIV testing and other services. We assessed the HIV PS contribution to HIV diagnoses in the United States and assessed priority areas for improvements. National HIV Monitoring and Evaluation Partner Services and case surveillance data reported to the Centers for Disease Control and Prevention for 2019 were used for this analysis. The percentage of all new diagnoses that HIV PS programs reported is described nationally and by state. Linkage to HIV medical care among newly diagnosed partners is described. Potential increases in diagnosing HIV infection are assessed by HIV PS step to identify priority areas for improvement. HIV PS contributed 1214 of 35,164 (3.5%) of all diagnoses nationally in 2019, and contributions ranged from 0% to 31.8% by state. Of partners tested with nonmissing data, 22.7% were newly diagnosed. An estimated 1692 new partner diagnoses were lost during HIV PS steps. Steps resulting in the highest losses included index patients not being interviewed, partners not being tested for HIV, and index patients not being located. Seventy-two percent of partners newly diagnosed with HIV were linked to HIV medical care. HIV PS is an effective strategy for diagnosing HIV, and a high percent of sex/needle-sharing partners was newly diagnosed with HIV. Expanded HIV PS in some states and targeted improvements in HIV PS steps can enhance the contribution of HIV PS toward achieving national goals.

Anti-retroviral Status and HIV Transmission Risk Behaviors are Associated with Age, Time Since Diagnosis, and Psychosocial Factors Among Women Living with HIV/AIDS Enrolling in the WILLOW Intervention at Community-Based Organizations.

Safe sexual behaviors and anti-retroviral use help prevent HIV transmission. In this cross-sectional study, we assessed correlates of anti-retroviral (ART) status and transmission risk (a constructed variable) among a convenience sample of n = 1041 HIV-positive women (pre-intervention) enrolled in an evidence-based intervention at four CBOs. Multinomial logistic regression models were used. Younger women and those diagnosed with HIV in the last 5 years more often reported that they had not been prescribed ART. Self-reported non-adherence to ART was less frequently reported among women who were older, had a higher HIV knowledge, and those with attitudes/beliefs supportive of condom use. The highest-risk transmission group (condomless sex with HIV-negative/unknown partner and not prescribed or non-adherent to ART) was associated with younger age, attitudes/beliefs less supportive of condom use, and low self-efficacy discussing condom use. Our findings inform HIV prevention efforts among similar populations of HIV-positive women enrolled in interventions at CBOs.

Reduced Sexual Risk Behaviors Among Young Men of Color Who Have Sex with Men: Findings from the Community-Based Organization Behavioral Outcomes of Many Men, Many Voices (CBOP-3MV) Project.

In 2006, the Centers for Disease Control and Prevention (CDC) funded community-based organizations (CBOs) to deliver Many Men, Many Voices (3MV) to young men of color who have sex with men. Although 3MV, a group-level behavioral intervention designed to reduce human immunodeficiency virus (HIV) risk behaviors of black men who have sex with men (MSM), has shown effectiveness when delivered in a controlled research environment, there is limited evidence that the intervention is associated with similar outcomes in "real world" settings. For the current project, CDC funded three CBOs to conduct outcome monitoring of the 3MV intervention to determine if young MSM of color report changes in HIV risk behaviors postintervention. Using a repeated measures design, risk behaviors were collected at baseline and again at 3 and 6 months postintervention. Changes in risk behaviors were assessed using generalized estimating equations. Participants (n = 337) reported decreases in sexual risk behaviors at both follow-up time points, such as sex without a condom, sex without a condom and multiple partners, and sex without a condom with serodiscordant or status unknown partners. Results suggest that 3MV may be an effective tool for reducing HIV risk behaviors in this critical target population.

Asian People Reached by the Centers for Disease Control and Prevention HIV Testing Program in the United States: HIV Testing, Linkage to HIV Medical Care, and Interview for Partner Services 2014-2020.

The purpose of this analysis is to describe HIV tests and associated outcomes for Asian people reached by the Centers for Disease Control and Prevention (CDC) HIV testing program. We analyzed CDC-funded HIV tests among Asian individuals in the United States, Puerto Rico, and the U.S. Virgin Islands (2014-2020). Of the 415,560 tests, the positivity of new diagnoses was higher among males (0.49%, aPR = 7.64) than females (0.06%), and in the West (0.42%, aPR = 1.15) than in the South (0.25%). In non-health care settings, positivity was highest among men who have sex with men (MSM; 0.87%) and transgender people (0.46%). Linkage to HIV medical care among Asian people was 87.5%, and 70.7% were interviewed for partner services. Our findings suggest that improvements are crucial, particularly for Asian MSM, in linkage to care and interview for partner services.

Adults Aged ≥50 Years Reached by the Centers for Disease Control and Prevention's HIV Testing Programs in the United States and US Dependent Areas, 2019.

