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The Effect of HIV Public Health Marketing Campaigns on Linkage to Care:
Can Advertisements Encourage Individuals to go to a Medical Clinic for HIV testing and/or
HIV care?
By
Holly Crane Watkins
A Master’s Paper submitted to the faculty of
the University of North Carolina at Chapel Hill
In partial fulfillment of the requirements for
the degree of Master of Public Health in
the Public Health Leadership Program.
2015
__________________________________
Advisor Signature/ David Steffen, DrPH, MSN
________________________________
Date
________________________________
Second Reader Signature/Heidi Swygard, MD MPH
________________________________
Date
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TABLE OF CONTENTS
Abstract
I.
INTRODUCTION
A. Purpose and Urgency
B. Overview of HIV in the United States
C. Overview of HIV in North Carolina
D. Barriers/Challenges of HIV testing and treatment
II.
METHOD
A. What is Social Marketing and How Does it Work?
B. Literature Review of HIV Social Marketing Campaigns
1. CDC campaigns
2. Other community based campaigns within the U.S.
C. “Get Real. Get Tested. Get Treatment.”
1. Campaign Development
2. Activities
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III.
RESULTS
A. Campaign results
B. Successes/Challenges
IV.
CONCLUSIONS/RECOMMENDATIONS
A. Future Research
B. Leadership Recommendations
References
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ABSTRACT
BACKGROUND: In recent years, North Carolina has averaged approximately 1,400 – 1,500
new HIV reports annually and a majority of those new cases are among African-Americans.
Approximately 30 percent of the individuals newly reported each year with HIV disease also
represents new AIDS cases. This significant proportion of late diagnoses (i.e. AIDS) indicates
the need for increased HIV testing, education and linkage to care in North Carolina.
OBJECTIVE: This paper describes how HIV affects North Carolinians and examines the link
between public health marketing campaigns and linking HIV positive patients to HIV care and
treatment.
METHOD: A public health marketing campaign that includes advertisements on television
stations and specific web sites will be available at given times throughout the calendar year. The
advertisements will include a specific call to action (either a web site address or phone number to
get more information) which can be measured an evaluated to determine if the individual gets
further information about getting tested for HIV and/or get into HIV care.
RESULTS: A marketing campaign using television commercials was launched in June 2012.
The television commercials aired during three separate time periods: June 2012 - August 2012,
December 2012 - February 2012 and January 2013 - May 29, 2013. Results from that campaign
showed that 54 individuals called to get more information on getting tested for HIV or getting
into care for HIV. 32 of those individuals were linked to HIV care and medications.
CONCLUSIONS: This campaign taught us valuable lessons, including the importance of using
not only television, but expanding to the use of web sites. Many of the individuals that we want
to reach use the internet as the primary means of getting information, meeting people and
communication. The question then becomes, “Can advertisements encourage people to get
tested for HIV or motivate them to get into care if they are HIV positive?”
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INTRODUCTION
Purpose and Urgency
Thirty years after the epidemic began Human Immunodeficiency Virus (HIV) continues
to remain problematic in North Carolina. HIV does not discriminate and can affect anyone of any
race, gender or sexual identity. Even with HIV medication and treatment available, many HIV
positive individuals find it challenging to pay for and stay adherent to these medications. While
much has been achieved in the field of HIV, much work is yet to be accomplished.
The HIV epidemic remains an urgent issue that must be addressed by local and state
governments along with the scientific community. HIV is a communicable disease and North
Carolina reports an average of 1,200 – 1,400 newly diagnosed HIV cases per year (North
Carolina HIV/STD Surveillance Unit, 2015). Many of the individuals who are diagnosed with
HIV do not have health insurance and cannot afford HIV medications. Even those who have
health insurance may not be able to afford co-pays and multiple doctor visits.
