Reducing AIDS-related mortality among rurally-located African American women in North Carolina: PRECEDE-PROCEED guided planning

Background: Studies have shown that adherence to anti-retroviral therapy (ART) can significantly prolong life in HIV/AIDS patients. However, HIV-positive African American women living in rural North Carolina are less likely to have access and adhere to ART and, consequently, are dying at an accelerated rate compared to other sub-groups of HIV-positive individuals. Methods: We utilized the PRECEDE-PROCEED (P-P) model to identify a theory and evidence-based, multi-level intervention to address mortality reduction and the strengthening of family/social networks for HIV-positive African American women in rural North Carolina. Planners using the P-P model first identify and then prioritize a health outcome (mortality reduction) and quality of life factor (strengthening family/social networks) of greatest importance to the target population (HIV-positive African American women). After a thorough review of epidemiologic evidence, an inventory of behavioral and environmental factors (e.g., access to healthcare and daily needs, physical and financial access to ART, adherence to ART, the negative stigma associated with HIV-positive status, and self-efficacy to adhere to the ART regimen) are identified and then prioritized based on importance and changeability. Next, predisposing, enabling, and reinforcing factors linked to those priorities are inventoried and prioritized; these then become the immediate targets of the intervention. Results: This paper describes a multi-component intervention guiding the operation of a co-located comprehensive care clinic in Edgecombe County, NC. The clinic includes: a policy/lobbying arm; provision of transportation and physical access to the clinic and other services; internal and outreach HIV/AIDS education programs aimed at health professionals and the general population; comprehensive case management; and ART adherence self-efficacy strategy development. Conclusion: Although co-located care facilities have proven very successful in treating HIV/AIDS in rural and urban settings, they often require extensive coordination and a large, sustained budget. Nevertheless, the later, more debilitating stages of AIDS necessitate the use of more expensive ART, thereby justifying the suggested policy changes. The benefits of implementing this intervention outweigh the costs: Currently underserved individuals in the target population would receive affordable, timely, and sustained HIV/AIDS care and treatment. Strategic planning and evaluation efforts using planning models are critical to address this important public health issue.