Meeting Minutes - October 24, 2007

Office of AIDS Research Advisory Council 
Twenty-Fifth Meeting
October 24, 2007 
National Institutes of Health
U.S. Department of Health and Human Services
5635 Fishers Lane Conference Center
Rockville, MD

Members Present: Dr. James W. Curran (Chair), Dr. Arlene D. Bardeguez, Dr. William A. Blattner, Dr. Coleen K. Cunningham, Dr. Sharon E. Frey, Dr. Betsy C. Herold, Dr. John H. Kempen, Dr. Kurt Organista, Dr. Michael S. Saag, Dr. Michael F. Summers, and Dr. Paul Volberding
Ex Officio Members Present: Dr. John G. Bartlett, Dr. Moon Shao-Chuang Chen, Jr., Dr. Carl W. Dieffenbach, Dr. Kevin Fenton, Dr. Jeffrey A. Kelly, Dr. Ellie E. Schoenbaum, and Dr. Ronald O. Valdiserri
Speakers: Dr. Adaora Adimora, Dr. John Bartlett, Dr. Hector Carrillo, Dr. Kevin Fenton, Dr. Robert Fullilove, Dr. Cynthia Gomez, Dr. Bronwen Lichtenstein, Dr. Bret Rudy, Dr. Irene Vernon, Dr. Leo Wilton, Dr. Gina Wingood, and Dr. Frank Wong

Welcome and Meeting Overview

The NIH Office of AIDS Research Advisory Council (OARAC) convened its twenty-fifth meeting at 9 a.m. at the National Institutes of Health (NIH) in Rockville, Maryland. Dr. James W. Curran, Chair, welcomed the OARAC members, invited speakers, and guests to the meeting.
The topic of the meeting was “The Prevention Research Challenges of HIV Infection in Racial and Ethnic Communities in the United States.” During the meeting, invited speakers discussed studies and research needs regarding HIV prevention in diverse populations, and the OARAC members had the opportunity to ask questions and recommend directions for future research.
The minutes of the April 19, 2007, OARAC meeting were approved as submitted. The OARAC members were asked to read and sign the conflict of interest form.

Director’s Report

Dr. Jack Whitescarver, Director of the NIH Office of AIDS Research, announced that Dr. Curran was appointed as Chair of the Council by the Secretary of HHS, and he welcomed three new OARAC members: Dr. Paul Volberding of the University of California, San Francisco, and San Francisco Veterans Affairs Medical Center; Dr. Betsy Herold of Albert Einstein College of Medicine and Yeshiva University; and Ms. Dawn Averitt Bridge of the Well Project, an organization that provides health information to HIV-infected women. He also announced the appointment of two new OAR staff members, Dr. Karin Lohman and Dr. Stacy Carrington-Lawrence. Dr. Mary Fanning of the National Institute of Allergy and Infectious Diseases (NIAID) has completed her detail with OAR. He also noted that members of the Prevention Science Working Group (PSWG), including Drs. Judy Auerbach, Tom Coates, Seth Kalichman, Judith Levy, and Ligia Peralta, and Mr. Jesse Milan, were participating in the OARAC meeting. The PSWG provides advice and guidance to the OAR Director on the prevention research agenda.
Dr. Whitescarver reported that the Senate had passed the fiscal year (FY) 2008 Departments of Labor, Health and Human Services, and Education, and Related Agencies Appropriations bill, which funds the NIH. The President’s budget had requested a 1 percent decrease below the FY 2007 level. The House of Representatives requested a 2.7 percent increase over the FY 2007 budget level, and the Senate now has requested a 3.5 percent increase. However, the White House has already announced that the President would veto the appropriations bill as currently proposed by Congress. The bill will now go to a Conference Committee to work out the final bill to the President. Until then, NIH is still operating under a Continuing Resolution at the FY 2007 level. Even at the higher Senate-proposed level, funding for NIH would not keep up with inflation. Since FY 2003, which was the end of the 5-year Congressional commitment to double the NIH budget, NIH has experienced a 15 percent loss in buying power. Dr. Whitescarver stated that these funding constraints mean that any new initiatives can only be funded at the expense of existing programs.

