Building Community Partnerships to Improve HIV Prevention Efforts: Implications for Nurses.

Acquired immune deficiency syndrome (AIDS), caused by the human immunodeficiency virus (HIV), is a major and complex public health crisis. The Centers for Disease Control and Prevention (CDC) issued effective community-based HIV prevention planning in its 1993 "Supplemental Guidance on HIV Prevention Community Planning" through the formation of community planning groups (CPGs). These guidelines are reviewed along with behavioral and social science theories that are the crux of HIV prevention theory-based research and program development. Nurses' roles in community-based HIV prevention as community advocates, HIV prevention program planners, practitioners, and researchers are discussed. The article concludes with nursing implications for HIV prevention.

Acquired immune deficiency syndrome (AIDS), caused by the human immunodeficiency virus (HIV), continues to be a major, complex, and multidimensional public health crisis. In 1993, AIDS became the leading cause of death in the United States among adults ages 25 to 44 (Centers for Disease Control and Prevention [CDC], 1995). Despite recent reports of declining mortality rates, AIDS continues to spread at an alarming rate, particularly in communities of colon Although African Americans and Latinos together represent only 17% of the nation's population, 53% of all reported AIDS cases are among these populations (CDC, 1996). The 1996 AIDS case rates per 100,000 population were 89.7, 41.3, and 13.5 among Blacks, Hispanics, and Whites, respectively (CDC, 1996).

Although attention is often focused on the biological scientific community and its efforts to discover a cure or develop a vaccine for HIV, the powerful contributions of behavioral and social scientists, including nurses in the development of effective prevention strategies, are being recognized. However, the question that still remains is, How can nurses best implement prevention strategies for communities at risk? One strategy is for nurses to be actively involved in the Community Planning Group (CPG) process mandated by the Centers for Disease Control and Prevention (CDC).

The CDC highlighted the role of behavioral scientists in HIV prevention in 1994, when it launched a new initiative called "HIV Prevention Community Planning." This initiative stressed the importance of behavioral and social science in designing, implementing, and evaluating HIV prevention and intervention strategies. The question that emerges is, What roles can nurses (researchers, educators, and clinicians) play in working with community HIV prevention programs? This article describes the CDC's recommended CPG process. Select behavioral theories used to design HIV prevention programs, program evaluation methods, and implications for nursing research and practice are explored.

CDC-Recommended CPGs

The CDC issued the "Supplemental Guidance on HIV Prevention Community Planning" in December 1993 and effectively changed the nature of prevention planning. This document mandated that all health departments receiving prevention funding from the CDC participate in a new cooperative system of developing and implementing a comprehensive HIV prevention plan. This planning was to be conducted through the efforts of local CPGs.

Flexibility is one of the defining characteristics of the new model of HIV prevention. The CDC set forth basic guidelines for the process but did not define its structure. The grand goal was to create new functional partnerships between key players such as health departments, service providers, people living with HIV/AIDS, populations at increased risk for infection, and the CDC. To ensure representation, the demographic composition of CPGs is required to reflect the demographic characteristics of the current and projected individuals infected with HIV in each target community (CDC, 1993). Additionally, CPGs must place special emphasis in the recruitment of marginalized and underserved community members and encourage them to voice their concerns in all phases of the planning process. Each member is expected to work for the greater goal--improving the quality and effectiveness of federally funded prevention efforts--although they may also be called to relate the experiences and voice the concerns of the target population with which they self-identify.

Through the formation of CPGs, the CDC sought to increase community input by allowing each to identify subpopulation(s) at highest risk of HIV infection, unmet prevention needs and barriers, and the best approach to HIV prevention in a particular community. This approach represents a return to the "bottom-up" method, which is a fundamental shift in planning direction. The shift is grounded in the belief that communities own not only the problems but also the solutions (DeAngelis, 1997) and that prevention is most effective when it is designed and initiated by the community.

The first task of the CPG is to complete a needs assessment that helps to define HIV prevention needs (CDC, 1993). This begins with the collection of epidemiologic data that reflects the trends and impact of HIV/AIDS in targeted populations (CDC, 1993). Epidemiologic profiles may include data such as the number of HIV infections and AIDS cases, sexually transmitted disease (STD) infection rates, pregnancy rates, and drug-treatment enrollment data (Cloutier, 1995). A thorough needs assessment incorporates information from a variety of sources using a variety of collection strategies. Scant quantifiable data may be available for some potentially high-risk populations. Therefore, quantitative data may be supplemented with qualitative data sources such as focus groups and key informant interviews. Ultimately, CPGs will face tough decisions about how to best balance the data collected through qualitative versus quantitative methods.

Equally important in the planning process is the assessment of current prevention strategies (primary, secondary, and tertiary) within the community. Creating an inventory of service providers that includes information about the types of interventions used is helpful. Every implemented prevention intervention should be challenged and changed if it no longer addresses the real prevention needs of people with HIV and those engaging in HIV risk-related behaviors (Levi, 1995).

A useful tool to guide the collection and organization of needs-assessment information was recommended by the Academy for Educational Development (1995). Six broad parameters of interest were identified for each service provider. All service providers were to collect information about the intervention, objective, target, frequency, setting, mode, and outcome evaluation. See Table 1 for complete details.

 
Table 1. Pertinent Information for Needs Assessments 
 
Parameter      Description 
 
Intervention   Any organized activity designed to influence 
               knowledge, attitudes, beliefs, or behavior 
               related HIV/AIDS prevention. Interventions 
               may vary in scope from a single educational 
               program to multifaceted comprehensive 
               programs. 
 
Objective      The behavioral determinants that the 
               intervention proposes to affect, for example, 
               cognitive change (information, skill, social 
               norms) or structural change (service, product). 
 
Target         The level at which the intervention is 
               targeted--ranging from individual to the public. 
 
Frequency      The number of times the intervention is 
               provided: once, ongoing, periodic. 
 
Setting        The specific place in which the intervention is 
               presented to the target population: institutional 
               site, the workplace, school, the street, and so on. 
 
Mode           The method or manner in which the intervention 
               is provided: …