An Ecological Approach to Addressing HIV/AIDS in the African American Community

Abstract

The disproportionate impact of HIV/AIDS on African Americans is a significant public health challenge. The complex constellation of individual, social, and environmental factors influencing transmission, require ecological solutions that recognize these multiple levels of influence and actively involve communities. This article describes the formation of a community-based coalition and highlights three initiatives it has undertaken in the areas of mobile HIV testing, HIV education, and faith-based work to improve HIV services for African Americans.

KEYWORDS:

• HIV prevention
• African American
• substance abuse
• coalition
• mobile testing
• faith-based HIV prevention

Introduction

The HIV/AIDS epidemic has plagued the United States for the past 25 years and continues to be a significant public health challenge. The impact of this challenge is felt most strongly among minority communities, particularly African Americans, who have been disproportionately affected by HIV since the beginning of the epidemic, accounting for 49% of reported HIV infections and 40% of reported AIDS cases (Centers for Disease Control and Prevention [CDC], 2005b). The chronic, disproportionate impact of HIV/AIDS on African Americans is a result of the complex interaction between individual, social, and environmental factors (Cargill & Stone, 2005; Farley, 2006; Sherman, German, Cheng, Marks, & Bailey-Kloche, 2006). Determinants of HIV, however, are often viewed from an individual perspective, focusing mostly on behavioral components of transmission (Adimora & Schoenbach, 2005; Sherman et al., 2006; Sumartojo, Doll, Holtgrave, Gayle, & Merson, 2000). In the case of African Americans, for example, sexual contact with a man is the leading cause of HIV infection (CDC, 2005b; Miller, Serner, & Wagner, 2005), with the prevalence rate of HIV transmission via male-to-male sexual contact highest among African Americans (CDC, 2005a; Valleroy et al., 2000). For African American women, although heterosexual transmission rates are similar across racial/ethnic groups, they are 20 times more likely to be infected with HIV/AIDS than their White counterparts (CDC, 2005b).

Substance use is another individual, behavioral factor that puts African Americans at heightened risk for HIV infection. Findings from a recent analysis of racial/ethnic injection drug use disparities revealed African Americans are more likely to inject drugs than Whites (Cooper, Friedman, Tempalski, Friedman, & Keem, 2005). Furthermore, research has consistently documented a positive relationship between substance use and high-risk sexual practices such as unprotected sex, multiple sex partners, and the exchange of sex for drugs and/or money, particularly among African Americans (Campsmith, Nakashima, & Jones, 2000; Ross, Kohler, Grimley, & Bellis, 2003; Timpson, Williams, Bowen, & Keel, 2003).

In response to this focus on individual-level risk behaviors, HIV interventions have centered on influencing intrapersonal factors such as knowledge, health beliefs, attitudes, and skills to impact behavior and reduce HIV transmission (Sherman et al., 2006; Sumartojo, 2000; Sumartojo et al., 2000; Trickett, 2002). Intervention methods typically employed to achieve positive behavioral outcomes include HIV education and risk reduction information, interpersonal and technical skill training, and the provision of support services (Herbst et al., 2005; Semaan, Kay, et al., 2002; Smoak, Scott-Sheldon, Johnson, Carey, and the SHARP Research Team, 2006). Overall, these behavioral interventions have reduced high risk behaviors among men who have sex with men (Herbst et al., 2005; Johnson et al., 2005), persons living with HIV (Crepaz et al., 2006; Johnson et al., 2005), substance users (Prendergast, Urada, & Podus, 2001; Semaan, Des Jarlais, et al., 2002), and women (Mize, Robinson, Bockting, & Scheltema, 2002). Results, however, are not unequivocal. A recent meta-analytic review of 206 condom-related interventions found these interventions did not increase or decrease the number of penetrative intercourse episodes or sexual partners, but did demonstrate a small, but significant decrease in sexual activity status (Smoak et al., 2006). Another behavioral intervention targeted to men who have sex with men showed a modest, nonsignificant reduction in HIV acquisition among the intervention group (Manhart & Holmes, 2005; The EXPLORE Study Team, 2004).