The OAR Advisory Council has played a critical role in helping OAR establish priorities for funding, and today’s meeting is particularly important. With the Council’s support, three years ago OAR established HIV prevention as the highest overall priority, including the areas of vaccines, microbicides, and behavioral interventions. To further refine OAR priorities within each of those areas, the current profile of the epidemic in the United States must be considered. As the FY 2009 OAR planning and budget development processes proceed, they must take into account the most current research needs to address HIV prevention in racial and ethnic populations in the United States, and determine those areas that require additional attention and trans-NIH collaboration.

Dr. Victoria Cargill, OAR, outlined the OARAC meeting agenda and described the impetus for focusing on prevention research challenges of HIV infection in U.S. racial and ethnic communities. She stated that more than 25 years since the epidemic began, many scientific challenges remain, as well as the persistence of complex socio-economic and structural barriers in racial and ethnic populations. Racial and ethnic populations in the United States are disproportionately affected by HIV/AIDS, and the epidemic reflects profound challenges, including weakening social structures within these populations and persistent racism, homophobia, disenfranchisement, social injustice, and inequality. Despite advances in treatment that have resulted in increased life expectancy and increased quality of life for those with access to treatment, disparities in access to care and treatment exist. She noted that the role of the meeting today is to focus on prevention interventions, as well as novel strategies and methodologies that are more culturally and contextually relevant to the sociocultural nuances of these populations, and to identify possible new scientific gaps and opportunities. She stated that the agenda was designed to stimulate reflection and discussion of these prevention challenges in communities most disproportionately affected by HIV infection in our country.

Update on OARAC Working Groups for Treatment and Prevention Guidelines

Dr. John Bartlett, Johns Hopkins University and Co-chair of the Working Group on Clinical Practices for the Treatment of HIV, summarized the recent activities of the five OARAC Working Groups for Treatment and Prevention Guidelines. Three of the Working Groups develop guidelines for the use of antiretroviral treatment: for adults and adolescents; for pediatric infection; and for prevention of mother-to-child transmission. Two of the working groups develop guidelines for the prevention and treatment of opportunistic infections (OI). The guidelines, which will all be reviewed by early 2008, are developed for providers and HIV-infected individuals in the United States, although several other countries, including Australia and Russia, have adopted the U.S. guidelines as their standards of care. Dr. Bartlett acknowledged the Working Group co-chairs and noted that more than 250 representatives from the Federal government, academic and medical centers, and community constituency groups serve on the Working Groups. 
Dr. Bartlett explained that the OI Working Groups address both treatment and prevention, including guidance for the clinical management of tuberculosis co-infection, human papillomavirus infection, and several tropical diseases. He presented the OI guidelines revision timeline, stating that the revised documents will be published in Morbidity and Mortality Weekly Report (MMWR) in mid-2008.
Dr. Bartlett noted several of the topics being addressed by the Working Groups on antiretroviral treatment for adults and adolescents, pediatric infections, and prevention of mother-to-child transmission. The adults and adolescents Working Group currently is considering when to initiate therapy, the management of treatment experienced patients, and several assays for drug sensitivity and resistance. The pediatric guidelines Working Group is reviewing the current guidelines to reflect drug toxicities, pain management, and the role of nutrition. The prevention of mother-to-child transmission Working Group is considering the applicability of results from several international studies, including treatment of co-infections in pregnant women.
The treatment guidelines are available on the HIVinfo website (https://hivinfo.nih.gov/home-page). Dr. Bartlett noted several recent improvements to the site, as well as upgrades that will link the guidelines to referenced literature.