As important as surveillance, identification of new cases, and insurance coverage are, the
bigger issue is medication adherence. For those who test HIV positive, it is imperative to get
onto a treatment regimen and stay on it. A study conducted by Dr. Myron (Mike) Cohen at the
University of North Carolina at Chapel Hill determined that an HIV positive individual who is
taking their HIV medication as prescribed has a 96% chance of not transmitting the disease to
their partner (Cohen, 2011).
HIV is a disease that continues to stigmatize those who are positive. The majority of HIV
cases in North Carolina are in the African American community – which is disproportionately
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affected by this disease. Many African Americans who test positive are often ostracized by their
families, churches or communities. This can result in HIV positive individuals hiding their
disease and refusing to seek treatment until they are in medical crisis.
This paper will give an overview of the HIV epidemic in North Carolina and explore the
use of public health marketing campaigns in reaching the African American community,
specifically men who have sex with other men (MSM), about the importance of getting tested
and getting linked to care.
Overview of HIV in the United States
According to the Centers for Disease Control and Prevention (CDC), HIV affects the
human immune system (CDC, 2015) by breaking down the specific cells in the immune system,
known as T cells, making an individual more susceptible to infections. Once the T cells in the
immune system are eliminated, it can advance to a more severe form known as Acquired
Immune Deficiency Syndrome (AIDS). There is no cure for HIV, so once someone tests positive
for this disease, then they will have it for the rest of their life (CDC, 2015). HIV is transmitted
through sexual contact, or the use of contaminated drug injection paraphenalia that has been
shared with someone who is HIV positive. It is not transmitted through casual contact.
Once the T cells in the body drop below 200 and an opportunistic infection is identified, a
patient will then be diagnosed with AIDS. It is possible to be diagnosed with HIV and AIDS at
the same time.
The CDC estimates that there are approximately 1.2 million people in the United States
who are living with HIV disease. Of that number, it is estimated that 156,000 people are unaware
that they are HIV positive (CDC, 2015). That translates to 1 in 8 people who are not aware that
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they are HIV positive. In 2012, it is estimated that 13,000 people with an AIDS diagnosis died
(CDC, 2015).
In the United States, African Americans and Latinos are disproportionately affected by
HIV disease. Gay and bisexual men, along with Men Having Sex with Men (MSM), are the
group that has the highest number of reported cases of HIV. This population is being
disproportionately affected by HIV and other sexually transmitted diseases. According to a
report, a study conducted in 21 major cities found that one in three black gay and bisexual men
are HIV positive (MMWR, 2010).
Women and injection drug users (IDU) continue to make up a significant proportion of
new diagnoses of HIV disease. IDU has become a particular concern recently due to the 2015
outbreak of HIV among IDU in Scott County, Indiana. Many states are trying to learn from this
situation and implement their own prevention plans.
Historically, several major urban areas such as New York City, San Francisco, Miami
and Chicago have reported the highest number of new HIV cases. Over the past several years,
there has been a transition. These cities continue to report high numbers of HIV cases, but states
in the South are reporting high numbers of newly reported HIV cases. In 2012, the states
comprising the southern portion of the United States reported over 48% of all newly diagnosed
cases of HIV. During that same year, North Carolina reported 1,389 new cases of HIV and
ranked 8th in the country for newly diagnosed cases of HIV (NC Epi Profile, 2015).
Overview of HIV in North Carolina
As of December 2013, there were 36,300 North Carolinians living with HIV. Of that
number, approximately 6,500 do not know that they are HIV positive. On average, North
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Carolina reports 1,400 – 1,500 newly diagnosed cases of HIV each year. The counties in North
Carolina with the highest rates of HIV infection is Mecklenburg, Edgecombe, Cumberland,
Durham and Guilford (NC Epi Profile, 2015).
The demographic breakdown of HIV cases in North Carolina is similar to the reporting at
the national level. African American men and women are disproportionately affected by this
disease. According to the North Carolina Epidemiological Profile for December 2013, the largest
group of individuals living with HIV is African American (18,377) followed by White/Caucasian
(7,071). The age group with the highest number of newly diagnosed HIV cases is ages 20-29.
