Running head: hiv treatment as prevention promotion Detroit

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Running head: HIV treatment as prevention promotion Detroit

HIV treatment as prevention promotion program in Detroit, Michigan

Tracy Liichow

Concordia University, Nebraska

Principles of Health Behavior

MPH 515

Instructor: Dr. Kimberly B. Brodie, CHES, ACSM-HFS

August 2014

Table of Contents

HIV treatment as prevention promotion program in Detroit, Michigan 3

HIV treatment as prevention 3

Previous HIV prevention as treatment programs 5

Objective 7

Health Behavior Theory 7

Social assessment 9

Epidemiological, behavioral and environmental assessment 9

Educational and ecological assessment 10

Administrative and policy assessment and intervention alignment 10

Implementation and Evaluation 11

References 12

Table 17

Figure 18

HIV treatment as prevention promotion program in Detroit, Michigan

According to the Centers for Disease Control and Prevention (CDC) (2013b), it could be estimated that “1,144,500 persons aged 13 years and older are living with HIV infection, including 180,900 (15.8%) who are unaware of their infection.” HIV (human immunodeficiency virus) has been a national public health epidemic for a long time and continues to be a public health priority well into the twenty-first century. The aim of this paper is to present a feasible HIV prevention strategy.

If HIV-positive individuals (newly diagnosed) are linked to care and start taking antiretroviral drugs (ARVs) and adhere to their prescribed regimen, then they are engaging in an HIV prevention activity. The goal of this HIV treatment as prevention promotion program is to increase the number of HIV-positive individuals taking and adhering to ARVs thereby promoting HIV prevention. Hopes have been raised that combining existing prevention efforts with HIV treatment as prevention can now end the spread of HIV infection around the world (J. Cohen, 2011). However, reaching the world is beyond the scope of this particular health promotion. The population of interest for this health promotion is the African American community residing on the eastside of Detroit, Michigan.

HIV treatment as prevention

It is exhilarating and challenging to contemplate the significance of the evidence resulting from the study entitled, “Prevention of HIV-1 infection with early antiretroviral therapy,” commonly known as the HPTN 052 study, conducted principally by M. S. Cohen. The conclusion of the study was “The early initiation of antiretroviral therapy reduced rates of sexual transmission of HIV-1 and clinical events, indication both personal and public health benefits from such therapy” (M. S. Cohen et al., 2011, p. 493).

It is established that the “probability of sexual transmission of HIV is strongly correlated with concentrations of HIV in blood and genital fluids” (Rayment, 2012, p. 193). Antiretroviral therapy (ART) consists of administering antiretroviral medications, which are intended to inhibit HIV replication preserving vital CD4 cells (Shechter, Bailey, Schaefer, & Roberts, 2008). Furthermore, sustained and prolonged suppression of HIV replication in blood and genital fluids occurs with effective ART (Rayment, 2012).

HIV and African Americans

HIV has become a chronic disease, and the number of people living with the virus continues to grow. The CDC (2013b) reports that African Americans are continuing to severely experience the affliction of HIV, compared with other races and ethnicities. According to the Henry J. Kaiser Family Foundation (2014, p. 1), “a number of challenges contribute to the epidemic among Blacks, including poverty, lack of access to health care, higher rates of some sexually transmitted infections, lack of awareness of HIV status, and stigma.” An HIV prevention strategy designed to target African Americans is challenging.

In the designing of the prevention program, it must acknowledge that African Americans generally have a different culture. The prevention program will be culturally sensitive along with taking an ecological approach that incorporates a health behavior change theory. “Culture and ethnicity are critical to consider when applying theory to a health problem” (Glanz & Rimer, 1997, p. 7). Furthermore, Airhihenbuwa and Obregon (2000, p. 6) argue “A critical point in this debate about relevant health communication theories/models is the recognition of culture as central to planning, implementation, and evaluation of health communication and health promotion programs in general. . . and HIV/AIDS prevention and care in particular.”

Treatment as prevention

According to the CDC (2013a), public health professionals in particular should realize the full prevention benefit of treating HIV infection and be mindful of importance HIV testing and early identification. “Early identification of infection empowers individuals to take action that benefits both their own health and the public health” (Centers for Disease Control and Prevention, 2013a). Subsequently, infected persons substantially decrease their risk of transmitting HIV when they are engaged in early treatment (Centers for Disease Control and Prevention, 2013a). Effective treatment requires adherence to ART and linkage to and retention in care.

