Reducing High-Risk Behavior and Improving HIV Test-and-Treat

    • August 5, 2013

There have been dramatic improvements in HIV/AIDS prevention and treatment across all populations in recent years. These advances highlight the need to examine ongoing disparities in transmission in certain groups and new prevention strategies such as HIV test-and-treat.

In new research, Natalie Crawford, PhD, an epidemiologist and Robert Wood Johnson Foundation (RWJF) Health & Society Scholar (2011-2013), examines the role of high-risk social relationships in the transmission of HIV/AIDS in different racial and ethnic groups.

For the study “The Relationship Between Discrimination and High-Risk Social Ties by Race/Ethnicity: Examining Social Pathways of HIV Risk,” published in the June 2013 Journal of Urban Health, Crawford and her co-authors analyzed patterns of social behavior among people who used drugs frequently.

“We looked at sexual and drug-use ties that were more likely to increase HIV transmission among injection and non-injection drug users as those behaviors relate to experiences of discrimination,” Crawford said. “We decided to look at this population because the literature shows that the higher rates of HIV transmission among Black and Hispanic drugs users [when compared to White drug users] cannot be fully explained by how often they use drugs or have unprotected sex.”  

Crawford cited experts in the field of HIV prevention who argue that racial disparities in HIV rates persist in part, because of “racialized social processes that influence participation in high-risk social network relationships.”

Discrimination and Social Interaction

Study data was gathered from a group of 652 injection drug users (IDUs) and non-IDUs enrolled in the Social Ties Associated with Risk of Transition into Injection Drug Use Study. Blacks, Hispanics and Whites in the group were asked: Have you experienced discrimination based on: 1.Your race; 2. Your drug use; 3. A history of incarceration.

“We found that the members of the group who most often answered “yes” they had been discriminated against were more likely to have social relationships with people who had sex for money or participated in other high-risk sexual or drug use behaviors, such as sharing needles,” Crawford reported. “There were also racial differences in the impact of different types of discrimination.”

Blacks who reported higher rates of race-based discrimination were more likely to have high-risk sexual relationships. Hispanics and Whites who reported being discriminated against because they were drug users were more likely to form high-risk injection drug use ties.

 A Community Problem

The findings suggest that social workers and others who work to prevent HIV/AIDS must recognize the potential impact of discrimination and other social stressors on high-risk behaviors. “It also points to the ongoing importance of harm reduction efforts such as providing clean needles and condoms,” Crawford said.

“An additional problem,” added Crawford, “is that drug use is seldom thought of as a community problem, but it is a family and community issue. We need to think about these social ties in the context of community health.”

A Better Approach to Test- and -Treat

RWJF Clinical Scholar, supported in part by the U. S. Department of Veterans Affairs, (2008-2011) Sonali Prakash Kulkarni, MD, MPH, is also investigating methods of preventing HIV/AIDS. She is seeking answers to the ongoing questions about the use of the HIV test-and-treat strategy.

Several studies have shown that the test-and-treat approach to reducing HIV infections is quite successful. Research funded by the National Institutes of Health in 2011 found that when HIV-infected people received anti-retroviral therapy (ART) soon after diagnosis and before developing AIDS, they were 96 percent less likely to infect their partners. This test-and-treat procedure is a departure from the current test-and-wait method of treating HIV/AIDS.

While Kulkarni agrees that test-and-treat has tremendous promise, she makes a case for addressing several issues that may reduce its effectiveness. Her goal is “to identify the clinical uncertainties, health service challenges, and ethical complexities that may impede the success of test-and-treat.”

Kulkarni, HIV medical director at the LA County Department of Public Health, Division of HIV and STD Programs, reviewed 123 studies for the article “Clinical Uncertainties, Health Service Challenges, and Ethical Complexities of HIV ‘Test-and-Treat’: A Systematic Review” published in the American Journal of Public Health in June 2013. She identified these key concerns:

  • Health Risks: Do the benefits of the early initiation of ART outweigh the potential—and at this point unknown—risks of lifelong treatment with the drugs? Kulkarni noted that the “Strategic Timing of Antiretroviral Treatment trial and HPTN052 study will provide some answers,” but more work needs to be done.
  • Effectiveness: Test-and-treat may reduce HIV virus levels to the point where they are undetectable in blood tests. But, the virus is still present in other body fluids. This leads to questions about the “real world effectiveness of the strategy,” Kulkarni advised. Further research needs to be conducted on people with advanced cases of HIV/AIDS.
  • Ethical Concerns: Kulkarni pointed out that the test-and-treat concept is justified by a public health approach to preventing HIV/AIDS, rather than the patient-centered method of HIV/AIDS treatment that focuses more on the interests of individuals. She called for greater attention to “the risks of early ART therapy, fair distribution of scarce treatment resources in the United States and around the world, and minimizing the potential for patients to be coerced into consenting to test-and-treat.”

Her recommendations included a call for greater community involvement and funding for projects that would increase access to HIV/AIDS treatment in non-traditional and culturally-sensitive environments.

Moving Forward

Kulkarni and her co-researchers suggested that the most effective way of addressing HIV/AIDS would be “achieving universal testing and treatment according to current World Health Organization guidelines for the initiation of ART,” until there is sufficient evidence about how to successfully implement HIV test-and-treat. She proposed “a strategic and thoughtful approach to research, implementation and community engagement…in order to make test-and-treat a reality.”


Related Websites

Learn more about the RWJF Clinical Scholars program.
Learn more about the RWJF Health & Society Scholars program.
For an overview of RWJF scholar and fellow opportunities, visit