OBJECTIVES: Older adults represent nearly half of people living with HIV in the United States. The objective of this analysis was to describe HIV testing, demographic characteristics, and risks of adults aged ≥50 years (older adults) reached in 2019 by HIV testing programs funded by the Centers for Disease Control and Prevention (CDC). METHODS: We collected data from 101 CDC-funded community-based organizations and 61 health departments. All funding recipients submitted deidentified program service data for 2019 through a secure online CDC-supported system. We used multivariable robust Poisson regression to assess the association between demographic and risk characteristics and the proportion of tests that resulted in a new diagnosis. We also assessed the proportion of people who received a positive test result, were linked to HIV medical care, and were interviewed for partner services. RESULTS: During 2019, among 2 452 507 CDC-funded HIV tests provided in the United States, 412 164 (16.8%) were provided to older adults. Among the 1059 (0.26% positivity) older adults with newly diagnosed HIV infection for whom we had data, 582 (68.4%) were linked to HIV medical care within 30 days of diagnosis and 494 (72.1%) were interviewed for partner services. Among the 2858 older adults with previously diagnosed HIV infection, 1321 (46.2%) reported not being in HIV medical care at the time of the test; of those with linkage data, 425 (49.9%) were linked to HIV medical care within 30 days of testing HIV positive. CONCLUSIONS: More rapid disease progression and higher morbidity and mortality rates among older adults suggest that services are needed to ensure early diagnosis, rapid linkage, and interview for partner services.

CDC-Funded HIV Testing and Linkage to HIV Medical Care Among American Indian and Alaska Native People in the United States, 2014-2020.

OBJECTIVE: An estimated 1 in 5 American Indian and Alaska Native (AI/AN) adults living with HIV are unaware of their status. We investigated HIV testing among AI/AN people receiving a Centers for Disease Control and Prevention (CDC)-funded test from 2014 through 2020. METHODS: We analyzed data on CDC-funded HIV tests reported by health departments and community-based organizations in the United States. We described the number of CDC-funded HIV tests, the percentage of people with newly and previously diagnosed HIV, and linkage to HIV medical care within 90 days of diagnosis. RESULTS: CDC-funded health departments and community-based organizations provided 99 227 HIV tests to AI/AN people during 2014-2020. Seven hundred thirty-five (0.7%) AI/AN people were diagnosed with HIV; 361 (0.4%) were newly diagnosed, 319 (0.3%) had a previous HIV diagnosis, and 55 (0.1%) had a previously unknown HIV status. Positivity for new diagnoses was highest among the following population groups tested in non-health care settings: men who had sex with men (MSM; n = 72, 1.2%), MSM who inject drugs (n = 12, 1.8%), and transgender people (n = 12, 1.5%). The percentage of linkage to HIV medical care was 80.6% for newly diagnosed people and 78.2% for previously diagnosed people. CONCLUSIONS: MSM AI/AN, including those who inject drugs, and transgender AI/AN may benefit from prioritized HIV testing. All AI/AN people with HIV, whether newly or previously diagnosed, should rapidly link to HIV medical care and receive support throughout the continuum of care. Our findings can inform which AI/AN population subgroups may benefit from enhanced HIV testing efforts and interventions.

Reduced sexual risk behaviors among people living with HIV: Results from the Healthy Relationships Outcome Monitoring Project.

In 2006, the Centers for Disease Control and Prevention funded seven community-based organizations (CBOs) to conduct outcome monitoring of Healthy Relationships. Healthy Relationships is an evidence-based behavioral intervention for people living with HIV. Demographic and sexual risk behaviors recalled by participants with a time referent of the past 90 days were collected over a 17-month project period using a repeated measures design. Data were collected at baseline, and at 3 and 6 months after the intervention. Generalized estimating equations were used to assess the changes in sexual risk behaviors after participation in Healthy Relationships. Our findings show that participants (n = 474) in the outcome monitoring project reported decreased sexual risk behaviors over time, such as fewer number of partners (RR = 0.55; 95% CI 0.41-0.73, P < 0.001) and any unprotected sex events (OR = 0.44; 95% CI 0.36-0.54, P < 0.001) at 6 months after the intervention. Additionally, this project demonstrates that CBOs can successfully collect and report longitudinal outcome monitoring data.

Provision of HIV counseling and testing services at five community-based organizations among young men of color who have sex with men.

In the context of monitoring and improving CDC-funded HIV prevention programs, we describe HIV tests and infections, provision of results, previous HIV tests, and risk behaviors for young (aged 13-29) men of color who have sex with men who received HIV tests at five community-based organizations. Of 1,723 tests provided, 2.1% were positive and 75.7% of positives were previously unaware of their infection. The highest positivity rate was among men aged 25-29 (4.7%). Thirty-four percent of tests were provided to men who were tested for the first time. Over half the tests (53.2%) were provided to men who reported sex with a person of unknown HIV status, and 34% to men who reported sex with an anonymous partner. Continued and more focused prevention efforts are needed to reach and test young men of color who have sex with men and to identify previously undiagnosed HIV infections among this target population.