Previous HIV prevention as treatment programs


Current literature discusses HIV prevention and the various means utilized in the field of public to address the pandemic. One identified implemented health promotion program that addressed HIV prevention and the impact of ART was the “Changes in sexual behavior and risk of HIV transmission after antiretroviral therapy and prevention interventions in rural Uganda” conducted by Bunnell, Ekwaru, Solberg, Wamai, Bikaako-Kajura, Were, Coutinho, Liechty, Madraa, Rutherford, and Jonathan Mermin in 2006. The health behavior theory used was the ecological perspective or approach. The objective was to “assess changes in risky sexual behavior and estimated HIV transmission from HIV-infected adults after 6 months of ART” (Bunnell et al., 2006, p. 85). The design was set up as a prospective cohort study, which was performed in rural Uganda. The results were positive. “Six months after initiating ART, risky sexual behavior reduced by 70% . . . Estimated risk of HIV transmission from cohort members declined by 98%, from 45.7 to 0.9 per 1000 person years” (Bunnell et al., 2006, p. 85).

HIV/AIDS Complacency

Another identified implemented health promotion program that addressed HIV prevention and the impact of ART was the “HIV/AIDS complacency and HIV infection among young men who have sex with men, and the race-specific influence of underlying HAART beliefs” funded by the CDC. In this author’s opinion, the health behavior theory used was social cognitive theory (SCT). “SCT is predicated on the concept that the social environment is a central influence on behavior, making personal characteristics alone an inadequate explanation of health behaviors” (DiClemente, Salazar, & Crosby, 2013, p. 165).

The method used was an analysis of data from a two year “cross-sectional 6-city survey of 1575 MSM aged 23 to 29 years who had never tested for HIV or had last tested HIV-negative” (MacKellar et al., 2011, p. 755). The researchers assessed the data for plausible influences overall and by race/ethnicity. The results produced were anticipated. “Young MSM who are complacent about HIV/AIDS because of HAART may be more likely to engage in risk behavior and acquire HIV. Programs that target HIV/AIDS complacency as a means to reduce HIV incidence among young MSM should consider that both the prevalence of strong HAART-efficacy beliefs and the effects of these beliefs on HIV-infection risk might differ considerably by race/ethnicity” (MacKellar et al., 2011, p. 755).

The HPTN 052 study

Another identified implemented health promotion program that addressed HIV prevention and the impact of ART was the above mentioned HPTN 052 study. The ecological perspective or approach was the overarching health behavior theory used. The participants were from nine countries. The researchers enrolled “1763 couples in which one partner was HIV-1–positive and the other was HIV-1–negative” (M. S. Cohen et al., 2011, p. 493). The results were impressive with a small number of HIV-1 transmissions observed.


The HIV treatment as prevention promotion program will provide crucial health information and education, which will lead to a change in health behavior among African American HIV-positive residents of Detroit. At the end of the first year of the program, 80% of HIV-positive individuals residing in on the eastside of Detroit will have begun adhering to their HIV ARV regimen, and a decrease in HIV infection will be demonstrated.

Health Behavior Theory

Using a health behavior theory to promote health protective behaviors is of upmost importance. According to Fishbein (2000, p. 273), “it has become increasingly clear that preventing the transmission and the acquisition of HIV must focus upon behaviour and behaviour change.”

Furthermore, planning is crucial to the development of public health promotion endeavors. One of the best planning instruments available for public health professionals is the PRECEDE-PROCEED Model.


As a logic model the PRECEDE-PROCEED Model (PPM) is effective in changing health behaviors, and it is an effective planning tool as well (Crosby, Salazar, & DiClemente, 2011). According to Glanz and Rimer (1997, p. 40), “Planning systems, such as social marketing and PRECEDE-PROCEED, facilitate the process of developing successful programs because they lead practitioners through a step-by-step process of examining health and behavior at multiple levels.”

PPM is “valuable to health promotion planning because it provides a format for identifying factors related to health problems, behaviours and program implementation” (The Health Communication Unit, 2001, p. 3). “PRECEDE stands for Predisposing, Reinforcing, Enabling Constructs in Educational/ Environmental Diagnosis and Evaluation . . . PROCEED, on the other hand, stands for Policy, Regulatory, and Organizational Constructs in Educational and Environmental Development” (Crosby et al., 2011, p. 48). One of the primary beneficial aspect of the PPM is its community level approach. It is adaptable and utilizes monitoring and adjusting methods. Figure 1 displays the PRECEDE-PROCEED Model.