Although individual-level risk factors play a significant role in HIV transmission and behavioral interventions, they are a necessary component of a comprehensive HIV prevention strategy, this focus does not consider the broader determinants that influence HIV transmission (Cargill & Stone, 2005; Sherman et al., 2006; Sumartojo, 2000). As noted by Cargill and Stone (2005), “the ongoing disproportionate transmission of HIV infection within racial and ethnic minority communities represents the confluence of many risk factors” (p. 898). These multiple risk factors include social and environmental determinants such as poverty, racism, incarceration rates, low sex ratios, unequal access to healthcare, and limited infrastructure and capacity, all which help facilitate HIV transmission among African Americans (Adimora & Schoenbach, 2005; Aral, Padian, & Holmes, 2005; Cargill & Stone, 2005; Farley, 2006; Sumartojo, 2000).

Given the multiple determinants involved in HIV transmission, ecological approaches that recognize the dynamic interplay between individuals, their environment, and health outcomes have emerged to address both the individual and broader determinants of HIV infection, and also cultivate community resources to help ensure the long-term sustainability of these initiatives (Merzel & D'Afflitti, 2003; Trickett, 2002). The approaches employed in these interventions include community mobilization, intervention implementation across multiple community settings, utilization of individual and environmental intervention strategies, development of community infrastructure, enhancing community capacity, and leveraging new community settings to serve hard-to-reach populations (Merzel & D'Afflitti, 2003; Trickett, 2002).

While not a panacea for addressing HIV, ecologically-grounded interventions have shown positive results (Braine, Des Jarlais, Ahmad, Purchase, & Turner, 2004; DeSimone, 2005; Gibson et al., 2002; Hays, Rebchook, & Kegeles, 2003; Henrickson, 1990; Kegeles, Hays, & Coates, 1996; Lauby, Smith, Stark, Person, & Adams, 2000; Liang et al., 2005; Liebman, Lamberti, & Altice, 2002; O'Connor, Patsdaughter, Grindel, Taveira, & Steinberg, 1998; Person, Cotton, and Prevention of HIV in Women and Infants Demonstration Projects, 1996; Sikkema et al., 2000). For example, the Center for Disease Control's AIDS Community Demonstration Projects used a community-level intervention to impact condom and bleach use in five U.S. cities. Specifically, the intervention increased the availability of condoms and bleach kits and mobilized community members to distribute HIV prevention messages, materials, and role-model stories describing how people in target communities were changing their HIV risk behaviors (The CDC AIDS Community Demonstration Projects Research Group, 1999). Community-level findings showed increased condom carrying in intervention communities, as well as a shift toward consistent condom use and increased condom carrying (The CDC AIDS Community Demonstration Projects Research Group, 1999). The Jewellery Education for Women Empowering their Lives (JEWEL) is another ecologically-grounded project that provided HIV prevention education, but also taught target women how to make, market, and sell beaded jewelry (Sherman et al., 2006). Multivariate results showed that money earned through jewelry sales was associated with a significantly lower number of sex partners, indicating the potential impact of licit income on behavioral decisions (Sherman et al., 2006).