Of the newly diagnosed cases of HIV reported in 2013, the highest risk of exposure was
MSM(656 cases). Heterosexual transmission for HIV is also a high risk with 499 HIV cases
reported in 2013. But MSM and IDU risk exposures made up 63% of the newly reported HIV
cases in 2013 (NC Epi Profile, 2015).
Barriers / Challenges to HIV Testing and Treatment
There are several barriers to getting tested for HIV, begin diagnosed with HIV or AIDS
and being treated for HIV. There is a great deal of stigma associated with HIV. Because of how
the disease can be transmitted (through sexual contact or sharing of contaminated needles), many
HIV positive patients face HIV related stigma. This is defined as negative attention or abuse that
is directed towards someone who is HIV positive (AVERT, 2014). Some of the stigmatizing
factors include place of residence and lack of HIV knowledge (in the patient, medical providers
or general population). In addition to stigma, several of the myths associated with HIV and AIDS
that were noted over 30 years ago still remain. Many people believe that HIV can be spread
through casual contact and eating or drinking after someone who is HIV positive.
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Living in a rural community is a stigmatizing factor. Many cities in North Carolina have
small populations where “everyone knows everyone”. People do not want to get tested or treated
for HIV where they live because they know someone who works in the medical clinics or health
departments where testing and treatment are offered. Many individuals who do want to get tested
for HIV will travel out of their city or even out of state to ensure that they will not be recognized.
Those who are HIV positive, live in a rural area and are in need of HIV treatment are challenged
due to the lack of infectious disease doctors in rural counties. Many travel two to three hours one
way just to see an HIV specialist.
Those living outside of rural areas face stigmatizing factors as well. Many
individuals who are diagnosed with HIV are ostracized from their families, friends and churches.
Some patients who are not shut out must deal with family members who are uneducated about
HIV and how it is transmitted. They are forced to eat off of paper plates and use plastic cups and
plastic utensils or they have to live in sheds or outbuildings away from the main house and
family. Churches can openly discriminate by asking HIV positive patients and their families to
leave and not attend services or participate in church activities. This is very challenging to a
family dynamic because the church is the core of the community. Many families have
generations that have attended the same church. For those HIV patients who rely on the church
as a source of faith and fellowship, not having that in their life can be devastating and affect their
health.
Transportation can prove to be a major barrier in staying healthy, getting to HIV care
appointments and getting HIV medications. HIV patients living in rural and urban communities
must have a source of transportation in order to get back and forth to doctor’s appointments.
Many HIV patients who do not have transportation or live in an area that does not have a mass
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transit system must rely on family or friends to help get them to medical appointments. There
may then be the added pressure of being able to trust people and ensuring that they can be
discreet when taking them to appointments.
In addition to these barriers, trust is also an issue. Many individuals do not want to be
tested for HIV because they do not trust government health care. The Tuskegee syphilis study
was conducted in 1932 and continued for 40 years. The study used African American men to
examine the effects of syphilis.
Unfortunately, many late diagnoses occur because a patient may not want to know, think
that they could not be HIV positive or a doctor does not think to test a patient for HIV.
Symptoms of HIV disease can mimic symptoms of a flu virus. Patients who go to a hospital
emergency room for medical care could wait for hours to see a doctor, nurse practitioner, or
physician assistant.
When working with a patient, medical providers may not ask for a sexual history and if
they present with headache, nausea, diarrhea and weight loss may be misdiagnosed and sent
home. According to a report in Infectious Disease News, primary and secondary syphilis is also a
concern for MSM. Physicians are being encouraged to screen MSM for all sexually transmitted
diseases anytime they can and they must discuss sexual history (Infectious Disease News, 2015).
The CDC recommends that MSM have an annual screening that includes testing for HIV,
syphilis, chlamydia and gonorrhea. MSM who have multiple partners should be screened every
six months (Infectious Disease News, 2015).
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METHOD
What is Social Marketing and how does it work?