Epidemiology of HIV Infection Among Racial and Ethnic Communities—A Call for Action

HIV Epidemiology and Trajectory in Racial and Ethnic Communities

Dr. Kevin Fenton, Director, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention (CDC), discussed determinants of sexually transmitted infections (STIs), the epidemiology of the U.S. HIV/AIDS epidemic, and the epidemic within the U.S. African-American and Hispanic populations. He described a multi-level approach for understanding STI epidemic trajectories, noting that risk behaviors occur in the context of sexual partnerships that can take different forms that vary across groups. Partnerships, in turn, exist in the context of sexual networks, which are embedded in communities and subpopulations that influence individual behaviors. He noted that while general population determinants of STI transmission are well-documented, sociocultural, economic, and cultural factors also play a role in transmission and influence the current burden and future trajectory of STIs.

Dr. Fenton reported that the number of HIV-infected individuals in the United States in 2005 was estimated to be between 1 and 1.2 million. Approximately 25 percent of that number is unaware of their HIV infection. He noted that the burden of the disease is very high in the African-American population. In the 33 states reporting HIV/AIDS data in 2005, 49 percent of the HIV/AIDS cases were in blacks, while blacks represent only 13 percent of the total population. There also is significant heterogeneity by sex and race, with a high prevalence of HIV/AIDS cases in black males, black females, and Hispanic males.

Among men in the United States, sexual transmission remains the predominant mode of transmission across racial and ethnic groups. The majority of these cases result from male-to-male sexual contact, not injection drug use (IDU). Dr. Fenton commented that there also are high rates of unrecognized HIV infection in men who have sex with men (MSM). Among adult and adolescent females, most infections are related to sexual transmission, although substantial numbers are infected through IDU.

Dr. Fenton stated that AIDS death rates have stabilized in the United States, but the rates vary by gender, race/ethnicity, and social variables (e.g., high school education). He noted that there is a severe burden of AIDS cases in the southern United States, particularly among black and Hispanic adults. In 2005, among nearly 1 million reported AIDS cases, blacks and Hispanics accounted for 40 percent and 19 percent, respectively, and the rate is rising more rapidly among blacks than other groups.

Dr. Fenton summarized that the HIV/AIDS epidemic in the United States continues to evolve and is marked by geographic heterogeneity and a disproportionate burden among racial and ethnic populations. He noted that the future trajectory of HIV/AIDS among African Americans will depend on demographic trends; disease prevalence and incidence; patterns of risk behaviors and sexual mixing; and the targeting and scale-up of effective interventions.

OARAC members noted that surveillance is critical to ensure accurate reporting of the evolving nature of the U.S. epidemic. They underscored the importance of using this information to target appropriate prevention programs in at risk populations.

Prevention of HIV Infection Among African-American MSM

Dr. Leo Wilton, State University of New York at Binghamton, described a meta-analysis published in 2007 that showed black MSM demonstrate comparable or lower rates of unprotected anal intercourse and fewer sexual partners than those of MSM of other racial/ethnic backgrounds. He stated that black MSM are less likely than white MSM to use highly active antiretroviral therapy and are seven times more likely to be unaware they are HIV-infected.

Dr. Wilton suggested that risk correlates, including biomedical and sociocultural factors, that contribute to the high prevalence of HIV/AIDS in black MSM should be studied more intensively. He commented that this research should utilize a variety of innovative, interdisciplinary quantitative and qualitative methodologies, and should be structured around culturally appropriate and culturally relevant theoretical frameworks.

Dr. Wilton also discussed the need for effective HIV prevention interventions for black MSM and commented that some interventions are being developed without adequate knowledge of the black MSM population. He called for the evaluation of HIV prevention intervention models for black MSM and the development of interventions that address the synergy among structural, community, and group-level constructs. He also noted that additional research is needed to better understand the impact of homophobia, stigma, incarceration, transgender identity and experience, violence, and STIs on black MSM.

Dr. Wilton proposed that research on black MSM at risk for HIV/AIDS be funded by multiple sources and conducted in partnership with black MSM organizations and individuals. He further proposed that: the research capacity of academic and non-academic black MSM be increased; research partnerships between academia and community-based organizations serving black MSM be encouraged; and existing strategies be evaluated and effective programs implemented in this population.

