The room was filled with a group of charismatic men, all warm, funny, well-liked – and all well-connected in Milwaukee's LGBTQ community. And while they were already influential in their respective social circles, they would also become the lynchpin in an HIV intervention project led by the Center for AIDS Intervention Research (CAIR) at the Medical College of Wisconsin.
The recent project included about 600 gay or bisexual black men in Milwaukee and Cleveland. "One of the challenges is how do you reach people who are hidden in the community with prevention messages and interventions, especially when they want to stay hidden," asks Jeffrey Kelly, PhD, MCW professor of psychiatry and behavioral medicine and director of CAIR.
The answer: their friends. CAIR first reached out to 30 to 40 gay or bisexual black men who were well-known and trusted in their social circles. The message was simple: "We want to save lives, and you can help, too."
Armed with brochures on HIV prevention and advice on how to talk to friends about the issue, the men recruited their friends, and then those men brought in others. Eventually, the peer-to-peer project reached hundreds of people almost entirely through social networking. Researchers found that this intervention reduced participants' risk behaviors and rates of syphilis infections, important as syphilis can make someone with HIV more infectious.
"People like to see they’re part of the solution," Dr. Kelly explains. "There's a lot of power if you tap into people’s desire to help."
That project is just one example of how CAIR's work is having an impact on HIV and AIDS in Wisconsin and around the world. With partner programs in Russia, the Ukraine, Hungary, Bulgaria and El Salvador, CAIR has designed and tested interventions to prevent new HIV infections, increase treatment rates for those already infected, and transfer the latest prevention research to AIDS service providers on the front lines of patient care.
CAIR is one of just a few federally funded centers focused on behavioral interventions to stop the spread of HIV and AIDS, and it's the only one located between America's two coasts. Over the past 23 years, the CAIR team has brought in more than $150 million in funding and published over a thousand research papers. The center's 12 full-time faculty are engaged in approximately 20 projects at any given time, with subjects ranging from adolescents to senior citizens.
But the center's biggest impact is more difficult to measure. "CAIR is a crown jewel," says Jon Lehrmann, MD, the Charles E. Kubly Professor and Chair in MCW's department of psychiatry and behavioral medicine. "They do incredible work. They probably have saved more lives than anybody here."
Dr. Kelly's work in the field began in the mid-1980s when the HIV/AIDS epidemic was still relatively new. "This was the era when the very first AIDS cases were starting to appear, and people that I knew or knew of were developing this disease and dying,” he recalls. "Then it became clear after a year or two that it was sexually transmitted and that there might be ways to get people to change their risk behaviors."
As a clinical psychologist, he was intrigued. "I'm an impatient type," he admits. "At the time the research was mostly in epidemiology – basically body counting, trying to figure out who's dying – whereas my interest was to figure out what kind of interventions could change the risk."
In 1989, Dr. Kelly published the first paper in this field. It focused on the results of an AIDS intervention with gay and bisexual men in the Deep South. A year later, he joined the MCW faculty and founded what would become CAIR.
In Wisconsin, like other parts of the country, most HIV infections are among gay and bisexual men, particularly black men. A much smaller percentage of HIV patients are drug injectors and women. "That has been true always, but we're seeing trends where HIV infections are decreasing in other populations, so that makes the health disparity even more significant," Dr. Kelly says.
According to a December 2015 report by the Wisconsin Department of Health Services, an estimated 7,900 people in the state have HIV, and nearly half of them live in Milwaukee County. While HIV rates are not as high in Wisconsin as some other parts of the country and new infections have decreased in recent years, Dr. Kelly and his colleagues are determined to reduce the numbers as much as possible. In 2016, the Shepherd Express honored Dr. Kelly with the LGBT Progress Award for Health and HIV Awareness in recognition of his work's impact on the community.
CAIR's researchers moved into international work around 2000. "We started thinking: 96 percent of HIV infections occur outside North America, and don't we have an obligation to bring our models to other places of great need?" Dr. Kelly explains. "Maybe we can learn things from other countries that would benefit them and also us here in the United States."