HIV prevention and education are critical in helping to control the number of new HIV
cases. One of the methods used to reach individuals with HIV prevention and education
messages is social marketing. In the 1970s, Philip Kotler and Gerald Zaltman realized that some
of the same principles that were used to sell products could be used to sell ideas and beliefs.
They define social marketing as a tool that “seeks to influence social behaviors not to benefit the
marketer, but to benefit the target audience and the general society” (Weinreich, 2006). Social
marketing uses four main elements – product, place, promotion and price - to reach the selected
target audience. While there are several benefits to using social marketing, such as reaching a
large number of people at one time, there are some challenges. In the fast paced digital world
that we live in, people want information quickly and attention span may be limited. Depending
on the audience, there may be many different messages that need to be created for multiple
outlets. For example, if Twitter is used for an HIV prevention message it can only be 140
characters. The message would need to be very concise and impactful. If a print advertisement is
placed in a newspaper or put on a web site, there may be more flexibility with the creation of the
message.
A social marketing campaign can be created around a health behavior that an agency
would like to change. There are six phases that should be incorporated into a campaign - problem
description, formative research, strategy development, intervention design, evaluation and
implementation (CDC, n.d.). Messages regarding healthy eating, exercise or safe sex can be
developed and branded. Then the campaign can be placed into television advertisements, print
ads and electronic media such as Twitter and Facebook.
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In order to create awareness and promote education and prevention messages, many
community organizations, local health departments and federal agencies have created HIV social
marketing campaigns. These campaigns are designed to promote changes and encourage
healthier behavior with the call to action being “get tested for HIV” or “talk to your doctor about
HIV medications and care”. Some of these campaigns have existed for several years.
Literature Review of HIV Social Marketing Campaigns
CDC Campaigns
The Centers for Disease Control and Prevention (CDC) established the Act Against AIDS
campaign in 2009. This is a large initiative that focuses on five different components – HIV
awareness, HIV testing, HIV prevention, HIV care and treatment and HIV providers. Act
Against AIDS has several smaller campaigns under its umbrella and was created due to lack of
awareness about the disease (CDC, 2015). Act Against AIDS focuses messages to high-risk
groups while attempting to raise awareness among all populations.
Included under the Act Against AIDS campaign arethe following social marketing
campaigns including “We Can Stop HIV One Conversation at a Time”, “Let’s Stop HIV
Together”, “Take Charge. Take the Test.”, “Testing Makes Us Stronger”, “Reasons/Razones”,
“Start Talking. Stop HIV”, “HIV Treatment Works”, “Prevention IS Care” and “One Test. Two
Lives.” Each of these initiatives focus on one population – African American MSM, Latino
MSM, gay and bisexual men, African American women and HIV medical providers.
One of the campaigns that specifically focuses on young, African American MSM is
“Testing Makes Us Stronger”. The goal of the campaign is to promote HIV testing with the focus
being empowerment – black gay and bisexual men should feel empowered and they can achieve
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this by getting tested for HIV and knowing their HIV status. Positive images of young, African
American men are shown. Some of these photos depict men standing together embracing or
holding hands. These types of images can help connect the audience to the campaign and make
them feel like “that could be me”. There are many promotional materials for this campaign
including posters and flyers that can be displayed in local health departments, clinics and
medical offices. Along with those, there are materials for providers that can be used to discuss
HIV treatment and care options with patients.
The CDC wants to ensure that women are being tested for HIV. There are high numbers
of African American women that are being diagnosed with this disease. Of the 1.1 million people
currently living in the U.S. who are HIV positive, 24% are women. (Kaiser Family Foundation,
2015). “Take Charge. Take the Test.” was created in 2012 and encourages African American
women between the ages of 18 and 34 to get tested for HIV (CDC, 2015). Through the
information included in this campaign, they are educated on the risk factors for HIV and
encouraged to get tested for HIV so that they can feel empowered and take control of their
health.
Other Community Based Campaigns within the U.S.