Health Belief Model

When designing a health promotion focusing on HIV prevention a multi-level approach should be adopted. The multi-level approach to health behavior change that this paper is addressing includes PPM and the Health Belief Model. According to Kaufman (2014, p. S250), “HIV risk and AIDS care involve complex behaviors influenced from multiple levels, from an individual’s knowledge, attitudes, emotions, and risk perception, to power dynamics between partners, accessibility of services, economic inequalities, criminalization of vulnerable groups, and policies that make HIV a priority health issue.”

Initially developed in the 1950s by social psychologists the Health Belief Model (HBM) is a widely used psychosocial approach to explaining health behaviors (Rosenstock, Strecher, & Becker, 1994). Several primary concepts are contained within HBM. These concepts “predict why people will take action to prevent, to screen for, or to control illness conditions; these include susceptibility, seriousness, benefits and barriers to a behavior, cues to action, and most recently, self-efficacy” (Glanz, Rimer, & Viswanath, 2008, pp. 46–47).

Social assessment

Community participation and relevance

Community participation is essential to the project. Community involvement will be highly stressed and valued. Planning for community participation will be one of the first items undertaken. Monthly meetings will be set up with community-based organizations (CBO) in the Detroit area. Focus groups will be developed from established partnerships with CBO in the Detroit area. A partnership will be established with a Federally Qualified Health Center (FQHC) in the area, namely Detroit Community Health Connection. A peer network will be developed as well as existing support groups will be strengthened and enhanced. Additionally, a multimedia sexual health media campaign will be developed. A city-wide kick-off event coordinated with the CBOs and FQHC will be held before the media campaign takes place. HIV counseling and testing will be made available at the kick-off event.

The following is a list of the CBOs who will be contacted:

  • AIDS Partnership Michigan (APM)

  • Community Health Awareness Group (CHAG)

  • Health Emergency Lifeline Program (HELP)

Epidemiological, behavioral and environmental assessment

Current data on HIV infection

“HIV among African Americans in Detroit is rising at an alarming rate” (James, 2014, p. 1). In the city of Detroit, African Americans comprise up to 72% of the HIV-positive population. See Table 1 for Michigan Department of Community Health’s July 2014 annual HIV surveillance analysis of Detroit. The contributing factors leading to HIV infection in the city of Detroit include, poverty, lack of access to health care, higher rates of sexually transmitted infections (currently particularly syphilis), lack of awareness of HIV status, and stigma (The Henry J. Kaiser Family Foundation, 2014, p. 1).

Educational and ecological assessment

The educational and ecological assessment will identify preceding (predisposing or cognitive), reinforcing, and enabling factors that must be in place to initiate and sustain change (Crosby et al., 2011; Glanz & Rimer, 1997). This is the place where the HBM will be used. During the educational and ecological assessment, all three levels (individual, interpersonal, and community) of change theories can apply and are relevant.

The predisposing factors will be dealt with using a health education initiative that will coincide with the peer networks and peer support groups. “Health education remains the front-line method of changing predisposing factors in public health” (Crosby et al., 2011, p. 54). The reinforcing factors, which are rewards or incentives, will be included in the media campaign, the kick-off event, and support group meetings. The incentives will include the most-common ones, such as gas cards and bus tickets. The participants will have to be praise and reassured during the program in various ways. The enabling factors will be addressed by advocating HIV social work case management services for all participants.

Administrative and policy assessment and intervention alignment

In the administrative and policy assessment phase, the capacity and available resources will be identified. A determination will be made to identify any additional resources that may be needed. Subsequently, after the assessment has been made then the intervention alignment can begin. “Intervention alignment is the point where [the] formative work (PRECEDE) ends and [the] action (PROCEED) begins” (Crosby et al., 2011, p. 53). The intervention alignment has a policy changing element that is daunting. The difficulties of accessibility (mass transit is not good in Detroit), affordability (the main outreach is to individuals who are low income or no income), availability (logistics involved in having services available during convenient hours), and acceptability (entrenched attitudes concerning HIV) have long been issues public health has dealt with in Detroit. Therefore, there will have to be several meetings with partners to address the current environment and all structural barriers.

Implementation and Evaluation

Implementation indicates the initiation of the program. The timeframe will be one year. The responsible party will be the Detroit Health Department working in collaboration with the Michigan Department of Community Health. The health departments will be responsible for the implementation plan. Resources will be mobilized, and partners (CBOs and FQHC) will be assigned duties.

