World AIDS Day, observed on Dec. 1 since 1988, has become a yearly reminder of the staggering statistics associated with a disease that continues to challenge health officials and the public. In 2009, over 1.5 million people in the United States were living with HIV or AIDS, and the Centers for Disease Control (CDC) estimates that approximately 50,000 people are infected with HIV each year.
African-Americans constitute 12 percent of the U.S. population but account for roughly 45 percent of those newly infected with HIV, according to the CDC. Furthermore, a large percentage of new infections occur in women as a result of heterosexual sex. In New York City alone, there are over 3,000 new HIV diagnoses a year.
Treatment options have effectively addressed the scourge; so have positive trends in prevention. Dr. Nabila El-Bassel, a professor at the Columbia University School of Social Work, has been involved in HIV studies for 20 years. Recently, she was the principal investigator on a couple-based prevention approach to lowering HIV vulnerabilities in African-American communities.
With funding from the National Institute of Health and research and analysis from Columbia University, the University of Pennsylvania, Emory University and UCLA, El-Bassel and an investigative team from each school designed and implemented Project Eban, a culturally congruent HIV prevention program for serodiscordant (one partner is HIV-positive, the other is not) African-American couples. The term Eban means “fence,” symbolizing safety and security. Indeed, the project was designed to consider overall health advancement along with HIV risk reduction.
AN EFFECTIVE COUPLE-BASED PREVENTION APPROACH
In keeping with public health officials’ recommendation to go beyond individual HIV prevention strategies, Project Eban is relationship-based. “Redirecting the focus to address relationship factors that influence sexual decision-making increases the likelihood that risk reduction will be stable over time among couples,” said El-Bassel.
Conducted in New York, Philadelphia, Atlanta and Los Angeles, Eban tracked 535 randomly selected, pre-screened couples for one year to assess and reduce their HIV/AIDS risk. The couples-all heterosexual, with at least one self-identified as African-American or Black-consisted of one HIV-negative and one HIV-positive partner of either gender. In addition to awareness of each another’s HIV status, the couples, at least 18 years and older, were required to have been together at least six months, with the intention to remain together at least 12 more months. The couples also reported having unprotected intercourse with their partner in the previous 90 days.
Project Eban couples were randomized into two groups: HIV risk reduction and health promotion. The groups consisted of eight weekly, structured two-hour sessions held over the course of one year. Half of the sessions included individual couples meeting one-on-one with a facilitator; the other half were group sessions with six to eight couples. The participants also met separately from their partners in same-sex groups with same-sex facilitators.
HIV risk reduction intervention is designed to raise participants’ involvement and awareness in the following ways: discussion of sexual behaviors and perceived risks; exercises encouraging talking and listening skills; use of video screenings and practice; problem-solving exercises; identifying and defining sexual violence; examination of gender roles; condom use; prostitution discussion; identifying social support systems; discussion of childhood and family history and trauma; and alcohol and drug use.
A vital aspect of Project Eban is its specific Afrocentric design. Applying Kwanzaa principles such as self-determination, cooperation and unity, and using Afrocentric videos, songs and literature effectively engaged the study participants. Additionally, the presence of highly qualified, trained African-American facilitators helped create an atmosphere of trust, lessening the stigma of HIV during the sharing of crucial information among the participants, both paired and individually.
“The unique realities of African-Americans who are at risk for HIV were addressed because Eban is a culturally congruent HIV prevention study,” said El-Bassel.
Couple-based approaches provide an opportunity for both partners to improve their HIV knowledge, disclose and identify risks and develop mutual goals and joint responsibility for protecting each other from STIs (sexually transmitted infections). The encouraging results also suggest that successful couples intervention helps protect the wider community from the spread of infection.
An important distinction of this study is that all of the participants knew their HIV status. Therefore, the results cannot be generalized for couples who are unaware of their status-all the more reason individuals and couples should know their HIV status and proactively safeguard their health.
PROMOTING MULTIPLE HEALTH BEHAVIORS
The health promotion aspect of Eban encourages healthy behavior. By recommending a diet rich in fruits and vegetables, a lifestyle that includes regular exercise, self-health exams and avoidance of tobacco and excess alcohol, the study demonstrated how much control African-Americans can assume for better ownership of their health. These protective health-related behaviors have been shown to reduce hypertension, diabetes, heart disease, certain cancers and other ills that are chronic in the Black community.
“Project Eban offers a prevention approach that may help reduce HIV risks as well as morbidity and mortality rates from chronic diseases in African-Americans,” said El-Bassel.
“To our knowledge, this is the first trial to evaluate health promotion intervention with African-American serodiscordant couples,” said El-Bassel. “The findings underscore the value of an intervention prevention model that targets multiple health behaviors.”
El-Bassel, who is also director of the Global Health Research Center of Central Asia, reported the positive results of the intervention study to the CDC and is looking into opportunities to share the findings with community centers and churches.
“In the one-year follow-up period, the proportion of condom-protected sex and the percentage of couples practicing consistent condom use increased, and over 70 percent of the participating couples remained together,” she said. “This represents a plus in sexual behavior outcomes, strengthens confidence in intervention efforts and has helped reduce the impact of HIV/AIDS on African-American communities.”