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Logo of nihpaAbout Author manuscriptsSubmit a manuscriptHHS Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
 
AIDS Educ Prev. Author manuscript; available in PMC 2010 April 6.
Published in final edited form as:
PMCID: PMC2850206
NIHMSID: NIHMS183435

MOBILIZING COMMUNITIES AROUND HIV PREVENTION FOR YOUTH: HOW THREE COALITIONS APPLIED KEY STRATEGIES TO BRING ABOUT STRUCTURAL CHANGES

Kate S. Chutuape, Nancy Willard, Kenia Sanchez, Diane M. Straub, Tara N. Ochoa, Kourtney Howell, Carmen Rivera, Ibrahim Ramos, and Jonathan M. Ellen, the Adolescent Medicine Trials Network for HIV/AIDS Interventions

Abstract

Increasingly, HIV prevention efforts must focus on altering features of the social and physical environment to reduce risks associated with HIV acquisition and transmission. Community coalitions provide a vehicle for bringing about sustainable structural changes. This article shares lessons and key strategies regarding how three community coalitions located in Miami and Tampa, Florida, and San Juan, Puerto Rico engaged their respective communities in bringing about structural changes affecting policies, practices and programs related to HIV prevention for 12–24-year-olds. Outcomes of this work include increased access to HIV testing and counseling in the juvenile correctional system (Miami), increased monitoring of sexual abuse between young women and older men within public housing, and support services to deter age discordant relationships (Tampa) and increased access to community-based HIV testing (San Juan).

Recent data from the Centers for Disease Control and Prevention (CDC) show that estimated new cases of HIV in the United States may be significantly higher than previously thought (CDC, 2008; Hall et al., 2008). Racial and ethnic minority adolescents experience higher than average rates of HIV (CDC, 2008). Of note, there are more new HIV infections in young Black men who have sex with men (MSM), aged 13–29 years, than any other age or racial group of MSM. Similarly, among Hispanic MSM, most new infections occur in the youngest age group (13–29 years) (CDC, 2008). Young Black women bear a disproportionate disease burden (CDC, 2008). Factors such as poverty, stigma, limited access to health care, higher rates of other sexually transmitted diseases, power imbalances, and drug use all contribute to these rates for minority populations (CDC, 2007).

Innovative strategies rooted in community problem solving are needed to meet these challenges. Increasingly, HIV prevention efforts must focus on altering features of the social and physical environment to reduce risks associated with HIV acquisition and transmission (Blankenship, Bray, & Nerson, 2000; Sumartojo, Doll, Holtgrave, Gayle, & Herson, 2000). Promising methods for achieving this goal include making structural changes, which are often referred to as new or modified laws and policies that can either create opportunities or remove barriers to promote HIV prevention (Rotheram-Borus, 2000; Sumartojo et al., 2000). Examples of structural changes are widespread in the public health arena, including policies to install walking paths to promote exercise and lower diabetes rates (Deshpande, Dodson, Gorman, & Brownson, 2008) and policies to reduce adolescent smoking (Forster, Widome, & Bernat, 2007). Less common but still evident are examples within the field of HIV prevention, which include local policies requiring condom use in brothels and distributing clean needles at local pharmacies (Fuller et al., 2002; Groseclose et al., 1995; Kerrigan et al., 2003).

Advancing HIV prevention focused on structural changes requires the support and participation of community members and organizations from varied settings and sectors including health and social services, business, government, faith, education and media, among others (Myrick, Aoki, Truax, Lemelle, & Lemp, 2005). The formation of coalitions provides a framework for advancing a mobilization effort aimed at changing structural determinants of health and has proven to be an effective vehicle in several instances (Bigby, Ko, Johnson, David, Ferrer, 2003; Meister, & Guernsey de Zapien, 2005; Roussos & Fawcett, 2000). Limited research exists demonstrating the ability of coalitions to mobilize and bring about structural-level changes that have the potential to affect HIV rates by preventing transmission and acquisition for individuals aged 12–24 years living in urban areas.

The primary goal of this article is to describe the approach utilized and lessons learned by three local coalitions to identify and bring about structural changes that are linked to HIV prevention for young people. The coalitions presented in this article are located in Miami and Tampa, Florida, and San Juan, Puerto Rico. They represent a collaborative effort between researchers and community partners, all of whom share the same mission of preventing HIV among young people. The coalitions were chosen for this article because their efforts targeted a variety of risk factors associated with HIV, including sexual networks and testing accessibility. In addition, each coalition employed diverse approaches and solutions that are progressing toward desired outcomes. The three brief case studies are intended to share empirical data that can help to further define scientific methods related to altering structural determinants linked to HIV prevention. The paper is organized to provide brief background for each coalition, discuss the approach they used related to one aspect of their strategic planning and mobilization, and identify outcomes of their approach. The material presented in each case study was identified and reviewed by the primary coordinators within each coalition. Finally, we summarize themes that emerged from each coalition. The themes identified reflect the strategies and action steps that were essential to the coalition’s success and illustrate an array of experiences and lessons that could be applicable within many settings. We felt they were themes that could best assist others who are interested in community mobilization.

