Description
Please review this document and answer the discussion questions at the end of the document. Submit your answers, numbered, here in a word document – Arial 11 point font, double spaced.
Internet-Based HIV/AIDS Education and Prevention Programs in
Vulnerable Populations: Black Men Who Have Sex with Men
Authors
Amar Kanekar, PhD, MPH, MB, MCHES, CPH .
Affiliations
Department of Health, Human Performance and Sport Management, University of Arkansas at
Little Rock, Little Rock, AR, USA
Email: ude.rlau@rakenakxa
This case is presented for instructional purposes only.
9.9.1. Background
Since surfacing more than 30 years ago, the HIV/AIDS pandemic has devastated populations
worldwide. Various factors have contributed to this epidemic, such as lack of awareness of HIV
status, stigma, homophobia, negative perceptions about HIV testing, socioeconomic factors,
behavioral risk factors, and high prevalence of sexually transmitted diseases (Centers for Disease
Control and Prevention 2015). In the United States, one goal of the national HIV/AIDS strategy
is to reduce HIV-related health disparities. Any reduction in the collective risk of acquiring HIV
will require behavior change interventions in communities with the highest HIV prevalence.
However, extending the reach of HIV/AIDS preventive interventions in remote areas with
limited access to HIV testing and prevention services has proved difficult (Office of National
AIDS Policy 2012).
The challenge of reaching some populations has led many practitioners to consider innovative
intervention methods that rely on technologies such as the Internet and mobile telephones. Public
health professionals are using these technologies to deliver health education to vulnerable
populations in big cities, small towns, and hard-to-reach rural areas. In particular, the past decade
has seen more health communication efforts using the Internet to prevent HIV and sexually
transmitted diseases (Bull et al. 2007, 2009; Rietmeijer and McFarlane 2009). Studies of
interventions that use Internet chat rooms, online modules, and health intervention websites show
promising results that bode well for the future of these technologies (Chiasson et al. 2009;
Moskowitz et al. 2009).
Studies conducted with marginalized and vulnerable populations such as black men who have sex with men (MSM) can pose difficulties. On the technology front, many difficulties reflect the Internet’s relative novelty for conducting studies and the consequent lack of clarity in dealing with the rules, language, and norms of a virtual community culture compared with a traditional community culture (Loue and Pike 2010). On the allocation front, having limited resources usually implies that tailoring interventions to a specific group will mean forgoing benefits to another group. Still, in promoting the health of populations, public health professionals must strive to distribute resources fairly while responding to the specific needs of racial, ethnic, and cultural groups. These concurrent goals require maintaining a delicate balance between targeted and population interventions. On the ethics front, because some projects straddle the line between research and practice, public health professionals can become unsure about whether the ethical guidelines of research or of community work should govern their actions. They must bear in mind that trust, which is essential for conducting community-based participatory research, becomes more crucial when working with vulnerable populations, which tend to show a high degree of mistrust (Loue and Pike 2010). Those who study vulnerable populations need to negotiate community entry either by developing trust or by working closely with local practitioners and building upon established trust.
In the United States, the HIV/AIDS epidemic has hit the African-American population hardest,
with black men accounting for 70 % of new HIV infections. Between 2006 and 2009, new HIV
infections increased 48 % among black 13- to 24-year-old MSM (Centers for Disease Control
and Prevention 2015); by 2009, 37 % of new HIV cases among black men were from black
MSM. Given this high prevalence, before the end of 2015, the U.S. national HIV/AIDS strategy
calls for a 20 % increase in the proportion of African Americans diagnosed with HIV who have
an undetectable viral load (Office of National AIDS Policy 2012). Already, information about
HIV issues affecting young MSM (Mustanski et al. 2011) is widely available on the Internet,
including messages about how to reduce risk (Hightow-Weidman et al. 2011) and interventions
to prevent HIV risk behaviors among MSM (Rhodes et al. 2010) and blacks who inject drugs
(Washington and Thomas 2010). Studies show that online delivery of HIV counseling and
behavioral interventions for MSM at high risk for HIV are successful, suggesting that the future
holds great promise for Internet-delivered interventions for this vulnerable population (Chiasson
et al. 2009; Moskowitz et al. 2009).
9.9.2. Case Description
Dr. Albert, a social scientist, and Dr. Baines, a community worker, are employed by a public
health agency in a medium-size U.S. town. The agency has asked them to determine whether a
skill-based, Internet-delivered intervention to promote safer sex among young Black MSM will
increase HIV knowledge and increase the frequency of using safer-sex practices.
Project participants will be recruited via the Internet in gay chat rooms and be verified
electronically by using Internet Protocol and Microsoft Access usernames and passwords (Bull
2011). Participants will be surveyed before they begin the training modules and again at 1- and
6-week intervals after completing the modules. Participants will be randomly assigned to control
and experimental arms. Those in the control arm will receive 6 h of online training about health
and well-being (e.g., nutrition, physical activity, stress reduction). The experimental arm will
receive a 6-h online program including two 1-h modules on each of the following topics: (a)
HIV/AIDS-related knowledge; (b) development and improvement of safe sex skills, such as
partner communication and monogamous sexual relationships; and (c) self-efficacy in using
condoms. The modules will include automated reminders for HIV testing. The study will
measure improved knowledge on HIV/AIDS, partner communication about safer sex, and
condom usage self-efficacy. Data will be analyzed using statistical software.
Dr. Albert thinks the results could be generalized not only to black MSM in the community but
also to black MSM overall. He plans to write an article describing the results for publication in a
scientific journal. Although Dr. Baines knows the impact of education on health, especially in
underprivileged communities, she wants to educate only a subset of the community they will reach. Besides, since their work is for a public health agency, she believes the intervention ought
to reach as many community members possible. She claims the project’s goal is to provide a
vulnerable and disadvantaged population with much needed education on health matters and
health-promoting behavior and doubts their project constitutes research.
Dr. Albert worries that, because his colleague lacks academic rigor and underappreciates the role of evidence, she fails to appreciate the project’s rationale and design and, as a result, is
indifferent to the challenges the Internet poses (e.g., technology-induced bias, protection of
confidentiality). Conversely, Dr. Baines believes Dr. Albert has missed the boat and is wasting
resources, spuriously introducing statistical analysis of experimental and control arms into what the agency clearly had intended as an education intervention.
9.9.3. Discussion Question
1. Is this a research project? Should approval from an ethics review committee be obtained? Or
should the project be considered non-research because it will improve the health of the
population? How should you decide?
2. Does the fact that the project is funded by a public health agency play a role in this
discussion? Should public health agencies conduct studies to generate evidence about HIV
education and prevention interventions? Should agencies focus on the delivery of interventions
based on the existing evidence?
3. How is this black MSM population vulnerable, and how should this vulnerability be
addressed in research and non-research interventions?
4. Do Dr. Albert and Dr. Baines have ethical obligations to other community populations? On
what basis is the public health agency justified in advancing interventions that target only a
subgroup of the community?
5. How should research studies on Internet-based interventions be conducted to ensure
scientific validity, given the difficulties of knowing, for example, whether the participant meets
the study’s inclusion criteria? Which measures should be taken to protect the privacy and
confidentiality of participants?
6. How should you decide what level and type of evidence you need to back a public health
educational intervention? Should public health professionals always use science to validate educational interventions?
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