Taxonomy for strengthening the identification of core elements for evidence-based behavioral interventions for HIV/AIDS prevention.

The concept of core elements was developed to denote characteristics of an intervention, such as activities or delivery methods, presumed to be responsible for the efficacy of evidence-based behavioral interventions (EBIs) for HIV/AIDS prevention. This paper describes the development of a taxonomy of core elements based on a literature review of theoretical approaches and characteristics of EBIs. Sixty-one categories of core elements were identified from the literature and grouped into three distinct domains: implementation, content and pedagogy. The taxonomy was tested by categorizing core elements from 20 HIV prevention EBIs disseminated by Centers for Disease Control and Prevention. Results indicated that core elements represented all three domains but several were difficult to operationalize due to vague language or the inclusion of numerous activities or constructs. A process is proposed to describe core elements in a method that overcomes some of these challenges. The taxonomy of core elements can be used to identify core elements of EBIs, strengthen the translation of EBIs from research to practice and guide future research seeking to identify essential core elements in prevention interventions.

Opening up their doors: perspectives on the involvement of the African American faith community in HIV prevention in four communities.

In 1998, the U.S. government launched the Minority AIDS Initiative (MAI) to address growing ethnic and racial disparities in HIV/AIDS cases. The CDC performed an evaluation of its MAI-funded programs, including an assessment of community stakeholders' perspective on the involvement of the faith community in HIV prevention. Individual interviews (N = 113) were conducted annually over 3 years in four communities. The majority of participants described a change in faith community's attitudes toward HIV and a rise in HIV-related activities conducted by faith-based organizations. Participants attributed changes to faith-based funding, acknowledgment by African American community leadership that HIV is a serious health issue, and faith leaders' desire to become more educated on HIV/AIDS. Participants reported conservative faith doctrine and stigma as barriers to faith community involvement. The findings suggest that although barriers remain, there is an increased willingness to address HIV/AIDS, and the faith community serves as a vital resource in HIV prevention.

Community-Based Organization Adaptations to the Changing HIV Prevention and Care Landscape in the Southern United States.

Community-based organizations (CBOs) provide HIV prevention services throughout the United States, including the South where HIV/AIDS burden is high. We assessed Southern CBO response to changes in the HIV prevention landscape, including the National HIV/AIDS Strategy, and the Centers for Disease Control and Prevention's (CDC's) High Impact Prevention. Both strategies aim to improve outcomes for people living with or at high risk for HIV. Inductive qualitative analysis of interviews and consultations with CBOs, capacity building assistance providers, and CDC staff revealed CBOs are building clinical service capacity and cross-agency partnerships to adapt, but face inadequate or reduced funding. A holistic approach to HIV prevention and care in the South is critical, where stigma and other socio-structural factors limit health care options for persons affected by HIV. Health care organizations may benefit by partnering with CBOs because CBOs have the skillsets and community rapport to effectively improve health outcomes of persons living with HIV.

HIV testing in nonhealthcare facilities among adolescent MSM.

OBJECTIVES: To describe the extent to which Centers for Disease Control and Prevention (CDC)-funded HIV testing in nonhealthcare facilities reaches adolescent MSM, identifies new HIV infections, and links those newly diagnosed to medical care. METHODS/DESIGN: We describe HIV testing, newly diagnosed positivity, and linkage to medical care for adolescent MSM who received a CDC-funded HIV test in a nonhealthcare facility in 2015. We assess outcomes by race/ethnicity, HIV-related risk behaviors, and US geographical region. RESULTS: Of the 703 890 CDC-funded HIV testing events conducted in nonhealthcare facilities in 2015, 6848 (0.9%) were provided to adolescent MSM aged 13-19 years. Among those tested, 1.8% were newly diagnosed with HIV, compared with 0.7% among total tests provided in nonhealthcare facilities regardless of age and sex. The odds of testing positive among black adolescent MSM were nearly four times that of white adolescent MSM in multivariable analysis (odds ratio = 3.97, P < 0.001). Among adolescent MSM newly diagnosed with HIV, 67% were linked to HIV medical care. Linkage was lower among black (59%) and Hispanic/Latino adolescent MSM (71%) compared with white adolescent MSM (88%). CONCLUSION: CDC-funded nonhealthcare facilities can reach and provide HIV tests to adolescent MSM and identify new HIV infections; however, given the low rate of HIV testing overall and high engagement in HIV-related risk behaviors, there are opportunities to increase access to HIV testing and linkage to care for HIV-positive adolescent MSM. Efforts are needed to identify and address the barriers that prevent black and Hispanic/Latino adolescent MSM from being linked to HIV medical care in a timely manner.

