CDC highlights interventions that reduce disparities in HAV, HIV/AIDS

The CDC featured several interventions in a recent MMWR supplement that effectively reduced health disparities in hepatitis A virus and HIV/AIDS care.

The interventions demonstrated how certain strategies such as increased vaccination and outreach efforts tailored to specific populations and individuals can reduce disease incidence and promote safe behaviors.

“Programs designed to build health equity are a smart investment for improving health outcomes,” Leandris Liburd, PhD, MPH, associated director for the CDC’s Office of Minority Health and Health Equity, said in a press release. “Public health professionals can enhance the impact of strategies for reducing health disparities, disseminate and tailor these strategies to reach more communities, and determine how to expand these strategies for even greater impact by rigorously applying lessons learned from these efforts.”

Changes to HAV vaccination recommendations increase coverage

Incremental changes to the Advisory Committee on Immunization Practices’ (ACIP) recommendations for hepatitis A virus vaccination increased nationwide coverage, particularly in individuals disproportionately affected by HAV disease such as adolescents, young adults, American Indian/Alaska Native ethnic groups, Hispanics, and individuals with low socioeconomic status.

Two-dose schedules of inactivated HAV vaccines were first approved in the U.S. for individuals aged 2 years and older in 1995 and 1996, according to Trudy V. Murphy, MD, from the CDC’s Division of Viral Hepatitis and the National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention, and colleagues. Vaccination efforts in 1996 initially targeted individuals living in areas with communitywide outbreaks and high rates of infection.

In 1999, ACIP updated its recommendations to incorporate children aged 2 years or older who were living in states with HAV disease rates that were at least twice the national average, which included Arkansas, Colorado, Missouri, Montana, Texas and Wyoming. The committee also proposed that older children aged up to 10 to 15 years and residing in communities with high disease rates receive a HAV vaccination to prevent epidemics. Eleven states met the incidence criteria for “recommend” vaccination, and six states met the incidence criteria for “consider” vaccination.

In 2006, ACIP changed the HAV vaccination recommendations to include all children aged 12 to 23 months in the United States.

Data collected from 2008 to 2013 revealed that HAV vaccination coverage was highest in states where the vaccines were recommended, slightly lower in states where vaccines should be considered, and lowest in states where vaccination was not recommended until 2006. By 2013, at least one dose of HAV was administered to 82% to 86% of children in every state, and disparities in vaccination were diminishing. By 2010, differences in coverage between previously identified vaccinating and nonvaccinating states were nonsignificant.

An increase in HAV vaccination coverage corresponded with a decrease in disease incidence, which declined from 11.7 cases per 100,000 in 1996 to 2.6 cases per 100,000 in 2003. Disease rates in states that recommended or considered vaccination were lower than in nonvaccinating states; however, geographic disparities nearly diminished by 2007.

The reduction in HAV disease rates were most evident in racial and ethnic groups disproportionately affected by HAV. The disease rate decreased by 98.8% (95% CI, 98.4%-99.2%) in Native Americans and 86.4% (95% CI, 85.3%-87.1%) in Hispanics by 2003. By 2011, HAV infections declined to less than 1.0 case per 100,000 people, eliminating “absolute disparities among racial/ethnic groups,” Murphy and colleagues wrote.

The researchers contributed the significant decline in cases to demonstration projects and campaigns that targeted vaccination efforts to children in high-risk areas and disadvantaged populations. The Vaccines for Children (VFC) program, for example, provided free vaccines to children from low socioeconomic backgrounds, which helped close the gap in economic disparities, they wrote.

Despite the decrease in HAV infections in children, however, an increase has been reported in 2012 and 2013 among adults aged 40 years and older. The majority of cases were attributed with international travel and contact with HAV-infected individuals.

“The increasing proportion of HAV disease cases among adults with identified and unidentified sources of exposure adds importance to considering new strategies for preventing HAV infection among U.S. adults,” Murphy and colleagues wrote. “The gap in HAV disease between young children and adults is an emerging health disparity that will require new strategies to continue progress toward elimination of HAV infection.”

