Integrated STD/HIV Messages: Potential Pros and Cons

24 August, 2009National HIV Prevention Conference

John M. Douglas, Jr., MD

Director

Division of STD Prevention

NCHHSTP

CDC

Outline

• Why integrate?• Pros and cons• Promising examples• Future opportunities

NCCHSTP, 2006 Disease Profile

HIV/STD disparities among African-Americans in the U.S.

Est. annual B:W Incidence / % all cases incidence Prevalence Ratio in blacks

HIV 56,000 7:1 45%GC 718,000 18:1 70%CT 2.8 m 8:1 48%P&S syphilis 11,500 6:1 46%Trichomoniasis 7.4 m 10:1 59%HSV-2 1.6 m 3:1 30%

Based on:

HIV estimated incidence (JAMA 2008) STD Surveillance 2007NHANES assessments of HSV-2 and TrichomoniasisWeinstock Persp Sex Rep Health 2004

Estimates of New Infections, 2006, By Race/Ethnicity, Risk Group, and Gender,for the Most Affected U.S. Subpopulations*

Impact of HIV/STD on MSM

• HIV: 53% all new infections• Syphilis: 65% all P&S infections• Evidence of growing role in other STD

– GC (20+% of cases in GISP)– Prevalence of GC, CT underestimated due to

limited rectal, pharyngeal screening– Outbreaks of LGV

• High rates of HIV co-infection (syphilis 40-60%, GC 5-10%)

Gonorrhea — Rates by state: United States and outlying areas, 2007

Note: The total rate of gonorrhea for the United States and outlying areas (Guam, Puerto Rico and Virgin Islands) was 117.4 per 100,000 population. The Healthy People 2010 target is 19.0 cases per 100,000 population.

Rate per 100,000population

Guam 82.4

Puerto Rico 8.2

Virgin Is. 63.5

<=19.0

19.1-100.0

>100

(n= 8)

(n= 25)

(n= 21)

VT 10.3NH 10.5MA 41.9RI 37.7CT 66.4NJ 69.6DE 151.5MD 120.5DC 408.1

236.7

86.4

82.1148.3

85.8 71.0

129.0

190.5

51.3

18.3

162.2 139.2

64.7

82.682.0

259.7

8.9

153.4

66.9

285.7

169.0

12.9

81.194.4

91.9

91.7

188.2

18.2

183.5

134.9

33.4

102.1

239.0

33.4

158.4

136.4

32.282.0

57.1

51.1

121.5

15.7

Program Collaboration and Service Integration: An NCHHSTP White Paper (draft Aug 2009)

• PCSI…mechanism for maximizing public health impact by establishing linkages to facilitate comprehensive service delivery.

• Small changes in service delivery have potential to improve efficiency, cost-effectiveness, and health outcomes

• Role of Health Education and Messaging in PCSI– Providers should look for appropriate comprehensive prevention

messages for populations served…– Bundling and integrating health messages…may help reduce

health disparities…in a more impactful, and cost-effective way– Given that populations most affected by HIV, STD are similar

(eg, MSM, AfAm), greater emphasis is needed on integration of messages and social marketing…that encourages appropriate testing/RX as well as use of other preventive services

– PCSI efforts should occur at all stages (eg, research, implementation and scale-up, evaluation)

Pros/Cons: Possible Impacts of Integrating Messages

• Antagonistic: messages are confusing, ineffective; integration reduces effectiveness of one or both

• Additive: multiple messages are delivered with effectiveness similar to delivery alone, but enhanced efficiency

• Synergistic: multiple messages are delivered with enhanced effectiveness for > one

Why might HIV and STD prevention messages be antagonistic?

• HIV prevention message could be diluted, especially if – some of the many specific STD were discussed– different indicated action steps (eg, with variable

timing, population, samples for testing)• STD prevention message could be diluted if HIV

concern overshadows important steps for other STD• Covering both HIV and STD could require

reduced/simplified information that could – be misleading (eg, “there is one test for all

STD/HIV”; “condoms are/are not effective for prevention”, etc.)

– Support misconceptions (eg, “all STD are the same”)

Why might HIV and STD prevention messages be additive or synergistic?

• Could alert persons at risk about range of sexual health issues and possible prevention steps

• May reduce message clutter by focusing on sexual health vs having separate messages for HIV, syphilis, CT, GC, etc.

• Could enhance primary prevention (eg, condoms):– If population already has experience with higher prevalence

STD, prevention message could be more credible (eg, RRC in STD clinics)

• Could enhance testing– If STD testing is perceived to be less “scary” or more credible

(higher prevalence), co-messaging could enhance HIV testing (eg, “gateway” testing)

• Potential for enhanced cost-effectiveness• Potential for greater satisfaction by communities/individual

consumers

Example: Preconception Health Message Bundling (King et al, personal communication)

• Assessment of ability of young women to process “bundled” preconception health messages (n=687)– Are bundled messages as effective as single messages?– How many messages can be bundled?– What types of messages can be bundled?