Prevention of HIV Infection Among Latino MSM

Dr. Hector Carrillo, San Francisco State University, discussed HIV infection in Latino MSM. He stated that half of the HIV/AIDS cases in Latinos are in MSM, underscoring the need to provide effective HIV prevention programs to this population. He commented that programs targeting Latino MSM address individual cognitive factors and personal skills based almost exclusively on theories of individual behavior. At the group or community level, the programs focus mainly on altering community norms or fostering peer/social support. In addressing the mediators of HIV risk, Dr. Carrillo noted that an emphasis has been placed on knowledge, cognition, emotional states, social influence and support, skills building, and service utilization, with little emphasis on other sexual and social factors.
Dr. Carrillo stated that existing research shows that while most urban Latino MSM are well-informed about HIV transmission and prevention and have the necessary HIV protection skills, others in this population continue to be at risk for HIV acquisition.

He briefly described the NIH-funded Trayectos Study on the social context and HIV risk behaviors among Latino MSM and bisexual men and their partners. He also described the Ethnographic Study of Migrants’ Sexuality and Sexual Health, a study on migrant history and the range of sexual behaviors and HIV risk at different points in migration. That study showed that immigrants who are MSM with diverse experiences in Mexico led to different kinds of sexual behaviors and HIV risk after migrating to the United States. The study also demonstrated that cultural differences exist between the immigrant Latino men and U.S. born Latino men.

Dr. Carrillo proposed that immediate research goals to address the needs of Latino MSM should include generating increased awareness of relational dynamics, identities, and roles that may complicate protection and strategies that can work. He also suggested that long-term research goals should include promoting structural changes related to reducing homophobia and its effects on HIV risk, confronting racial discrimination, improving socioeconomic status, and reducing health disparities.

Prevention of HIV Infection Among Asian MSM

Dr. Frank Wong, Georgetown University, presented data on the Asian and Pacific Islander (API) population in the United States, which is one of the fastest growing ethnic minority populations in this country. He noted that data on HIV/AIDS in the API population are limited. Since many of the studies were conducted in San Francisco, the findings may not be generalizable across API subgroups throughout the United States. He commented that most API are foreign-born and more than half of them live in New York, California, and Hawaii. He stated that approximately 1 percent of API are HIV-infected, with 61 percent of those cases in MSM. Studies of risk behaviors show that API MSM are as likely as other MSM to engage in high-risk behaviors, but API MSM are significantly less likely than others to report having been tested for HIV. He suggested that these low testing rates mean that many API MSM are unaware of their serostatus and therefore place their partners at risk. Dr. Wong described several HIV prevention challenges that have been identified through projects such as the D.C. Men of Asia Prevention Study (MAPS), including socio-cultural norms, stigma, and the migration experience. Dr. Wong also presented data on HIV risk perception and differential risk based on the race of an MSM’s partner. For example, API MSM report the highest rate of unprotected anal intercourse, surpassing that of white MSM. He also stated that regardless of an individual’s race, having an API partner has been associated with increased likelihood of high-risk sexual behaviors.

Dr. Wong discussed issues related to HIV transmission across the U.S.-Asia “air bridge” (e.g., travel between the United States and Asia). He reported that between 2003 and 2006, there was a 23 percent increase in the number of Asian travelers to the United States, and between 2003 and 2005 there was a 17 percent increase in the prevalence of AIDS in Asia. He noted that these data underscore the need for HIV surveillance among APIs in the United States.

Dr. Wong also described HIV intervention research in API. He suggested early HIV testing as a way to engage API in prevention interventions, API be considered members of distinct populations, and small-population methodologies be considered to capture the extent and nature of the AIDS epidemic among API in this country.

Prevention of HIV Infection Among Native Americans

Dr. Irene Vernon, Colorado State University, opened her presentation by stressing the importance of understanding differences among Native Americans, a population that comprises more than 560 federally recognized tribes totaling 2.4 million individuals who classify themselves as American Indian/Alaska Native (AI/AN). She noted that an additional 1.9 million individuals classify themselves as AI/AN but are not part of those tribes. All of these subpopulations have different languages, customs, beliefs, concepts of illness and wellness, and strategies to deal with health issues.