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HIV prevention interventions increase safer behaviors among Hispanic men, high-risk MSM

To reduce health disparities in HIV for men who have sex with men, who accounted for 54% of all HIV infections in the United States in 2011, the CDC funded research to investigate the Personalized Cognitive Counseling (PCC) intervention — a 30- to 50-minute counseling session that addresses self-justifications men use to engage in risky sexual behaviors despite the risk for contracting HIV. The intervention was identified as a “best evidence” HIV intervention for its brevity, access to HIV testing, cost-effectiveness (estimated $145 per client), flexible delivery settings and personalization, according to Jeffrey H. Herbst, PhD, from the CDC’s Division of HIV/AIDS Prevention and the National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention, and colleagues. A user-friendly intervention package is available online for HIV prevention providers at effectiveinterventions.cdc.gov.

The effectiveness of PCC was assessed during a randomized trial in San Francisco from May 2010 to May 2012. The trial included MSM who reported unprotected anal intercourse (UAI) while under the influence of alcohol or drugs. The participants were randomly assigned to the intervention session plus HIV testing (n = 162) or HIV testing alone (n = 164). In the intervention group, participants recollected an UAI event, completed a questionnaire of self-justifications and then, with the help of a counselor, decided how to handle similar situations in the future.

According to the results, PCC participants reported a greater reduction in UAI events compared with the control participants (RR = 0.57; 95% CI, 0.33-1.01). In addition, PCC participants reported greater abstinence rates from alcohol (RR = 0.93; 95% CI, 0.89-0.97), marijuana (RR = 0.84; 95% CI, 0.73-0.98), and erectile dysfunction drugs (RR = 0.51; 95% CI, 0.33-0.79) vs. the control participants.

For another prevention intervention targeting Hispanic men, who have the second highest rate of AIDS diagnoses among all ethnic groups and are two to four times more likely to contract gonorrhea, chlamydia and syphilis vs. non-Hispanic whites, researchers developed the HoMBReS intervention to promote consistent condom use and HIV and STD testing. The intervention uses informal community leaders called lay health advisers who are trained to work with other community members and increase access to care among populations who might otherwise be hard to reach, Scott D. Rhodes, PhD, from the Wake Forest School of Medicine, and colleagues wrote.

The effectiveness of the HoMBReS intervention was assessed in a social network of 30 soccer teams comprised of immigrants from Mexico (60%) and Central America (40%). Fifteen teams were enrolled in the intervention arm and selected a teammate to serve as a lay health adviser. Each adviser was trained and received financial incentives for each training session and data collection. For the next 18 months after training, the health advisers educated the other players on STD prevention, care and treatment; distributed resources such as condoms; and discussed ways to access care.

Results adjusted for relationship status and within-team clustering showed that intervention participants reported more consistent condom use (adjusted OR = 2.3; 95% CI, 1.2-4.3) and HIV testing (aOR = 2.5; 95% CI, 1.5-4.3). Lay health advisors also reported during post-intervention interviews that they distributed condoms to a few female sex workers and Hispanic MSM, which suggests the effects of the intervention extend beyond the targeted individuals.

The intervention is commercially available at www.socio.com. An enhanced version called HoMBReS Por un Cambio (Men for Change), which includes DVD segments for lay health advisers, as well as a revised version of the intervention called HOLA, which is focused on Hispanic MSM and transgender individuals, also was developed.

“Because the populations disproportionately affected by HIV and STDs often lack needed prevention resources, wide implementation of interventions that harness community social networks, such as HoMBReS, HoMBReS Por un Cambio and HOLA, could decrease behaviors that increase risk for HIV infection among Hispanics/Latinos in the United States, including MSM and transgender persons,” Rhodes and colleagues concluded. “In addition, the strategy might be effective among other populations and applicable to other health issues.” – by Stephanie Viguers

References:

Herbst JH, et al. MMWR Suppl. 2016;doi:10.15585/mmwr.su6501a7.

Murphy TV, et al. MMWR Suppl. 2016;doi:10.15585/mmwr.su6501a6.

Rhodes SD, et al. MMWR Suppl. 2016;doi:10.15585/mmwr.su6501a8.

Disclosure: The researchers report no relevant financial disclosures.