While the CDC conducts multiple national and international campaigns, local social
marketing campaigns have also been created to address specific local needs. In San Francisco,
the “Healthy Penis” campaign was created to address a sharp increase in syphilis cases. The
campaign was targeted in neighborhoods with the highest concentrations of gay and bisexual
men. There were posters and palm cards that were distributed in clubs, bus shelters and other
high traffic areas promoting the need to get tested for syphilis.
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In 2007, the Bronx had the highest HIV death rate in New York City. Almost one in four
residents were diagnosed with AIDS (NYC Dept of Health, 2011). As a result, the New York
City Department of Health created and launched “the Bronx Knows” which was designed as an
initiative to encourage and increase voluntary HIV testing for residents between the ages of 13
and 64. The campaign featured posters encouraging residents to get tested. The health
department partnered with community health organizations, churches, hospitals and others to
conduct over 600,000 tests. Of that number, 4,800 were diagnosed with HIV.
“Get Real. Get Tested. Get Treatment.”
Campaign Development
In early 2006, the State Health Director for North Carolina gave the Branch Head at the
Communicable Disease Branch, North Carolina Division of Public Health a directive – develop
an HIV testing campaign utilizing social marketing and street outreach to get people tested for
HIV. During this same time, the CDC issued new guidelines for routine HIV testing. The
guidelines stated that everyone between the ages of 13 and 64 should be tested for HIV and those
at high risk for contracting HIV should be tested at a minimum of once per year (MMWR, 2006).
“Get Real. Get Tested.” was developed with three goals in mind: 1) to test and educate
people for HIV and sexually transmitted diseases, 2) identify persons living with HIV/AIDS who
need care, and 3) to link HIV-positive patients to care. The campaign was billed as “North
Carolina’s HIV education and testing campaign”. Once a plan was established, a media partner
was brought on board to help create and produce campaign television and radio commercials.
These commercials began airing during prime time programming across multiple media outlets
in North Carolina. By getting educational messages out to the general public, we believe that
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they will be more inclined to be tested for HIV and other sexually transmitted diseases and to
learn about prevention methods and education.
These commercials featured local people who worked at local health departments and
HIV service organizations. This was done intentionally so that when someone went to one of
these places to get tested; they would feel more comfortable seeing someone that they
recognized. The call to action on each of these commercials was to a phone number which the
viewer could call and get more information about HIV or get information on where they could
get tested for HIV in their area. This method provided some anonymity for people that had
specific questions about HIV and their status, but may have been concerned about going to local
organization to ask the questions in person.
In order to generate interest, the staff at the Communicable Disease Branch met with
local health departments across the state and also met with media to create awareness, screen the
campaign commercials and discuss the importance of getting tested for HIV. Once that took
place, the staff at the Branch began the second phase of the campaign.
Activities
The second phase of the campaign began in December 2006 with the first “Get Real. Get
Tested.” community testing event in Fayetteville. In advance of this testing event, the campaign
commercial was aired in Fayetteville and multiple media interviews were conducted in order to
promote the testing event. The staff at the Communicable Disease Branch partnered with the
local health department in order to determine the best areas to offer testing. There were multiple
locations set up for HIV screening including door to door, clubs and community locations such
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as a grocery or discount store. The promotion that was done for this event resulted in over 300
people getting tested.
These testing events continued across the state through 2009. Beginning in 2010, the
campaign went through some changes. Due to decreased resources, both financial and personnel,
the staff at the Branch began to focus on specific groups to screen for HIV. At that time, there
were two issues that needed to be addressed: the number of new HIV cases begin reported in
African American men was increasing and emphasis needed to be placed on getting into HIV
care and treatment. The decision was made to create two new commercials, one focusing
specifically on African American men who have sex with other men and the second focusing on
the importance of HIV positive individuals getting into HIV care and treatment.