Collaborative partnerships are another ecological approach used to change the environment in which health behaviors occur by mobilizing communities and engaging them at multiple levels and in multiple settings (Roussos & Fawcett, 2000; Wandersman et al., 1996). New or modified programs, policies, and practices are all ways collaborative partnerships work to achieve these goals (Roussos & Fawcett, 2000). Coalitions are a particular type of collaborative partnership that have been utilized for HIV prevention efforts (Darrow et al., 2004; Griffin & Floyd, 2006; Metayer, Jean-Louis, & Madison, 2004). While coalition goals vary and include such things as building capacity, increasing risk factor awareness, improving access to health services, and leveraging community strengths (Chavis, 2001; Griffin & Floyd, 2006), coalitions play a critical role in identifying community needs, designing solutions, and mobilizing community support for these efforts (Foster-Fishman, Berkowitz, Lounsbury, Jacobson, & Allen, 2001; Wolff, 2001). For example, a coalition of public health professionals was utilized in Broward County, Florida to address racial and ethnic disparities in HIV (Darrow et al., 2004). The coalition's community assessment informed the development and implementation of an action plan that included outreach, strategic communications, capacity building, and infrastructure development (Darrow et al., 2004). Evaluation of coalition intervention efforts showed significant increases in HIV testing and HIV/AIDS problem recognition, as well as increased participation in community HIV-prevention efforts (Darrow et al., 2004). The Metro Boston REACH 2010 HIV Coalition is another example of a community partnership designed to engage local stakeholders in the identification and resolution of gaps in HIV prevention and services for the Haitian community (Metayer et al., 2004). Coalition successes included the creation of an HIV/AIDS prevention curriculum, HIV media campaign, mobilization of community resources, and the development of long-term, collaborative relationships to address HIV and other public health issues (Metayer et al., 2004).

Given the complexity of HIV transmission, comprehensive approaches are needed in communities to address the growing disparity of HIV infection among African Americans (Cargill & Stone, 2005). This paper describes the efforts one community has taken to tackle the multiple issues surrounding HIV in the African American community. Specifically, the Brothers-to-Brothers/Sisters-to-Sisters Coalition (BB/SS), a Substance Abuse and Mental Health Services Administration/Center for Substance Abuse Treatment-funded (SAMHSA/CSAT), Targeted Capacity Expansion HIV grant, adopted an ecological framework for addressing minority disparities in HIV/AIDS in Montgomery County, Ohio. This article provides a brief overview of the coalition's development and describes three specific initiatives the coalition has undertaken to address HIV/AIDS in the African American community, mobile HIV testing, HIV education with substance abusers, and work with the faith community.

Brothers-to-Brothers/Sisters-to-Sisters Coalition Development

The Brothers-to-Brothers/Sisters-to-Sisters Coalition was established in 2002 in response to the growing disparity of HIV infection among African Americans in Montgomery County, Ohio and the lack of coordination among service providers in addressing this issue. The coalition was conceptualized after discussions between Wright State University's Substance Abuse Resources and Disability Issues Program (WSU-SARDI) and a local AIDS Service Organization (ASO) identified local service needs and available resources. The primary sources of initial data were ASO service data, notes from minority-focused HIV committees, and Centers for Disease Control (CDC) information. Since substance abuse played such a pivotal role in HIV transmission within the county, several local treatment agencies were invited to join the effort as well. Overall, the original six partner agencies included the local ASO, three substance abuse treatment programs (including the primary opioid addiction treatment agency), the county Health District, and WSU-SARDI who has a long history of research in substance abuse and HIV. The agreed upon principles for this coalition were: (a) joint control over project goals and objectives; (b) shared funding dedicated to this project (to be initially funded via an application to SAMHSA/CSAT for a Targeted Capacity Expansion grant); (c) strong consumer involvement and input in project design and operation, and; (d) shared supervision of staff assigned to coalition activities. Two coordinated intervention approaches were initially conceptualized. The first involved targeted outreach to persons at high risk for, or living with HIV, with subsequent screening and referral into substance abuse treatment for those in need. The second approach focused on recruitment of persons in substance abuse treatment to provide HIV education and case management.

Several approaches were taken to further identify needs in the local African American community. These included five bi-weekly meetings involving all agencies listed, plus several other community organizations involved in HIV-related activities. More frequent meetings were held between WSU-SARDI and the ASO. Concurrently, a consumer group was identified through partner agencies, and individuals were recruited to participate in a series of focus groups and meetings to discuss their needs and perceptions regarding HIV prevention and substance abuse treatment. The consumers were provided with stipends for attending these groups. Other sources of data used in planning included Ohio Department of Health data, county Health District HIV testing data, Montgomery County Alcohol, Drug, and Mental Health Services Board data, and epidemiological data compiled through several related university studies.