Evaluation will take place before implementation. “Evaluation is the thread that holds any health promotion program together” (Crosby et al., 2011, p. 55). There will be a formative evaluation as well as a summative evaluation. The process, impact, and outcome evaluations are the most aspects of the summative evaluation. A separate document will be written describing the entire evaluation process. The summative evaluation will assess the effectiveness of the program in meeting objectives.

According to Glanz and Rimer, “Interventions that evolve from a comprehensive planning process, build on prior research, and use health behavior theories are more likely to be effective.” The HIV treatment as prevention promotion program can the potential to be effective. In conclusion, “ART can now definitively be lauded as a powerful HIV prevention tool . . . 'Treatment as prevention' can join one of many proven bio-behavioural prevention tools” (Rayment, 2012, p. 193). Nonetheless, further research is needful to implement effective HIV treatment as prevention health promotion initiatives.


Airhihenbuwa, C. O., & Obregon, R. (2000). A critical assessment of theories/models used in health communication for HIV/AIDS. Journal of Health Communication, 5(sup1), 5–15.

Bunnell, R., Ekwaru, J. P., Solberg, P., Wamai, N., Bikaako-Kajura, W., Were, W., … others. (2006). Changes in sexual behavior and risk of HIV transmission after antiretroviral therapy and prevention interventions in rural Uganda. Aids, 20(1), 85–92.

Centers for Disease Control and Prevention. (2013a, April 15). Prevention Benefits of HIV Treatment. Retrieved July 13, 2014, from

Centers for Disease Control and Prevention. (2013b, December 3). HIV in the United States – Statistics Overview. Retrieved August 6, 2014, from

Cohen, J. (2011). HIV Treatment as Prevention. Science, 334(6063), 1628–1628. doi:10.1126/science.334.6063.1628

Cohen, M. S., Chen, Y. Q., McCauley, M., Gamble, T., Hosseinipour, M. C., Kumarasamy, N., … Fleming, T. R. (2011). Prevention of HIV-1 Infection with Early Antiretroviral Therapy. New England Journal of Medicine, 365(6), 493–505. doi:10.1056/NEJMoa1105243

Crosby, R. A., Salazar, L. F., & DiClemente, R. (2011). The PRECEDE-PROCEED Planning Model. In Health Behavior Theory for Public Health: Principles, Foundations, and Applications (p. 45). Burlington, MA: Jones & Bartlett Learning.

DiClemente, R. J., Salazar, L. F., & Crosby, R. A. (2013). Health behavior theory for public health: principles, foundations, and applications. Burlington, MA: Jones & Bartlett Learning.

Fishbein, M. (2000). The role of theory in HIV prevention. AIDS Care, 12(3), 273–8.

Glanz, K., & Rimer, B. K. (1997). Theory at a glance a guide for health promotion practice. Bethesda, MD: U.S. Dept. of Health and Human Services, Public Health Service, National Institutes of Health, National Cancer Institute.

Glanz, K., Rimer, B. K., & Viswanath, K. (2008). Health behavior and health education: theory, research, and practice. John Wiley & Sons.

Green, L., & Kreuter, M. (2005). Health Program Planning: An Educational and Ecological Approach. McGraw-Hill Education.

James, D. (2014, June 18). HIV Crisis In Detroit. The Michigan Chronicle. Retrieved from

Kaufman, M. R., Cornish, F., Zimmerman, R. S., & Johnson, B. T. (2014). Health Behavior Change Models for HIV Prevention and AIDS Care: Practical Recommendations for a Multi-Level Approach. JAIDS Journal of Acquired Immune Deficiency Syndromes, 66, S250–S258. doi:10.1097/QAI.0000000000000236

MacKellar, D. A., Hou, S.-I., Whalen, C. C., Samuelsen, K., Valleroy, L. A., Secura, G. M., … Torian, L. V. (2011). HIV/AIDS Complacency and HIV Infection Among Young Men Who Have Sex With Men, and the Race-Specific Influence of Underlying HAART Beliefs: Sexually Transmitted Diseases, 1. doi:10.1097/OLQ.0b013e31820d5a77

Rayment, M. (2012). Prevention of HIV-1 infection with early antiretroviral therapy. Journal of Family Planning and Reproductive Health Care, 38(3), 193–193. doi:10.1136/jfprhc-2012-100379

Rosenstock, I. M., Strecher, V. J., & Becker, M. H. (1994). The Health Belief Model and HIV Risk Behavior Change. In R. J. DiClemente & J. L. Peterson (Eds.), Preventing AIDS (pp. 5–24). Springer US. Retrieved from

Shechter, S. M., Bailey, M. D., Schaefer, A. J., & Roberts, M. S. (2008). The Optimal Time to Initiate HIV Therapy under Ordered Health States. Operations Research, 56(1), 20–33.