In creating the first commercial, it was somewhat controversial because a commercial
featuring MSM and targeting MSM had never been done at the local level. The commercial had
to be done in such a way that the subtle messages would reach the right audience. The
individuals featured in the commercial were young African American men who were known in
the community. The call to action was a phone number and web site address that viewers could
use to get more information on HIV and getting tested. The commercials used in the campaign
took four to six weeks to create and get on the air. Due to the subject matter, this particular
commercial took nine months.
The second commercial featured a local infectious disease doctor who met with two
“patients”. The doctor looked directly into the camera and talked about the importance of getting
on and adhering to an HIV medication treatment plan.
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RESULTS
Campaign Results / Successes
Beginning in 2012, a marketing campaign was launched using these two television
commercials. The television commercials aired during three separate time periods: June 2012 August 2012, December 2012 - February 2012 and January 2013 - May 29, 2013. Results from
that campaign showed that 54 individuals called to get more information on getting tested for
HIV or getting into care for HIV. 32 of those individuals were linked to HIV care and
medications. While the campaign results were not viewed successful by the CDC, the staff at the
Communicable Disease Branch felt it was a success because of the people that were directly
linked to HIV care and medications. Getting an HIV positive person on HIV medications will
help reduce the possibility of transmitting the disease to someone else.
Campaign Results / Challenges
Even with the challenges, there were many successes during the “Get Real. Get Tested.”
campaign. In 2009, the State Lab for Public Health in North Carolina has reported a73% increase
in HIV tests processed from 144,000 in 2006 to 250,000 in 2009. Between 2006 and 2012, there
were over 4,500 people who were tested for HIV and sexually transmitted diseases at a Get Real
Get Tested event. The campaign was presented at state and national conferences. There were
several organizations across the country and internationally that wanted to know how to conduct
a similar type of campaign.
The major problem with this social marketing approach was that people visiting the web
site or calling the number could not be tracked. Because “Get Real. Get Tested.” is a campaign
that is managed by the Division of Public Health; there was no ability to have a separate web
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site. There was one web page that was on the Division web site and it was very hard to find.
Many young people do use government web sites to get information. There was no way to track
the number of people that visited the web site as a result of the commercial and there were no
staff available to track the number of calls that were generated as a result of the commercial.
Management at the Communicable Disease Branch assigned staff from the AIDS Drug
Assistance Program (ADAP) to handle any incoming calls from people who saw the commercial.
A basic tracking system was put in place to capture demographics, location and any treatment
history or questions pertaining to HIV.
CONCLUSIONS / RECOMMENDATIONS
Future Research
It is critical that further work be conducted with MSM to better understand how they
would best be reached with public health messages. Currently, North Carolina is experiencing a
sharp increase in syphilis and MSM are being disproportionately affected. While the “Get Real.
Get Tested. Get Treatment.” campaign did not use social media, it is important that this
component be considered moving forward. In early 2015, the Communicable Disease Branch
conducted two focus groups with MSM to learn how they were communicating with each other.
All of the focus group participants were using social media (Facebook, Instagram, other MSM
sites) to meet and communicate with each other. Additional focus groups should also include
potential public health messages to determine the response with an opportunity to develop
messages that they feel would be appropriate.
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Leadership Recommendations
My leadership training throughout this program has shown me some areas where I could
improve when conducting future public health or social marketing campaigns. When I came into
public health, I had one job that was fairly straightforward – establish a team that will be
dedicated to an a public health marketing campaign focused on HIV testing and education. In
order for this project to be successful, I had to become extroverted. The job involved talking to
my team on a daily basis and working with several staff at local health departments and
community organizations that would require building strong relationships and a lot of public
speaking.
During the campaign, my leadership style developed so that I was always working to
include my team and other staff working on the campaign. I still remained thoughtful and
intuitive, but I learned to understand their strengths and weaknesses as well as promote their
ideas. Another step in making the campaign successful was promoting their leadership to upper
management. I was always conscious of acknowledging their skills and strengths. I did not want
to be the only “face” of the campaign. Individuals from the team took the lead on several events
and presented the campaign at state and national conferences. I would consider this one of the
strengths of my leadership style. I believe that it is important to build the skills of others so that
they remain happy and reach their full potential – I don’t ever want to hold anyone back.