Dr. Vernon commented that AI/AN represent less than 1 percent of the reported AIDS cases and less than 1 percent of the U.S. population, yet they are at high risk for acquiring HIV infection, with an estimated rate of 10.4 cases per 100,000. These numbers suggest that there is a limited problem with HIV/AIDS in AI/AN communities, making it difficult to receive funding for programs to monitor health status and to prioritize tribes’ funding streams. However, she noted that healthcare professionals working in AI/AN communities believe that the reported numbers are not fully indicative of the epidemic in this population due to jurisdictional and bureaucratic complexities. She also observed that many AI/AN choose not to be tested for HIV because of confidentiality issues and mistrust in their close-knit communities.

Dr. Vernon described several biological, economic, social, and behavioral factors that place AI/AN individuals at risk of HIV, including high rates of STIs, alcoholism, substance abuse, as well as poverty, discrimination, homophobia, stigma, denial, and mistrust of the medical system.

The CDC requires AI/AN community-based organizations to use Diffusion of Effective Behavioral Interventions (DEBIs). Dr. Vernon proposed the use of the Community Readiness Model for community mobilization and change. This model incorporates an assessment of a community’s stage of readiness so that an action plan is tailored to the community. She stated that most AI/AN communities are at the denial/resistance stage about the AIDS epidemic.

Dr. Vernon outlined many of the challenges to HIV/AIDS prevention programs in AI/AN communities, including: the complex health care system, inadequate funding, reluctance to discuss sexuality, challenges in garnering tribal leadership, complacency and denial about risk, insufficient tribal resources, lack of cultural competency, social issues such as racism and homophobia, and competing health priorities (e.g., diabetes). She stated that increased funding is needed to support research to: evaluate the effectiveness of HIV/AIDS prevention interventions in the AI/AN population; report data for small population samples; conduct tribe-specific studies; develop evidence-based practices; and study the impact of urban-rural migration, stigma, and the relationship between methamphetamine use and HIV/AIDS. She also described particular issues for AI/AN women. 
Several OARAC members commented that HIV prevention may not be a high priority for many groups at substantial risk for HIV, and that more formative research and assessment is needed to better understand HIV prevention in the hierarchy of public health within the AI/AN and other populations.

Prevention of HIV Infection Among African-American Women

Dr. Adaora Adimora, University of North Carolina Chapel Hill, described some of the reasons why HIV infection rates are disproportionately high among African-American women; the impact of concurrent partnerships, incarceration, and poverty on HIV transmission rates; gaps in the current HIV prevention research approach; and the need for better interventions to prevent HIV transmission and acquisition among African Americans. She noted that individual behaviors are important in explaining the high rates of HIV infection among African-American women. Among young people with low-risk behaviors, the prevalence of HIV infection among blacks is 25 times that of whites. She cited a population-based case control study of risk factors that reported independent risk factors for having heterosexually transmitted HIV included smoking crack cocaine, having less than a high school education, and having a partner who injected drugs or smoked crack. She reported on other research studies that showed most African Americans with heterosexually-acquired HIV report high-risk behaviors, but more than one-fourth of them deny having had high-risk partners or behaviors.

Dr. Adimora stated that sexual network patterns are key factors in transmission of HIV. Concurrent sexual partnerships are significantly more common among African-American women than other women, and among women who are single and were at a young age at sexual début. She noted that concurrency permits more rapid spread of STIs throughout a population. She described two types of sexual mixing patterns: assortative mixing, which involves partnerships between individuals who are at similar risk for infection, and dissortative mixing, which involves partnerships among high- and low-risk individuals.

Dr. Adimora also discussed the social context of sexual relationships among rural African Americans that may promote transmission of STIs, including economic and racial oppression, a lack of community recreation opportunities, a shortage of black men, and widespread concurrency among unmarried individuals. She noted that among African Americans, contextual factors include the low sex ratio for women, racial segregation, and the high rate of male incarceration. Black men are 10 times more likely than white men to be incarcerated, and women whose partners were incarcerated are more likely to have concurrent sexual relationships.

