Over the last decade, researchers, doctors and the life-sciences industry have made great strides in treating HIV. Medications once routinely delivered through complicated multidose cocktails are now, for some patients, available in a one-pill-a-day form. While adhering to even a once-daily regimen is still a challenge, significant progress on the treatment of HIV is undeniable.
On the prevention front, however, there’s still work to be done. Despite a significant public-education campaign on preventing HIV infection, the CDC reports that new infections in the United States have remained more or less stable at an estimated 50,000 new cases each year for the past decade.
As a recent front-page New York Times article brought into sharp and disturbing focus, one group seemingly impervious to prevention efforts is poor young men under age 29 who have sex with men (YMSM). The particular subgroup of black and Latino YMSM has actually seen an increase in new infections for the past several years. According to the CDC, among YMSM under age 25 who contract HIV nationally, an alarmingly high 78 percent are black and Latino/Hispanic. As healthcare providers and public health institutions, we clearly need to do better at reaching this group.
Why are HIV rates so high?
Many studies — including our own recent research findings — show that among young black and Latino YMSM in New York City, the frequency of individual risk behaviors is the same as, if not lower than, that of those engaged in by white and older MSM: condom use is the same if not higher compared to whites, substance use is at similar or lower levels and this group may have fewer sex partners than nonblacks. Additionally, rates of condom use are much higher among MSM who are not in relationships compared with their heterosexual peers who aren’t in relationships. So what’s going on, if individual-level behaviors (traditionally associated with HIV infection) do not explain why the epidemic is disproportionately affecting these communities in New York City and the United States?
Several hypotheses exist, but as with most things in medicine and public health, the causes are multifactorial and dynamic. Multiple co-occurring public health problems—including poor mental health, violence and victimization, discrimination and homophobia, racism, substance use, unemployment and homelessness (collectively referred to as the social determinants of health) — produce complex and dynamic interactions leading to increased vulnerability to HIV and poor health for different populations. While safer-sex counseling and HIV-testing programs are essential elements for HIV prevention and treatment interventions, programs that focus solely on these elements (at the individual level) and fail take into account the social determinants that strongly influence such behaviors have not worked well enough to reduce the rate of HIV infection.
Finding root causes for HIV infection in high-risk populations
What’s needed is a paradigm shift in how we conceptualize health issues. We need to think more broadly about root causes and then redesign how health interventions are delivered. This applies not only to HIV but also to many other diseases, including obesity, diabetes and conditions with a similarly strong behavioral component.
In addition to designing relevant outreach efforts, one major challenge is effectively reaching gay, bisexual and other MSM with outreach messages and health interventions. While many in this group are increasingly “out” and aware of HIV-prevention behaviors, others, especially those in minority groups, are “hidden,” largely because they don’t identify with gay/bi/transsexual labels or they might not be reached by the medical and public health communities.
The promising role of social media in preventing HIV
Advances in social networking offer a new route to engage YMSM. Social-media sites such as Facebook, Twitter and Tumblr, and online dating and other mobile phone–based applications, allow us an unprecedented opportunity to reach and engage with traditionally hard-to-reach populations.
According to the Pew Internet and American Life Project, 90 percent of 18- to 29-year-olds in the U.S. use social media. Our own study of young LGBT people, primarily black and Latino, in the Bronx found nearly universal and frequent use of social media — even among the 18 percent who reported being homeless in the past several months. This led to a feasibility trial of a social media–based intervention called theSEXword. The project, whose efforts have been profiled by the New York Times, was funded by the Einstein-Montefiore Center for AIDS Research. I served as co–principal investigator on the project along with David Lounsbury, Ph.D.
The objective of theSEXword was to use social networking to reach YMSM in the Bronx. We partnered with peer leaders and a social-media marketing company to develop an intervention in which the peer leaders designed and disseminated tailored HIV-prevention messages to their large online networks of “friends.” Through this process, we reached an estimated 5,000 young MSM in the Bronx and other boroughs in New York City with tailored messages about regular HIV testing and consistent condom use. We also collected a tremendous amount of rich data that we’re analyzing for future research.
Currently we are beginning work on another social media–based intervention. EngageBx is a collaboration between Montefiore Medical Center and the Bronx Community Health Network to develop and implement a linkage-to-care outreach program for gay, bisexual and other at-risk MSM in the Bronx. This group we’re seeking to reach does not have regular primary-care providers or healthcare. We will develop an online campaign on various general social-media and MSM-specific dating platforms to reach such individuals.
To enhance the feasibility and acceptability of the program, we will be working with community members to understand and address some of the barriers that may prevent individuals from seeking care. While the intervention is in its earliest planning stages, we’re encouraged by its potential and the enthusiasm expressed by community members.
Building partnerships to drive down HIV infection
Social media and other digital technologies are not a panacea, but they provide an arguably underused opportunity to reach and engage with communities on health issues. We already have an arsenal of effective tools to prevent new HIV infections (for example, treatment as prevention; behavioral interventions, including condoms; preexposure prophylaxis). What we need is a better way to link at-risk communities to these resources. This will require an interdisciplinary effort—a partnership among groups with whom we healthcare providers have not traditionally interacted.
In order to achieve measurable, sustained gains in HIV prevention among young black and Latino MSM, we will need greater collaboration with the target communities themselves, social-media marketers, technology corporations and other relevant parties.
Together, we can find a way forward to protect and empower this vulnerable and hard-to-reach group.
Viraj V. Patel is an internal medicine physician and assistant professor, Albert Einstein College of Medicine. He blogs at The Doctor’s Tablet.