Brothers-to-Brothers/Sisters-to-Sisters Coalition Action Plan

To address HIV in the African American community, BB/SS developed an ecological action plan that targeted both individual and broader determinants of HIV in the local community. The plan was based on community needs and resources, with a particular focus on building sustainable solutions. The primary intervention strategies that initially emerged included: (a) community outreach and prevention education via the ASO and Health District clinics, with referrals to HIV and/or substance abuse treatment services as needed; (b) recruitment of African Americans, especially those with HIV, into an intensive project to provide additional HIV education and case management services; and (c) modification of an existing curriculum developed by another ASO for use with both the outreach and substance abuse treatment components. Application for funding was made to SAMHSA/CSAT and the project was awarded a grant beginning in late fall 2002.

The project was fully staffed within three months, and coalition meetings were held bi-weekly, then monthly during the first year. Several ecological barriers ultimately resulted in changing the original design of the project. These factors included the following: Health District clinics proved to be ineffective sites for recruiting high risk individuals, as these individuals did not tend to use health clinics. The Health District proposed that a mobile testing van would be more effective for conducting outreach and HIV testing.

The ASO had considerable difficulty in identifying and recruiting a cohort of their consumers who were active substance abusers, and then subsequently engaging those persons in substance abuse treatment. Paradoxically, six of eight HIV-positive persons who were engaged in treatment from this site ended up attending a substance abuse treatment program that was not part of the BB/SS coalition, making additional BB/SS services unavailable to these persons. Difficulties with BB/SS supervision of the ASO case worker contributed to this disconnect.

Data on the number of HIV-positive persons in substance abuse treatment provided by local agencies were not substantiated by subsequent recruitment efforts in these programs. Moreover, soliciting this information from persons in substance abuse treatment was not efficient due to client fears and stigma, as well as staff discomfort with asking these questions even after receiving training on the topic. Consequently, there were few individuals with HIV in treatment who could be offered case management services.

The curriculum chosen for modification could not be used in a time-efficient manner due to copyright concerns and management changes in the organization that created the original product. No other available curriculum appeared to match the needs for the BB/SS project. The consumer advisory board, identifying themselves as Citizens Against Death, suggested that African American churches needed to be more involved with HIV prevention.

As a result of the above conditions and findings, the project was modified during the first year to focus on: (a) establishment of a mobile HIV testing van; (b) development of two HIV education curricula for substance abuse treatment programs, including a version designed exclusively for women, and; (c) creation and expansion of wellness ministries in African American churches. Over the last two years these activities have been implemented and have begun to impact the target community in several ways. Each of these activities is described in the following sections.

Public Health Mobile Unit

Mobile HIV testing is a creative outreach strategy that has been used to access high-risk populations who do not utilize traditional health services (Liebman et al., 2002; O'Connor et al., 1998). In the area serviced by BB/SS, HIV testing has only been available from stationary testing sites operated by the Health District, local ASO, and hospitals. HIV testing data from the community assessment revealed that local HIV testing numbers decreased by 27% between 1999 and 2002 (Ohio Department of Health, 2005). In addition to testing data, there was strong support from community stakeholders and local consumers for mobile HIV testing. Community stakeholders noted that high-risk populations were not accessing HIV services at traditional testing sites. From a consumer perspective, significant barriers to getting tested for HIV included transportation issues, lack of time to get tested, and the stigma associated with going to a known HIV testing site in the community. Based on these data, BB/SS collaborated with the Health District to sponsor the purchase of a Public Health Mobile Unit (PHMU) in 2004. The PHMU was specifically developed to increase community access to health screening services by providing free, confidential HIV testing and counseling, as well as blood pressure, blood glucose, and Prostate Specific Antigen screenings to targeted areas in the community. Free educational materials on various health issues and safer sex kits are also available.