This is one of the most important lessons that I have learned in the public health
leadership program – the power of inclusion. A team that is part of an organization or a project
will dictate success or failure. As Claudia Fernandez states, “positive personal regard” focuses
on how a team speaks to one another, how we appreciate one another and how we listen to each
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other (Fernandez, 2007). Ensuring that a public health marketing team is cohesive and working
together can help ensure a successful campaign.
References:
AVERT, (2014). “HIV and AIDS Stigma and Discrimination”. Retrieved from:
http://www.avert.org/hiv-aids-stigma-and-discrimination.htm
Centers for Disease Control and Prevention,(2015). “HIV Basics”. Retrieved from:
http://www.cdc.gov/hiv/basics/index.html
Centers for Disease Control and Prevention, (2015). “HIV At A Glance”. Retrieved from:
http://www.cdc.gov/hiv/statistics/basics/ataglance.html
Centers for Disease Control and Prevention. (n.d.). “Social Marketing Planning Process”. Social
Marketing Nutrition and Physical Activity. Retrieved from:
http://www.cdc.gov/nccdphp/dnpa/socialmarketing/training/basics/planning_process.htm
Centers for Disease Control and Prevention, (2015). “Act Against AIDS”, Retrieved from:
http://www.cdc.gov/actagainstaids/campaigns.html
Centers for Disease Control and Prevention, (2015). “Take Charge. Take the Test.” Retrieved
from: http://www.cdc.gov/actagainstaids/campaigns/tctt/index.html
Cohen, J. (2011). Science Journal; Science 23 December 2011: Vol. 334 no. 6063 p. 1628.
Retrieved from: http://www.sciencemag.org/content/334/6063/1628.full
Fernandez, C. (2007). “”The Power of Positive Personal Regard”. Journal of Public Health
Management Practice. 13(3), 321-323.
Infectious Disease News, (2015). “STDs Pose Major Health Threat to MSM”. Vol. 28, no. 8,
pages 1, 10-12. Retrieved from: http://www.healio.com/infectiousdisease/stds/news/print/infectious-disease-news/%7Bdb9afe5d-d382-478d-b884213ba8170ffb%7D/stds-pose-major-health-threat-to-msm
Kaiser Family Foundation, (2015). “Women and HIV/AIDS in the United States”. Retrieved
from: http://kff.org/hivaids/fact-sheet/women-and-hivaids-in-the-united-states/
Morbidity and Mortality Weekly Report (MMWR), (2010). “Prevalence and Awareness of HIV
Infection Among Men Who Have Sex With Men --- 21 Cities, United States, 2008”, September
24, 2010 / 59(37);1201-1207. Retrieved from:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5937a2.htm
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Morbidity and Mortality Weekly Report (MMWR), (2006). “Revised Recommendations for HIV
Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings”. 55(RR14);1-17.
Retrieved from: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm
New York City Department of Health, (2011). “The Bronx Knows”, HIV Testing Initiative and
Final Report. Pages 2,3. Retrieved from: http://www.nyc.gov/html/doh/downloads/pdf/ah/bronxknows-summary-report.pdf
North Carolina HIV/STD Surveillance Unit. (2015). 2013 North Carolina HIV/STD
Epidemiologic Profile. North Carolina Department of Health and Human Services, Raleigh,
North Carolina. pages xii – xiii. Accessed on September 5, 2015.
North Carolina HIV/STD Surveillance Unit. (2015). 2013 North Carolina HIV/STD
Epidemiologic Profile. North Carolina Department of Health and Human Services, Raleigh,
North Carolina. Page 15. Accessed on September 5, 2015.
Weinreich, Nedra Klein. (2006). “What is Social Marketing”, Weinreich Communications.
Retrieved from: http://www.social-marketing.com/whatis.html
http://www.cdc.gov/actagainstaids/campaigns/tctt/index.html
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