Research needs identified by Dr. Adimora include: additional epidemiological studies to better understand risk factors and the implications for interventions; identification of effective HIV prevention interventions for African Americans, factors that place populations at risk of HIV, and the social determinants of HIV risk; consideration of policy and program interventions to address those determinants; studies on structural interventions to expand the public health research paradigm; multidisciplinary studies that critically evaluate underlying structural inequities; and evaluation of mechanisms to increase economic opportunities and decrease incarceration and its adverse impact.

Dr. Cynthia Gomez, University of California, San Francisco, stated that the HIV epidemic provides a study on how health disparities occur in the United States in that it began in a relatively wealthy white population and moved into populations of color and of low socioeconomic status. Dr. Gomez suggested that in discussing research and interventions related to HIV infection in Hispanic women, scientists should consider altering their views of “what a Latina woman is.” She noted that the 2000 Census showed that 13 percent of the overall U.S. population is Latino—a 58 percent increase over the number shown by the 1990 Census, during a time when the overall U.S. population grew by 13 percent. Among U.S. Latinos, 56 percent are of Mexican origin, 34 percent are younger than 18 years (with a median age of 27 years), 38 percent are not U.S. citizens, half live in California and Texas, and 88 percent live in 10 U.S. states and Puerto Rico. Nearly half of Latinos identify themselves as white. Among Latina women, who total 15 million in the United States, 47 percent are married, 62 percent are U.S. born, and 26 percent are not U.S. citizens.

Dr. Gomez stated that sex is a behavior governed by social rules that cut across race and ethnicity. In discussing sexuality and HIV infection, it is important to recognize the importance of belief-driven cultural myths about sex. She noted that for all women, knowledge is important and powerful; and women across groups confront violence, coercion, and economic challenges.

Dr. Gomez described an NIH-sponsored study examining the extent to which the intersection of socioculturally prescribed sexual gender norms and socioeconomic context are associated with sexual risk behaviors among African-American and Latina women. She concluded her presentation by emphasizing the need for researchers to consider the spectrum of Latina women who should be reached (e.g., immigrants, first-generation, and second-generation) and the need for innovative interventions to engage communities rather than only studying their sexual behaviors.

Prevention of HIV Infection Among Adolescents of Color

Dr. Bret Rudy, University of Pennsylvania, described adolescent development, risk, and the relationship between prevention research and diagnosis/linkage to care. He stated that African Americans ages 13 to 24 are disproportionately affected by HIV/AIDS. MSM transmission is driving HIV transmission in the adolescent population. During the period from 2001 to 2005, 77 percent of HIV/AIDS cases among males ages 13 to 19, and 75 percent of cases among males ages 20 to 24 years, resulted from MSM transmission. The CDC reported a decrease in HIV/AIDS cases in young women and an increase in young males from 1999 to 2003. He cited the NIH-sponsored National Longitudinal Study of Adolescent Health that showed the estimated prevalence of HIV among individuals ages 18 to 28 to be 1 per 1,000 overall, but 4.9 per 1,000 among non-Hispanic blacks.
Dr. Rudy stated that brain development is a dynamic process throughout adolescence and explained that adolescence is a unique part of life that can be divided into three stages with cognitive and development milestones. Early adolescents (ages 11 to 14) think very concretely and have little perception of consequences, but are interested in their changing bodies. Mid-adolescents (ages 15 to 17) can think abstractly, but revert to concrete thinking in times of stress. Those in late adolescence can think abstractly. He also discussed the importance of thinking about the stages of homosexual identity formation.

Dr. Rudy stated that biological factors also can increase risk. In women, these factors include cervical ectopy, concomitant STIs, trauma during intercourse, and douching leading to inflammation. In men these factors include concomitant STIs and trauma during intercourse. He noted that behavior does not always equal risk. He commented that community engagement and mobilization are key to prevention, and it is important to consider both risk reduction and how a community changes as a result of an intervention.