For persons who elect to have an HIV test, pre-test counseling is provided immediately to assess client risk behaviors, readiness for HIV testing, and support systems in the event of a positive result. Counselors are certified in Counseling Testing and Referral and Partner Testing and Referral Services, following the CDC's recommendations for HIV testing. After pre-test counseling, individuals complete OraQuick Rapid Advance HIV ½ Antibody Testing (OraSure Technologies, Inc., Bethlehem, PA), a preliminary HIV test with results available in 20 minutes (blood specimen collection is performed when rapid tests are unavailable). While waiting for test results, the counselor talks to the person about personal risks and harm reduction strategies, and develops a harm reduction plan. Post-test counseling occurs once test results are ready. If the test is negative, the counselor reviews the harm reduction plan and reinforces risk reduction strategies. If the test is a preliminary positive, the counselor conducts a confirmatory blood draw, processes the positive result with the individual, and conducts daily follow-ups until confirmatory results are received by the Health District. Once confirmatory results are in, the counselor re-contacts the individual and arranges a time to provide the confirmatory result. For persons whose confirmatory test comes back positive, the counselor processes the results again, provides information on Ryan White funding, and immediately refers the person to medical care.

Since the PHMU began providing services in December 2004, it has been scheduled to service different parts of the community for events at least twice each week, including weekends. Targeted sites include substance abuse treatment programs, social services agencies, and community health fairs (see Table 1).

Overall, the PHMU has significantly increased the number of HIV tests conducted in the community. Between December 2004 and March 2006 the Health District's two stationary testing sites conducted 323 HIV tests. During this same time period the PHMU conducted 949 HIV tests across 220 testing events in the community. In 2005, no persons receiving an HIV test on the PHMU tested positive. Therefore, the PHMU outreach plan is being modified to include more high risk sites and will work more closely with a Health District team that conducts street outreach among intravenous drug users.

TABLE 1 Overview of Public Health Mobile Unit Testing Sites

Public health mobile unit testing site	Percent of testing events
Substance abuse treatment programs	21%
Churches	17%
Social service agencies (e.g., homeless shelters, food banks)	17%
Low-income housing developments	17%
Grocery stores	11%
Community health fairs	10%
Community centers	5%
Schools	1%
Neighborhood associations	1%

HIV/AIDS Prevention 101 Curricula

Given the strong link between substance use activities and HIV infection, BB/SS needed to include HIV education as a component of its overall community action plan. This decision was supported by counseling and testing data from 2003 for the target area which showed the majority of clients (39%) who obtained an HIV test indicated their exposure category was having a sex partner who was at risk, which includes sex partners who are injection drug users (Ohio Department of Health, 2005). Another 14% of HIV tests conducted noted some exposure category related to substance use (Ohio Department of Health, 2005). As a result, BB/SS, the ASO, the Health District, two substance abuse treatment providers, and WSU-SARDI worked to develop two HIV education curricula targeting minority substance abusers, with one specifically for women. The primary result of the group's work was a 75-minute workshop entitled, HIV/AIDS Prevention 101: Reducing the Risk of Getting HIV/AIDS from Substance Abuse and Other High Risk Activities (SARDI, 2004). This workshop was designed to help individuals understand the local impact of HIV, identify behaviors that put them at risk for HIV infection, learn risk reduction strategies, and provide information on how to obtain HIV testing. The workshop contains five topics and is accompanied by a pre-post survey of knowledge and behavior. Participants respond to each statement using a five-point Likert scale from 0 (disagree strongly) to 5 (agree strongly). The curriculum components include: What are HIV and AIDS and How They Impact Our Community; Reducing the Risk of Getting HIV/AIDS; a personal Risk Assessment Questionnaire; Negotiating Safer Sex; and Should I Get Tested?

