Combating HIV by ZIP Code

HIV rates in some urban American neighborhoods rival those of Haiti and Ethiopia, according to a researcher at Brown University in Providence, R.I.

And while affected communities include big-city gay enclaves, such as New York’s Chelsea district, minority neighborhoods in the Bronx and Harlem make the list, too. The difference is that those in mostly white neighborhoods are more likely to be tested and treated than those in minority neighborhoods.They are also less likely to die of AIDS.

In an era of Internet targeting, Dr. Amy Nunn’s approach of going door-to-door if necessary to reach people with HIV may seem old-fashioned. But in areas with limited access to health care, employment, and education, HIV experts agree that a new model is needed to reach at-risk groups of black and Hispanic Americans.

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Of the 50,000 new HIV infections in the U.S. in 2010, gay and bisexual men accounted for two-thirds of them, according to the U.S. Centers for Disease Control and Prevention (CDC). Black men and women are eight times more likely to become infected than whites, based on population size. Of all groups, white men who had sex with men comprised the largest segment of new infections, at 11,200. Black men who had sex with men were second, with 10,600 new infections.

Dr. Nunn, an assistant professor of medicine at Brown, told Healthline that more money must be targeted toward poor and minority neighborhoods. “If this were happening to white people there would be protests," she said. "It’s so easy to overlook poor people.”

Of the more than 1.1 million people in the U.S. living with HIV, almost 16 percent don’t know they have it, according to the CDC. Powerful antiretroviral medications available to most everyone in the U.S. can suppress viral loads to the point that transmission is unlikely. But they will only work if they are taken regularly.

“We’ve got to get these people into treatment come hell or high water,” Nunn said.

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Cultural Considerations a Must

In a commentary published in the May edition of the American Journal of Public Health, Nunn calls for engaging neighborhood stakeholders to create culture-specific solutions. Overcoming the disease’s stigma, which can be even more pervasive in minority communities, and getting people tested and treated is job number one, she said.

She hopes to broadcast pro-testing messages from respected neighborhood leaders and even enlist the help of church pastors. And by making HIV tests available to everyone, block by block if necessary, her idea is to target HIV where it is most highly concentrated.

It’s a method that has already been proven effective.

In her commentary, Nunn describes the results of the sort of outreach she proposes. An effort called The Bronx Knows has targeted the community with the highest HIV-related death rate in New York City.

The campaign saw 75 groups band together in 2007, with financial support from the city health department. Administering some 607,000 HIV tests over three years, they identified over 4,820 positive results. More than 1,700 of the people who tested positive said they did not previously know about their infection. The New York City Department of Health and Mental Hygiene has since replicated the program in Brooklyn.

Putting Money Where It’s Needed Most

Nunn’s work comes in the wake of the CDC's pledge to put $64 million toward HIV outreach programs that promise to be high-impact, she said. The new strategy focuses on targeted groups instead of region-wide funding. Twelve U.S. cities comprise 44 percent of the nation’s AIDS cases, including New York City, Los Angeles, Houston, Philadelphia, San Francisco, Baltimore, Atlanta, Miami/Fort Lauderdale and Washington, D.C.

The southern U.S. is also seeing rising infection rates, both in rural areas as well as in cities like Memphis, Tenn. and Jackson, Miss., Nunn said. In all of these places, stigma and a lack of testing and discussion about HIV appear to be driving up infection rates, many HIV prevention specialists have noted. Access to care can also be a problem in rural areas.

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Nunn said that the stigma associated with homosexuality further complicates outreach efforts in minority communities. But she has had success working with traditionally conservative clergy members, whom she calls “the backbone of the black community.”

“I’ve never had a black pastor say ‘no’ to me,” she said. “It’s how we approach it. You say, ‘I need your help getting a message to your congregation,’ rather than saying, ‘I want you to hand out condoms at church’.”

Kyle Murphy, director of outreach and public affairs at the Washington, D.C.-based National Minority AIDS Council (NMAC), called Nunn’s work “ambitious” and “just what we need.” At the same time, such a project would require “a massive shift in the allocation of current HIV funding or a new injection of resources, neither of which seem likely,” he told Healthline.

He also noted an “overlap” between communities for gay men of color. Those who live in “the same impoverished communities as their heterosexual counterparts” also intersect with the gay, white community. He suggested that targeting that overlap may be an area for further research.

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