An Evaluation of Mpowerment on Individual-Level HIV Risk Behavior, Testing, and Psychosocial Factors Among Young MSM of Color: The Monitoring and Evaluation of MP (MEM) Project.

Young men who have sex with men (MSM) of color are at increased risk for HIV infection. Mpowerment (MP) is an intervention designed to reduce risky sexual behavior and increase HIV testing among young MSM ages 18-29. From 2009 to 2012, three community-based organizations with support from the U.S. Centers for Disease Control and Prevention evaluated MP among N = 298 participants. Following a repeated measures design, data from 3- and 6-month follow-ups were compared to baseline. HIV testing and self-efficacy for safer sex increased at both follow-up time points; self-acceptance as an MSM was higher at follow-up 2. Condomless anal/vaginal sex was lower at follow-up 1 only. Frequency of exchange of safer sex messages among gay/bisexual/transgender friends was lower at follow-up 1, but similar to baseline at follow-up 2. Exposure to MP was associated with improved perceived positive social norms about safer sex and safer sex messages among gay/bisexual/transgender friends.

Evaluation barriers and facilitators among community-based HIV prevention programs.

Funding agencies are using technical assistance to promote evaluation of their community-based HIV prevention programs. Using qualitative methods, we identified 11 factors that hinder and facilitate evaluation within community-based organizations (CBOs): staff perceptions, availability of funding, data collection, data validity, data utility, technical assistance, effects on services, effects on funding, staff skills, tools and technology, and expectations of the funding agency. Using these factors, we developed eight strategies to promote CBO evaluation. These strategies go beyond the traditional role of technical assistance and address the broader context within which CBOs evaluate their programs. Funding agencies and technical assistance providers can use these strategies to enhance CBO evaluation, which may result in more and better quality evaluations and, ultimately, improvements in the effectiveness of HIV prevention services.

The value of engaging stakeholders in planning and implementing evaluations.

Stakeholder participation in evaluation has surfaced as a major factor contributing to the effectiveness of HIV prevention programs. In recognition of the multiple benefits, the Centers for Disease Control and Prevention (CDC), has used a framework to involve stakeholders in the evaluation of its programs. This article describes the framework used by the CDC and provides examples of four studies that involved various stakeholders from health departments, community-based organizations, and community planning groups to national and regional organizations in designing and implementing evaluations that yielded results useful for program improvement. The participatory process involved stakeholders in each of the four phases of the framework: evaluation planning, implementation, development of action plans, and dissemination. Lessons learned include the importance of having a facilitator to coordinate activities and ongoing communication with those involved in the evaluation. Stakeholders shared that using the evaluation results for action planning was beneficial for improving their programs. Despite many challenges faced in the stakeholder evaluation process, most stakeholders agreed that many benefits grew out of the multiple perspectives presented and understanding of the service agencies.

Evaluation of a sexual health approach to prevent HIV among low income, urban, primarily African American women: results of a randomized controlled trial.

This randomized controlled trial evaluated an innovative culturally specific sexual health intervention-targeting, but not limited to, low-income African American women-in which HIV and sexually transmitted disease prevention strategies were combined with comprehensive sexuality education. The intervention was delivered and evaluated in community-based settings to 218 participants randomly assigned to treatment or a no-treatment control group. Participants were interviewed at pretest and 3 and 9 months after the intervention to assess changes in both sexuality and HIV risk variables. The intervention was effective in improving sexual anatomy knowledge at both 3- and 9-month follow-up. For a subset of women engaging in unprotected sex at pretest, the intervention group reported an increase in positive attitudes toward the female condom at 9-month follow-up. Reasons for the weak treatment effect are discussed in the context of challenges inherent in conducting community-based research with high-risk populations and sensitive topics. Recommendations are provided for improving sample attrition, statistical power, and response bias and for altering the intervention so as to strengthen its impact.

Technical assistance for the evaluation of community-based HIV prevention programs.

Funding agencies are using technical assistance (TA) to strengthen the evaluation capacity of community-based organizations (CBOs) engaged in HIV prevention efforts. The authors used qualitative methods to identify the types of evaluation TA needed by CBOs, to understand CBOs' past experiences with evaluation TA, and to elicit ideas for optimal delivery of evaluation TA. Assistance in developing evaluation tools and data analysis were the most commonly cited needs. Preferred TA providers were characterized as having practical expertise, accessibility, cultural competence, communication skills, and collaboration skills. Critical elements of an ideal TA system were adequate funding, program-specific TA, and extensive interaction between TA providers and CBO staff. Study data were used to generate a set of recommendations for health educators and others who may provide CBOs with TA for evaluating prevention programs.