To date, the workshop has been implemented with a total of 530 individuals. The majority are male (61%) and have been tested for HIV before (71%). The mean age of participants is 34.22 years old SD = 10.52, range 18–73). A Wilcoxin Signed Ranks Test was conducted to assess the impact of the workshop (see Table 2). To control for Type I error, a Bonferroni technique suggested by Glass and Hopkins (1996) was utilized in which the .05 alpha was divided by the number of statistical tests computed (14), resulting in a .003 alpha level.

Results revealed significant improvement between participant pre- and post-test scores for seven of the 14 items. In terms of HIV susceptibility, there was significant improvement in scores associated with the statement, “You believe that you could become exposed to the AIDS virus.” While it is not possible to associate any findings with particular workshop components, completion of the Risk Assessment Questionnaire, as well as general discussion of how HIV is transmitted likely led to the improvement in participants' beliefs that their personal behaviors could expose them to HIV. In contrast, participant scores on the related statement, “You think that you really could get AIDS,” did not reach statistical significance. For this group of participants there appears to be a disconnect between believing one can be exposed to HIV and actually thinking this exposure can result in HIV infection, indicating an area to improve upon within the workshop content.

TABLE 2 Summary of Wilcoxin Signed Ranks Test for HIV Workshop

Evaluation question	Z-score	p-value
You believe that you could become exposed to the AIDS virus.	−3.959	.000*
You think that you really could get AIDS.	−2.765	.006
You want to make some changes now that will reduce your AIDS risks.	−2.736	.006
You need help in dealing with your drug use.	−1.763	.078
You need help to change some of your sex activities.	−7.528	.000*
You get tired of the problems caused by drugs.	−1.251	.211
You are going to change your drug use activities to avoid AIDS.	−2.371	.018
You are going to change your sex activities to avoid AIDS.	−4.539	.000*
You already know what you must do to reduce your AIDS risks.	−1.044	.296
You feel sure of yourself in controlling your risky drug use activities.	−4.603	.000*
You feel sure of yourself in controlling your risky sex activities.	−3.800	.000*
I know where to go to get tested for HIV.	−5.369	.000*
There are more good things about getting tested for HIV than bad things.	−1.901	.057
I am ready to get tested for HIV.	−3.873	.000*

Participants' scores also improved in areas related to readiness to change risky sex practices (e.g., “You are going to change your sex activities to avoid AIDS”), as well as confidence in controlling both risky sexual and substance use behaviors (e.g., “You feel sure of yourself in controlling your risky drug use activities”). While participants were more likely to agree that they were ready to change risky sex behaviors to avoid AIDS after workshop participation, the workshop did not have an impact on participant desire to change risky drug use activities to avoid AIDS. This is likely related to the fact that the individuals participating in this workshop are already in substance abuse treatment and have already made the decision to change drug use activities prior to workshop exposure. However, participant scores related to confidence in controlling both risky substance use and sexual activities did improve between the pre- and post-test, indicating an increased level of confidence after participating in the workshop. Exposure to information on HIV transmission and risk reduction strategies likely bolstered participant confidence in controlling both risky sexual and substance use behaviors.

Finally, improvements were noted for knowledge of where to get tested for HIV and readiness to get tested. These improvements are likely connected to section five of the workshop, Should I Get Tested that provides specific information on testing locations and different types of HIV tests. As the project continues, findings from the workshop evaluation will be used to revise the curriculum. In addition, it will continue to be implemented at two treatment programs, with a push to integrate the workshop into each program's overall substance abuse curriculum before the project ends.