Dr. Rudy stated that more research is needed to address the needs of young MSM of color by enhancing our understanding of sexual and gender identity formation within the social/racial/community context, potential uses of technology-based interventions, interventions targeting young MSM, and community mobilization. For young women, there is a need for more research to better understand partner selection, as well as studies on interventions targeting young women before initiation of sex, potential uses of technology-based interventions, interventions targeting young women of color, and the influence of peer networks on sexual risk activities. 
The OARAC members discussed the need to initiate trials with participants who are younger than 16 years and issues related to parental consent. Members noted that parents of all racial and ethnic backgrounds will give consent if they believe that an intervention will protect their children. Council members also stated that it is important to make HIV prevention interventions available to healthcare service providers to test and refine them.

Stigma and Sexually Transmitted Diseases

Dr. Bronwen Lichtenstein, University of Alabama, stated that stigma is a form of social power and a means to control individuals and behaviors. Historically, stigma has created a cordon sanitaire during plagues and epidemics. She noted that stigma associated with STIs is based on stereotypes and involves discriminatory attitudes or actions, intersecting with race/ethnicity, gender, and poverty.

Dr. Lichtenstein commented that religiosity is a widespread value and an important part of culture and social interaction in Alabama. A community survey in that state found that, while HIV disease was initially considered a gay white men’s disease, women were the most stigmatized and their personal integrity was most threatened. She noted that women also are generally blamed for other STIs. She reported on a survey of college students in Alabama that found HIV/AIDS was the most stigmatized of STIs, but all STIs had high rates of stigma.
Dr. Lichtenstein presented findings from qualitative studies of stigma-related barriers to STI care including reluctance to go to a clinic, gender issues (i.e., dichotomies between genders), and contact tracing. She observed that small town environments prevent individuals from going to STD clinics. A study of Alabama college students found that stigma causes individuals to delay or refuse treatment and to avoid notifying partners.
Dr. Lichtenstein stated that there is evidence that shifts in blame for STIs have occurred during the HIV/AIDS epidemic and that community stigma affects funding, knowledge, programs, and treatment. She noted that African Americans experience multiple stigmas that are barriers to prevention and treatment. She also reported that individuals’ feelings about stigma result in avoidance, privacy concerns, refusal to disclose, and other actions that impede STI control.

Prevention of HIV Infection Among the Incarcerated

Dr. Robert Fullilove, Columbia University, described the issues and prevention research opportunities related to HIV and incarceration. The high rates of HIV infection among persons who are incarcerated and the relationship between race and incarceration are well-documented. He noted that between 40 and 45 percent of the incarcerated are African-American males, and one in three African-American males will spend time in jail in his lifetime. Dr. Fullilove noted the need for HIV testing of incarcerated individuals when they are first imprisoned, while they are incarcerated, and shortly before release.

Dr. Fullilove stated that opportunities potentially exist in jails and prisons to conduct HIV testing; provide treatment; and provide HIV prevention and other interventions. Prevention interventions at entry into incarceration could include HIV testing, provision of educational and job training opportunities to reduce recidivism, drug treatment, and HIV/AIDS education. Other prevention opportunities include improving parole and probation drug monitoring, provision of clinical and social services for those requiring treatment, and housing and employment opportunities to increase social stability upon release from prison.

Dr. Fullilove stated that the incarceration system drives social inequalities and structural interventions (e.g., to promote return to families and jobs) should be considered. These interventions could include: establishment of “drug courts” as alternatives to incarceration that could address multiple public health problems; investment in recidivism-prevention programs; reduction of barriers that prevent access to care upon release; and institutionalized pre-release planning and counseling for those who are HIV-infected. He suggested that structural intervention programs throughout the United States could be studied to identify model programs and best practices. Dr. Fullilove stated that there are unique opportunities to study interventions to prevent HIV infection among the incarcerated.

