At the 2010 U.S. Conference on AIDS last month, speakers blasted the White House for providing only $35 million of the budgeted $110 million to the AIDS Drug Assistance Program. ADAP needs these funds to provide life-saving medications to people living with HIV. A few angry protesters stormed the podium in the opening plenary where Secretary of the Department of Health and Human Services Kathleen Sebellius came to defend the $35 million concession. They shouted “AIDS means death, ADAP means life.” The crowd of conference-goers, surprised and confused by the foray, instead rippled with talk of the White House’s new National HIV/AIDS Strategy.
The White House released the National HIV/AIDS Strategy in July 2010. In it, the administration pledges support for reducing new infections, improving care for people living with the disease and lessening HIV-related health disparities. Sebellius called the strategy an unprecedented step toward ending the HIV/AIDS epidemic. The crowd cheered. However, as conference-goers read the strategy their enthusiasm waned. This National HIV/AIDS Strategy was not new at all. The White House Office of National AIDS Policy just combined all popular approaches to HIV/AIDS prevention and treatment. Many disenchanted conference-goers had hoped for a critical review of existing prevention and treatment approaches and some innovative new ones.
Some hoped the Strategy would review the Center for Disease Control and Prevention’s process for endorsing and evaluating evidence-based interventions. The CDC currently endorses and funds interventions that in controlled scientific studies reduce high-risk sexual behavior at a statistically significant level.
However, the agency does not require researchers to identify what exact components of interventions cause behavioral change. The CDC instead approaches these HIV prevention interventions like a doctor would medication to a patient, useful only with the right blend of ingredients. Therefore, HIV prevention programs must maintain fidelity to intervention models, even when specific components of the models conflict with community values.
Yet interventions are not medications. Many HIV interventions could probably still be effective without some components as long as the causal or “systematic” ones remained in place. The problem is that CDC officials do not seem to know which components are systematic.
The CDC-funded Mpowerment Project model illustrates this point. Mpowerment is a community-level intervention that seeks to create safer-sex norms among gay and bisexual men. Mpowerment does this by holding discussion groups that address the main causes of gay sexual risk behavior. Mpowerment also hosts social events that give men a chance to encourage their friends to practice safer sex.
The CDC and other funders expect agencies to adhere to this model, but many do not because it conflicts with their communities’ values. For example, some Mpowerment projects serve hyper-masculine closeted men who curl their lips at the program’s requirement for volunteers to wear flamboyant outreach costumes (e.g. “condom fairies”) when conducting safer-sex outreach in gay bars. Other projects serve university students who detest the model’s strict prohibition of women. They see it as sexist and antithetical to building queer community. For some, the model just does not fit.
However, with modifications it could be a better fit for some communities. The challenge is to convince the CDC to require researchers to identify which components actually cause behavioral change. Researchers would have to support each component with a social science theory and evidence to back it up. If they can not provide this support, then the component is inconsequential and the CDC should not require agencies to adhere to it.
In the case of Mpowerment, this would be a hard pill to swallow for a few researchers at the University of California at San Francisco (UCSF) who have much invested in keeping the model as is. If agencies changed inconsequential components of the intervention, then the technical assistance these researchers provide would be less relevant.
Pity that resistance to such changes in interventions like Mpowerment inhibit programs from doing what they should do best — outreach to high-risk populations in the most effective manner. An even bigger pity that the White House will not amend its new HIV/AIDS Strategy until 2015. This leaves evidence-based interventions four and a half more years to parade around wearing the mantle of rigorous science.