Faith-Based HIV Prevention Initiative

Churches can play a pivotal role in promoting the health and wellness of the African American community through their ability to mobilize awareness, distribute critical information, and support healthy choices. In addition, 70% of African-American adults identify with a church or denomination (CDC and Interdenominational Theological Center, 2001). The community needs assessment conducted by BB/SS also revealed a strong local presence of church involvement in the African American community. Specifically, findings from a local survey of 73 churches revealed over half had wellness ministries, although none of the ministries addressed HIV/AIDS or other infectious diseases. As a result of these findings, BB/SS included in its action plan a faith-based HIV prevention initiative designed to: (a) increase recognition among church leaders of HIV as a critical health issue facing the African American community, and provide leaders with specific spiritual approaches for addressing this within their churches and the larger community; (b) provide an HIV prevention workshop within local churches to expand HIV/AIDS education and testing, and; (c) establish and expand wellness ministries within churches.

A critical first step in this process was engaging key stakeholders in the local African American faith community. Commitment from these leaders was essential in moving any HIV awareness and prevention initiative forward. To establish these relationships, BB/SS approached two local ministerial alliances representing over 100 churches in the area. Presentations were conducted with the pastors affiliated with them, focusing on HIV/AIDS facts, the impact of HIV on African Americans, and the church's role in creating solutions to the HIV crisis. By working with these two organizations, as opposed to networking with individual churches, BB/SS was able to maximize its resources and reach a greater portion of the faith community. More importantly, this approach granted BB/SS entrée by building trust with key leaders and actively involving them in the local solution to the HIV epidemic.

Once these partnerships were established, BB/SS worked with these churches, along with WSU-SARDI and the Health District, to develop an HIV prevention workshop. The result of this effort was a day-long workshop entitled, Affirming a Future with Hope, Health, and Leadership, based upon a CDC faith-based HIV and substance abuse prevention curriculum that emphasizes a personal relationship with God and utilizes faith-based narratives, spiritual principles, and personal experience to address HIV prevention (CDC and Interdenominational Theological Center, 2001). From this larger curriculum, BB/SS utilized one specific study guide targeted to working with faith leaders, A Conversation at the Well: Jesus and the Samaritan Woman (CDC and Interdenominational Theological Center, 2001). In the context of HIV and the church, this study guide taught the lesson that all people have access to God regardless of who they are. In addition, the workshop included break-out sessions that focused on HIV and the African American Community, African American Women and HIV, and Establishing Wellness Ministries. The Establishing Wellness Ministries session was developed by a Health District staff person and provided information on faith-based wellness programs and the steps involved in establishing these programs. The PHMU was also available at each workshop to provide free HIV testing.

Once developed, historically African American churches were invited to host the workshop. Initially, invitations were extended to churches recommended by the two ministerial alliances originally approached to participate in the initiative. These churches were selected because of their influence in the community and their willingness to tackle the barriers surrounding HIV in the church. Once the workshops began, however, word-of-mouth resulted in other churches contacting BB/SS to arrange their own workshop.

Overall, Affirming a Future with Hope, Health, and Leadership was implemented at 18 churches between June 2005 and January 2006. On average, 36 people attended each workshop. In total, the faith-based workshops involved 798 people, with 29% of participants (N = 229) getting tested for HIV (no previously undiagnosed HIV was detected). In addition, the workshops resulted in six of the participating churches incorporating HIV/AIDS information into their existing wellness ministries. The churches that have not taken this step yet are primarily smaller churches with limited staff resources; however, BB/SS is developing a training program to help these churches establish their own wellness ministries. The ultimate goal of this component of the faith-based initiative is for local churches to serve as satellite operations in the community to provide HIV prevention education and testing, and serve as links to other community agencies proving HIV, substance abuse, and other health services. One church has already volunteered to open a satellite office in the community to encourage HIV awareness and provide services to persons living with HIV. Seed funding is being sought at this time to initiate this program.

Overall, the faith-based initiative has played an important role in the BB/SS project. It has leveraged an important community resource, churches, and actively included them in the local solution to the rising HIV epidemic among African Americans. In particular, this initiative has started a dialogue within churches around HIV, provided HIV prevention education and testing to a significant number of African American community members, and has begun to establish a faith-based network that will continue to address HIV once formal funding for the project ends.