METHODS

The three coalitions featured in this article are part of an ongoing mulitsite community mobilization study that is focused on reducing HIV rates among individuals aged 12–24 years. The primary goal is to bring about changes that affect structural-level determinants, which are features of the environment that exist outside of the individual’s participation or control. Targets of change include such things as availability of resources, physical structures, organizational structures and laws or policies (Blankenship et al., 2000; Sumartojo et al., 2000).For this research protocol, coalitions identified structural changes that were defined as new or modified programs, policies or practices that are logically linkable to HIV transmission or acquisition and are sustainable over time.

The research study is entitled Connect To Protect®: Partnerships for Youth Prevention Interventions (C2P) and is part of the Adolescent Trials Network for HIV/AIDS Interventions (ATN), a National Institutes of Health-funded network that conducts research related to youth who are living with or are at risk for HIV. Currently, 13 research sites within the network, all located in urban areas, are implementing the C2P research study. Although each site is responsible for maintaining protocol fidelity, there is significant flexibility in how each site and their respective community carries out the elements of the protocol. This flexibility is necessary given the dynamic and fluid nature of community-focused research. For a complete listing of participating research sites, go to http://www.atnonline.org.

As briefly described below, C2P has proceeded through three phases (Ziff et al., 2006) and is currently being considered for renewal. During Phase I, each C2P community used geographic information software (GIS) mapping techniques and epidemiological data to identify neighborhoods of high-risk and youth populations with high rates of sexually transmitted infections (STIs) and HIV to help narrow to a specific geographic area and population of focus (Geanuracos et al., 2007). This process helped to frame the coalition’s strategic plan, as described below. Eight communities identified young females of color, six communities identified young MSM of color, and one community identified male and female drug users. Phase II entailed collecting detailed HIV risk behavior data from members of the population of focus, including collecting an anonymous HIV antibody assay to assess local HIV prevalence. Throughout Phases I and II, communities engaged in intensive partnership building activities leading to the formation of a local coalition and the start of Phase III (Straub et al., 2007).

C2P coalitions typically ranged from 15 to 35 members and included people from a variety of sectors, including education, social services, health care, government, judicial services, law enforcement, faith-based and business. Given the fluctuating nature of coalition work, participation varied among members over time, but coalitions typically had a core group of three to five partners that joined early in the process and signed nonbinding memorandums of understanding (MOUs) describing their role (e.g., assist with recruitment, participate in strategic planning, attend coalition meetings) and the resources available to them (e.g., local epidemiologic maps for grant submissions, professional development opportunities, networking with high level officials). No coalition member was provided direct financial support. Two staff members at each of the 13 research sites served as the core coordinators of the coalition and assisted with providing managerial direction, such as arranging coalition meetings and guest speakers, offering a framework for strategic planning and documenting coalition progress. In addition, coordinators worked with coalition members to facilitate discussions and activities related to the sustainability of the coalition, including developing leadership or marketing plans, identifying potential new sources of funding, and establishing new structures within the coalition, such as an executive body. Over time new coalition leaders emerged to assist with various aspects of the coalition’s functioning and work.

The coalitions used a systematic planning process derived from the Community Tool Box (KU Work Group for Community Health and Development, 2007) that includes creating an overarching vision and mission to guide the coalition, and identifying locally relevant structural change objectives (SCOs) (e.g., a policy requiring schools to offer comprehensive sex education in high schools). Specific action steps to accomplish the SCO (e.g., presentation to the school board, meeting with medical staff at school clinics) and strategies to facilitate community mobilization (e.g., advocacy, education and awareness, creating linkages) were outlined, recorded on work-sheets and reviewed at regular coalition meetings. The ongoing development of new SCOs and the actual execution of the action plans, which was a dynamic process over the course of several years, constituted our community mobilization intervention.

As objectives and action plans were developed, additional community members and leaders may have been needed for their knowledge or influence to help achieve a SCO. For example, a SCO may have needed the support of a specific manager within a city’s department of housing. Diversifying membership was an ongoing process for each coalition and an important step toward building and implementing their strategic plan. Those who participated in implementing the strategic plan were assigned a code and recorded in a central database, thereby allowing the study to track (in a nonidentifiable manner) the participation of new and existing coalition members.