The Community Tool Box. (2013). Other Models for Promoting Community Health and Development PRECEDE/PROCEED. Retrieved July 14, 2014, from

The Health Communication Unit. (2001, April). Introduction to health promotion program planning. The Health Communication Unit. Retrieved from

The Henry J. Kaiser Family Foundation. (2014, April 25). Black Americans and HIV/AIDS. Retrieved August 7, 2014, from

Final Research Project Paper Rubric



Minimum Points


Medium Points


Maximum Points


The writer does not demonstrate understanding of subject matter, and the analysis does not reflect the basic concepts associated with the topic. Key elements of the assigned topic were omitted.






The writer demonstrates limited understanding of the subject matter in that discussion of the theory was not applied correctly and the required components were not fully addressed.




29-39 POINTS

The writer demonstrates an understanding of the subject matter by clearly applying and analyzing the required theory, model or framework. Specifically, the writer;

Health behavior is explained in detail with supporting evidence justifying is public health concern.

Identified a specific population in which the behavior poses a specific threat.
Discussed the problem the behavior poses for the public health sector.
Explained the basic constructs and concepts associated with the chosen theory, model or framework.
Reviewed and discussed current literature on health promotion programs addressing the “change target”
Proposed a health promotion program with a theoretical foundation.

You have done a wonderful job with the final project! You have addressed all required elements as listed in this section above. Your proposed program using the PPM and HBM is attentive the audience and you capture the main elements of the model toward proper application in practice. Well done!

40-50 POINTS



Paragraphs do not focus around a central point, and concepts are disjointedly. The write does not present an introduction or conclusion. Writing lacks flow, clarity and does not conform to APA style.




Content could be organized in a more logical manner.  Transitions from one idea to the next are often disconnected and uneven. An introduction and conclusion are presented but may be incomplete or do not present the purpose of the paper. The writing does not conform completely to APA style (e.g., citations, references, and font requirements).

 10-19 POINTS

The writer presents a main idea and supporting concepts within paragraphs. Each topic is presented clearly and flows logically.  There is a succinct introduction and conclusion. The writing is correctly formatted to APA style (e.g., citations, references, and font requirements).

APA style is formatted correctly for both the paper and in-text citations. There is an introduction the presents the main ideas of the paper. Ideas flow logically.

20-30 POINTS



The writer demonstrates limited understanding of academic writing standards. Grammar and punctuation are consistently incorrect.  Tone is incorrect and focus is limited.


The writer occasionally uses awkward or complex sentence structure. Problems with word usage (e.g., evidence of incorrect use of Thesaurus) and punctuation persist may be evident. Minor spelling, grammar or syntax issues.


The writer demonstrates correct usage of formal English language in sentence construction.  There are no spelling, punctuation, or word usage errors. Writing is concise and clear in message.

Your writing style is clear and concise. Main ideas are easy to find and there are no grammar issues.

10-20 POINTS


*Risk categories used in Michigan are redefined as of January 2012. NOTE: Heterosexual contact for males includes only males whose sexual partners are known to be HIV infected or at high risk for HIV (HCFR). Heterosexual contact for females includes all females who have had sex with a male regardless of what is known about the male’s HIV status or behaviors (HCM).

Includes reports that contain patient name or are otherwise unduplicated. <5 and '*' = 1, 2, 3, or 4 cases.

‡ To calculate "1 out x" statements, divide the census number by total reported prevalence. For example, for non-Hispanic whites: 58,662 / 341 = 172. Thus, 1 out of every 172 non- Hispanic white persons in DETROIT are living with HIV. Rates and "1 out of x" statements are not reliable for <10 cases. Thus, rates for <10 cases are shown as "---".

§ Rates are not reported for risk categories and age at diagnosis because no reliable denominator data exist for these groups.

¥ In this report, persons described as white, black, Asian/Pacific Islander (PI), or American Indian/Alaska Native (AN) are all non-Hispanic; persons described as Hispanic might be of any race


Figure 1. Generic representation of the PRECEDE-PROCEED Model. From The Community Tool Box, Kansas University (2013). Additionally, from L. Green and M. Kreuter, Health promotion planning: an educational and ecological approach (fourth edition), Mountain view, CA: Mayfield Publishers, (2005).
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