CHALLENGES AND FUTURE DIRECTIONS

Coalition Challenges

The initial funding of the BB/SS project introduced WSU-SARDI to the county HIV service delivery providers in a new way. For the first time, a university program was positioned to provide HIV and substance abuse services directly to the African American community. The existing network of providers had relatively well-defined service areas and territories, and there was concern by several that WSU-SARDI and BB/SS would re-distribute the power structure, and more importantly, adversely impact funding and service delivery for some providers. Consequently, BB/SS was not invited to join other HIV-related events or community committees formed to address this issue for the first two years of the project. BB/SS staff addressed this issue in two ways: (a) all agencies providing HIV-related services were always invited to BB/SS meetings; and (b) the project made certain there was BB/SS representation at HIV-related public meetings, forums, and events whenever possible. Since the project began, these turf issues have abated considerably and other partnerships have been forged with BB/SS that actually facilitate procurement of additional HIV-related funding and services.

A second challenge experienced by the project was that some coalition partners, by the nature of their services, were more invested in HIV prevention and treatment than others. Substance abuse treatment agencies, for example, must balance their participation in HIV-related meetings with many other responsibilities. To bolster BB/SS participation, the coalition has sponsored trainings on topics related to HIV and provided incentives (gift certificates) to substance abuse counselors who meet established goals for enrolling individuals into the BB/SS project.

Building Sustainable Solutions

The BB/SS project intended from the inception to create interventions and approaches that could be integrated into community agencies by the end of the funding cycle. The strategies for integrating coalition activities within existing provider networks included adoption of the HIV/AIDS Prevention 101 curricula within substance abuse treatment programs; adoption of county-wide prevention, referral, and treatment goals for high risk populations by the county service delivery planning mechanisms; and on-going collaboration with the Ohio Department of Health for provision of a continuing supply of rapid HIV test kits.

During this time, a true collaboration has been formed between WSU-SARDI and the county Health District, with much of this effort focusing on the efficacy of the mobile testing unit as a means for outreach and community-wide testing. At this point, outreach activities conducted by the Health District are jointly staffed by their department and WSU-SARDI personnel. The faith community has also become a strong collaborator on this project. The training provided by BB/SS to create new wellness ministries and expand the focus of existing ones to include HIV will continue to impact the community once funding has ceased.

Future Directions

As BB/SS transitions into its final funding year, there are several directions it will take to continue its HIV efforts in the African American community. First, the activities described in this paper will continue, with a focus on ensuring their sustainability after the project ends. Second, it has become clear during the course of the project that previous efforts at county-wide data collection on HIV testing and high risk populations are inadequate. Consequently, a task force has been formed to focus on improving a timely system for evaluating outreach efforts and their impact on target communities. Particular focus is being placed on persons in re-entry from criminal justice, African American women, and faith-based initiatives to better inform African American churches about community needs and their potential responses. Third, the rapidly increasing rate of Hepatitis C in the African American community is becoming a critical concern. As a result, the HIV/AIDS Prevention 101 curricula are being expanded to include Hepatitis C, and a sub-group of county providers are working with the state health department to provide wider access to Hepatitis C testing and medications for county residents. Finally, recent advances in case management design suggests this approach may benefit persons living with HIV or Hepatitis C. For this reason, several approaches are beginning to emerge that provide this critical service to more residents who otherwise do not qualify for current services.

Notes

Support for this project came from the Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment, Targeted Capacity Expansion HIV grant (5-H79 TI14546014).

This project was carried out with funding from a Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Substance Abuse Treatment (CSAT) grant from the Targeted Capacity Expansion Program for Substance Abuse Treatment and HIV/AIDS Services (TCE/HIV). The views and opinions contained in the publication do not necessarily reflect those of the Center for Substance Abuse Treatment, the Substance Abuse and Mental Health Services Administration, or the U.S. Department of Health and Human Services, and should not be construed as such.

Note. *p < .003.