• 15 messages in 4 categories [healthy lifestyle, screening/testing (both HIV and STD), immunizations, management of medical problems]

• Awareness after message exposure: % correct answers– Control 11% – One message 58%– 4 messages, in categories 59%– 4 messages, not categorized 51%– All 15 messages, in categories 27%– All 15 messages, not categorized 29%

Example: Get Real Get Tested, North Carolina (Leone P, Watkins H)

• Statewide HIV testing campaign– Primary focus HIV; secondary

emphasis STD– Initiated Oct 2006

• Targeted community campaign– Door-to-door and venue-based

testing (eg, Walmart), both HIV and syphilis

– 11 locales statewide– 3683 persons tested 2006-8, 34 (

0.9 %) HIV+ and 30 (0.9%) syphilis +

• HBCU campaign– Multiple campuses around NC– Example: Elizabeth City State

Univ• 170 students tested for HIV,

syphilis, GC, CT• 37 (22%) + for GC or CT;

none + for HIV or syphilis• Organizers think inclusion of

STD adds credibility

Example: It’s Your Sex Life/Get Yourself Tested

• Get Yourself Tested (GYT)

– partnership of MTV platform of It’s Your Sex Life (IYSL)

– with Kaiser FF and Planned Parenthood

– to inform youth about STD/HIV and normalize testing

• Based on on-air/online promotions to drvie consumers to IYSL/GYT website

GYT Overview

• Targeted to youth, particularly young women and minorities• Messaging focused on branding the campaign and ease of testing

(eg, quick, urine/oral swab)– Concept was to get kids talking comfortably about sexual health– Might it be easier to broach sexual health/testing without overt

focus on scary or stigmatizing terms (eg, HIV, chlamydia)?– If GYT could become part of vernacular (like OMG) could sexual

health testing be easier to talk about and thus normalized?– Neither HIV or STD mentioned in on-air programming, but both

mentioned on website• Free/low-cost testing proactively offered by 97 Planned Parenthood

Affiliates, approximately 800 health centers• Comparison data (April 2009 vs April 2008) available from 10 sites

GYT: Locating HIV/STD Testing

• Builds on HIVtest.org to provide information on STD testing

• Usability surveys indicate preference for all information for HIV/STD testing (and immunization) in 1 place

GYT: Client visits and STD/HIV tests 04/09 vs 04/08

Females Males

# visits + 18% +36%

Testing

GC +20% +49%

CT +17% +55%

HIV +53% +55%

% STI visit w HIV test 29% 61%

Planned Parenthood Federation of America, forthcoming report.

CDC Websites: What is the Public Looking For?

• Top searchwords leading to CDC webpage from external search engines (Google, Yahoo, MSN), Oct 08-June 09

• Most common were “CDC” and “swine flu”

• Of top 10, 6 were related to STD terms (45% of all searches)

• Of top 20, 14 were related to STD terms

• HIV was #40 (153,600)

Opportunities for Web Links

• CDC web pages undergoing major changes to migrate to new CDC.gov templates– New templates provide better synergies– Cross linking with HIV information will be included as

part of design and architecture of STD webpages; HIV to STD should be considered

– Areas for possible enhancement• HIV and STD testing recommendations• HIV/STD co-infection• Groups most affected by both STD and HIV and

for whom testing particularly recommended

Internet/Health Communication Guidance

Social Marketing Campaigns: Chlamydia Testing, LAC-HD (J Montoya)

Social Marketing Campaigns: Act Against AIDS

• First federally-funded national HIV/AIDS social marketing campaign in 20 years.

• Multiple phases, multiple audiences over 5 yrs, $10 m– Kick-off phase: Every 9 ½ minutes

someone in the US is infected with HIV

– MSM HIV Testing phase – African American MSM

– “Take Charge. Take the Test.”phase – African American Women

– “I Know” phase – General Population of African American Young People

Final Reflections• Who to consider for integrated HIV/STD messages?

– Populations with substantial burdens of both HIV and STD– Populations in whom STD testing/prevention might have an

impact on HIV prevention – Highest priority: African Americans, young MSM, South and

selected urban areas• Should be a priority for

– Health communications research– Evaluation of existing efforts– All integrated HIV/STD programs

• Urgent issue given – entwined epidemics – worsening disparities – finite resources – potential opportunities presented by Health Care Reform,

National HIV Strategy

AcknowledgementsPeter LeoneHolly WatkinsJorge MontoyaKaren KingAmy Pulver Allison FriedmanMary McFarlaneRachel KachurMatthew HogbenVannessa CoxSevgi Aral

The findings and conclusions in this presentation are those of the author and do not necessarily represent the views of the CDC/ATSDR