From School of Public Health, Columbia University, New York, New York
Correspondence: Robert E. Fullilove, EdD, Associate Dean, School of Health, Columbia University, 600 W. 168th St., New York, New York 10032. E-mail: firstname.lastname@example.org; email@example.com.
Received for publication January 4, 2007, and accepted January 8, 2007.
The article by Crepaz et al. in this issue provides an important addition to the wealth of evidence we already possess about the efficacy of behavioral interventions to reduce and/or prevent STDs and HIV infections in the United States. Their study—a meta-analysis of 18 randomized controlled trials of behavioral interventions directed at black and Hispanic STD clinic patients—concludes: “this review shows that behavioral interventions result in significant reductions in unprotected sex and new STD acquisition among black and Hispanic STD patients.”1
The interventions had a number of notable characteristics. First and foremost, these programs were based on formative research of the populations that attended the clinics where the studies were conducted. Such research significantly improves the likelihood that “culturally appropriate” strategies can be developed to reach the patients in question. More importantly, such an approach is also likely to reduce the errors that are often made when blacks and Hispanics are treated as if they are members of a homogeneous group. Given the enormous variation that is observed in such populations across such factors as neighborhood, social class, level of acculturation, and age, tailoring interventions so that they are appropriate to the location and patient population being served is critical to the success of any public health program.
The second characteristic of note is that the interventions were directed to populations whose level of risk is self-evident—they are patients seeking treatment for an STI—and programs are initiated at a point in time that educators would characterize as “a teachable moment.” What better time to intervene with someone at risk for exposure to infection than when they seek treatment for such an infection? Given the need to develop interventions that are both behaviorally effective and cost effective, using STD clinics as sites for prevention programs has a certain logic that is both appealing and obvious.
But the question that this study raises for all of us who read this journal is “what next?” That prevention “works” is not news. What is of paramount importance for all of us who work in public health is the national failure to take the programs that have demonstrated efficacy in 1 setting and disseminate them to others; this is particularly necessary in locales where high concentrations of STD-related morbidity and mortality are prevalent. Crepaz and colleagues1 themselves cite CDC estimates of 19 million HIV and/or STD infections occurring annually in the United States as factors underscoring “the importance of identifying interventions successful in reducing STD acquisition and sex behaviors related to HIV and STD transmission.”1–3
The problem, of course, is that we live in an era during which the need for such programs (and the dollars to disseminate them) is far greater than the supply. We are forced, therefore, to be conscious of these constraints when we strive to answer the “what next?” question. One conclusion that we might draw from the Crepaz and colleagues meta-analysis could be: “We must direct interventions to other sites that offer the same sorts of strategic advantages that STD clinics provide.” One obvious set of locations that neatly fill this bill would be the nation’s prisons and jails.
Tragically, America’s prison population was larger in the year 2004 than ever before, with some 2.13 million inmates “doing time” that year. Moreover, prisoners were overwhelmingly from ethnic minority communities with approximately two-thirds of all inmates in the United States being black and/or Hispanic.4,5 Of particular significance, however, is the fact that prisoners as a group are disproportionately affected by HIV/AIDS. Hammett and colleagues, for example, estimate that in 1997, between 150,000 and 200,000 people living with HIV/AIDS passed through a US correctional facility. Put in other terms, in that year, approximately twenty-five percent of all people living with HIV in the United States were locked up for some period of time in a US prison or jail.6
The conclusion that centers of incarceration provide both the population and the risk behaviors that must be addressed is almost self-evident. Prisons and jails are sites with large numbers of men and women at risk for STDs and HIV/AIDS. In many states, the inmate population is overwhelmingly black and Hispanic and, as is the case in New York State, 48% of prisoners diagnosed with AIDS in 1997 were black and 45% were Hispanic.6 Correctional facilities are, in addition to a host of other characteristics that need not be mentioned here, ideal settings for health education and behavioral interventions. At the risk of citing the obvious, problems with “loss to follow-up” are not really an issue, particularly when implementing interventions that require, for example, more than 1 session with a patient.
This recommendation that prisons become the next strategic target for STD and HIV prevention programs is consistent with recommendations made by the CDC in its 2006 Morbidity and Mortality Weekly Report on “HIV transmission among male prisoners in a state prison system – Georgia, 1992–2005.”6 In an investigation that examined HIV seroconversion among the state’s male inmate population, investigators from the Georgia Department of Corrections and the CDC identified 88 inmates who were HIV-negative at entry to prison and who contracted an HIV infection during the period that they were in that facility. “Findings from the investigation demonstrated that risk behaviors such as male–male sex and tattooing were associated with HIV transmission among inmates, highlighting the need for HIV prevention programs in this population.”6 p421
The Report’s recommendations were clear. “Corrections officials, in partnership with public health officials, should assess the adequacy of existing programs and services for incarcerated populations and develop strategies to reduce HIV infection, both in prisons and in the community.”6 p425
The good news in this otherwise bleak picture is that Crepaz and colleagues have demonstrated that the creation of such interventions is possible, and more importantly perhaps, that such programs are capable of producing significant, positive results. The only question that remains is whether we are willing to put our money where our evidence suggests it will yield the greatest good. It will not be lost on any student of American history that this nation is at its absolute worst when confronted by the challenge of race and racism, particularly in matters related to health and health care7 and most particularly if the population in question involves inmates of color.4
And therein lies the dilemma; Crepaz and colleagues have made it clear that the issue of race and risk for exposure to (or infection with) HIV or another STDs are highly correlated. The challenge that we face, therefore, is not in developing the science or the behavioral technologies to work with minority populations. The challenge is to find the political will to do what our research has proven we have the savoir-faire to do.
1. Crepaz N, Horn AK, Sima MR, et al. The efficacy of behavioral interventions in reducing HIV-risk Sex Behaviors and incident STD in African American and Hispanic STD clinic patients in the United States: A meta-analytic review. STD 2007; 34:319–332.
2. CDC. HIV transmission among male prisoners in a state prison system – Georgia, 1992–2005. MMWR 2004; 55:421–426.
3. Weinstock H, Berman S, Cates W, Jr. Sexually transmitted diseases among American youth: Incidence and prevalence estimates, 2000. Perspect Sex Reprod Health 2004; 36:6–10.
4. Golembeski C, Fullilove RE. Criminal (in)justice in the city and its associated health consequences. Am J Pub Health 2005; 95:1701–1706.
6. Hammett TM, Harmon MP, Rhodes W. The burden of infectious disease among prisoners of and releasees from US correctional facilities. Am J Pub Health 1997; 92:1789–1794.
7. Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Barriers in Health Care. Washington, DC: National Academic Press; 2002.