Prevention of HIV Infection in Racial and Ethnic Communities—Next Bold Steps

Dr. Gina Wingood, Emory University, described the current knowledge about HIV prevention in racial and ethnic communities and proposed next steps for addressing the HIV/AIDS epidemic in these populations. She stated that the field must shift from its focus from individual intervention theories toward the use of broader population-based, social-level theories and frameworks that address issues of communication, ecology, community participation, diffusion, economics, empowerment, gender and power, and resource mobilization. She noted that certain populations and settings should be priorities, including HIV-infected individuals in the acute stage of the disease; those with other STIs; men, women, and adolescents who are exiting prison; individuals living in areas characterized as HIV “hot spots”; and those residing in the rural South.

Dr. Wingood noted that African-American adolescents and adults are at increased risk for HIV infection compared with Caucasians, even when they engage in lower-risk individual-level behaviors. She emphasized that for this population, attention should be directed to population-level factors, including concurrent sexual partners, sexual networks, sexual mixing patterns, and STI prevalence. She suggested that emphasis also should be continued on injection drug use and other substance use (e.g., methamphetamine). She described several interventions that could be used to reduce HIV transmission in racial/ethnic minorities including: technological/new media interventions; dual-focused interventions to reduce HIV risk and poverty, violence, drugs, and stigma; network interventions to reduce HIV risk among core transmitters in a network; culturally acceptable family-level interventions; and combination biomedical and behavioral interventions.
Dr. Wingood also proposed novel methods that should be considered, including:

• community-based participatory research to design interventions for diverse ethnic and cultural minority populations;

• approaches to facilitate adaption of evidence-based interventions (EBIs) for diverse ethnic and cultural minority populations;

• translational research to better understand how to disseminate EBIs to agencies and public health departments;

• operations research to better understand how to facilitate the integration and institutionalization of EBIs into sustainable programs within institutions such as churches, prisons, and jails;

• health services research to better understand ways to enhance access to rapid STI/HIV testing, treatment, and care;

• cost-effectiveness research to better understand the trade-off of different types of interventions (e.g., multi-session versus brief); and

• multi-level/ecological research to impact two or more levels of influence to sustain the effects of HIV intervention.

Dr. Wingood proposed several steps that could be taken now, including: development of interventions that reduce population-level outcomes; targeting high-risk populations; and engaging in research that applies novel intervention methods. She also suggested refining the current infrastructure necessary to support and sustain the continuum of HIV prevention research with racial and ethnic minorities. This will require increased funding and allocation for targeting of funds through requests for applications (RFAs).

Discussion

The Council members discussed the importance of translating science into practice, and members recommended that agencies within the U.S. Department of Health and Human Services continue to work together to bring evidence-based prevention interventions to communities. Linking HIV testing, treatment, and prevention also is an important priority. Dr. Curran stated that with Federal government coordination, the states also may play a stronger role in linking HIV testing, treatment and care, and substance abuse treatment. The Council further recommended that NIH continue to invest in training of minority scientists and to consider research methodologies that go beyond the current methods, for more appropriate and effective HIV prevention research in different communities and populations.

Public Comments

Mr. Steven Wakefield recommended that the Council look for ways to accelerate HIV prevention research and to more effectively disseminate the research results to individuals in the communities so that model interventions and best practices can be implemented. He also suggested that representatives of the affected communities be invited to participate in OARAC meetings. 
Ms. Candy Ferry of the National AIDS Fund stated that foundations and other private-sector organizations can play an important role in bringing innovative, evidence-based HIV prevention programs into communities. She offered to help involve private funding organizations in translating research into practice.

Adjournment

Dr. Curran thanked the OAR staff for its role in planning the Council meeting.
Dr. Whitescarver thanked the speakers and the Council members for their thoughtful comments and noted their important innovative suggestions. He also noted that the Prevention Science Working Group would convene the following day to discuss priorities for NIH HIV prevention research. 
The meeting adjourned at 5:15 p.m. on October 24, 2007.

Signed:
/Jack Whitescarver, Ph.D./
Jack Whitescarver, Ph.D., Executive Secretary
/James W. Curran, M.D., M.P.H./
James W. Curran, M.D., M.P.H., Chair