At the time, the HIV epidemic in Russia was not widely studied. "The country moved from having 6,000 HIV infections in the mid-to-late '90s to now having more than 1.5 million infections. It has been a huge, explosive increase," says Dr. Kelly, who visits CAIR's partners in Russia and Bulgaria about eight times each year. "Initially it was because of injection drug use. In the era after the Soviet Union fell apart, vast numbers of young people were injecting drugs."
Today, about 40 percent of CAIR's research is international, and the researchers have found that different countries require different prevention approaches. In the U.S., HIV primarily affects men who have sex with men, while in Africa, it affects mostly heterosexuals. Both drug use and unprotected sex are major drivers of the spread of HIV in Eastern Europe.
One of the things that Dr. Kelly is most proud of is putting CAIR's research into action. "Very often the people who really need our research, who are leading frontline programs in Russia or Guatemala or Tanzania, don't read our research journals, and they don't have nearly enough information to carry out our interventions," he says. "So how can you take our research findings and put them in the hands of community leaders around the world?"
In 2001, Dr. Kelly and his colleagues designed a project to do just that. They identified the main HIV service provider in 78 countries in the world, from Africa to Latin America to Central Asia to the Caribbean. The goal was to share with those agencies the characteristics of effective HIV prevention programs.
"We were trying to bring together the science of HIV prevention with the service of HIV prevention," Dr. Kelly explains. "The question was: Could this package of programs help organizations who are on the front lines in faraway countries, with little resources, benefit from the science we’re doing?"
In short: yes. CAIR researchers offered detailed manuals and ongoing distance education in English, French, Spanish and Russian to all 78 countries. Those who were familiar with each region provided ongoing consultation and worked with local program leaders to tailor the interventions to their region's needs.
"It was probably the most ambitious thing we've ever done. People were working all night because of the time differences," Dr. Kelly says. The majority of service providers adopted the science-based programs as a result, and the findings were published in Science in 2004.
New directions for prevention
These days, the focus in HIV and AIDS prevention is different.
"The whole field of HIV prevention has changed dramatically in the last five years," Dr. Kelly explains. "Prior to that, the focus was on reducing risk behaviors. Now if someone is HIV positive and gets quickly diagnosed and starts taking AIDS medications, they're going to live a very long time, and their viral load declines markedly and is much less likely to transmit to someone else. So now prevention means a lot more than condoms. It means getting people who have HIV quickly into care so the virus is suppressed and they’re less likely to transmit HIV."
Another new development is a medication called pre-exposure prophylaxis, or PrEP, which can protect people who are at high risk for developing HIV before they contract the virus. PrEP is much more commonly used on the coasts than in the Midwest, so one of CAIR's current research goals is increasing awareness of PrEP this region.
Increasing rates of medical treatment is also a focus of CAIR's international work. In St. Petersburg, Russia, CAIR researcher Yuri Amirkhanian, PhD, professor of psychiatry and behavioral medicine, recently tested a social network-based intervention with people who are HIV positive but not presently receiving medical care. Similar to the recent project in Milwaukee and Cleveland, the peer-to-peer program in Russia emphasized reasons to get medical care and take medications.
"What we're finding is that it helps people get care more quickly," Dr. Kelly says.
"It's not just a way to reach people; these kinds of interventions are more effective. People pay attention to their friends, and these kinds of social norms can influence behaviors."
Dr. Kelly is excited to continue the peer-to-peer approach with future interventions.
"Something that surprises me is that ordinary people are willing to do extraordinary things to prevent HIV, if we only ask," he says. "If we ask people who have had a lot of challenges in their lives and affirm that they are good, that they have an important role to play and they can play it better than anyone else, then people want to be part of the solution. What we have to do is develop interventions that tap into the altruism. The fact that it works so well is heartening to see."
More than 30 faculty, fellows and staff carry out CAIR's work. The center's 11 full-time researchers are:
- Yuri A. Amirkhanian, PhD
- Michelle R. Broaddus, PhD
- Julia Dickson-Gomez, PhD
- Carol L. Galletly, JD, PhD
- Laura R. Glasman, PhD
- Jeffrey A. Kelly, PhD
- Timothy L. McAuliffe, PhD
- Andrew E. Petroll, MD, MS
- Katherine G. Quinn, PhD
- Sergey S. Tarima, PhD
- Jennifer Walsh, PhD