As part of the Community Tool Box process, an infrastructure was established that included mechanisms for technical assistance, ongoing training, documentation of coalition progress and coalition feedback to assist with coalition functioning and progress. A central administrative team funded by the ATN network assisted each coalition with aspects of this infrastructure.

RESULTS

CONNECT TO PROTECT: MIAMI

Background

The C2P: Miami coalition began developing its strategic plan in January 2007 with a focus on young women of color living in the Liberty City and Little Haiti neighborhoods, two areas with high rates of HIV in Miami Dade County according to local health department data. Facilitated by the ATN site housed within the Department of Adolescent Medicine at the University of Miami’s School of Medicine, the coalition began by exploring systems where young women were coming into contact with high-risk sex partners. Based on input by coalition members and presentations by community experts in fields related to HIV, adolescent health and social services, the coalition initially identified three primary areas: school system, foster care system, and the juvenile correctional system. This case study focuses on the coalition’s work in the juvenile correctional system.

Some members of the C2P: Miami coalition were formerly members of the Jail Linkage coalition, a local group that pushed the implementation of HIV testing and prevention in the adult correctional facility in Miami-Dade County from 2003 to 2005. Their knowledge, in conjunction with Department of Juvenile Justice data showing that youth in the juvenile correctional facilities were frequently from the geographic area of focus, prompted the coalition to consider the implications of young men (under 24 years) being released from the system without knowing their HIV status. It was known that these young men were socializing and partnering with young women from Liberty City and Little Haiti.

Approach

The coalition’s primary strategy that facilitated its progress was forming relationships with other stakeholders within county correctional institutions, the county health department and the state legislature, who possessed influence, knowledge or decision-making authority related to the coalition’s SCOs. Some of the coalition’s early connections were with local judges and lawyers who worked within the juvenile justice system and could offer expertise and open doors as the coalition began to dissect the issues and navigate the system. Community members who were involved with the Jail Linkage coalition provided needed grassroots support. Other critical partnerships evolved with the superintendent at Department of Juvenile Justice and the health service manager at the Miami-Dade County Department of Health. These individuals were decision makers with influence and extensive knowledge of how the system operated. As the coalition’s work progressed, their partnerships expanded to include alliances with state level officials, such as a state representative, a state senator and the HIV/AIDS director the Florida Department of Health, all of whom were agenda setters with high-level authority (i.e., individuals who could personally bring about a desired change given their authority over the direction of an institution or system.)

The partnerships helped the coalition identify several SCOs needed to tackle the issue: (a) provide HIV prevention information to incarcerated youth, (b) provide HIV testing and counseling at the detention facility, (c) prevent loss to follow up by maintaining on-site records that can be transferred to another detention facility if necessary, and (d) create linkages to care for those who are identified as HIV-positive during their incarceration and upon release from the system. One tactic the coalition used in formulating their package of SCOs was to approach officials within the county juvenile correctional system and ask how the coalition could support youth within the system, rather than taking the approach of “fixing” the system. By positioning the issue this way, it helped build collaborative, trusting relationships.

The coalition identified three facilities to target with their SCOs: the Juvenile Assessment Center, a county funded processing facility; the Department of Juvenile Justice, a state funded facility that detains youth; and Bay Point, a private, state-funded residential rehabilitation facility for 12–17-year-olds. Through research and discussion, the coalition quickly learned that each facility had a unique set of needs and capabilities related to the coalition’s SCOs. This required the coalition to tailor its strategies and negotiations to suit each facility.

In brief, the Juvenile Assessment Center did not have an on-site health clinic or offer medical services, which meant there was a need to establish basic infrastructure to support HIV/STD testing, counseling and the distribution of HIV education materials. In contrast, the Department of Juvenile Justice offered routine testing for STIs but only sporadic HIV education and testing. It needed to adopt new standards of practice to include consistent HIV testing, counseling, and delivery of prevention information. Similar to the Department of Juvenile Justice facility, Bay Point had a health clinic, but the consistency of HIV/STD testing and counseling and the ability to maintain in-house records needed to be addressed.

To open the door with each facility, the coalition was able to link them with local HIV/STD service providers, such as Care Resource, which provided the youth with free HIV prevention information and HIV/STD testing and counseling, depending on the facility’s current situation. This proved to be an effective way to quickly gain buy-in with officials by offering tangible and valuable services free of charge for the facility. While working with each facility to address the testing component, the coalition learned that none was registered with the Florida Department of Health as a HIV testing site, which hampered the ability to maintain on-site test results and to track HIV-positive youth within the system. The coalition formulated and achieved three new SCOs related to this issue, thereby closing a gap in the system and promoting stronger linkages to care.

Outcomes

As a result of the strong partnerships, the coalition was able to clearly define the issues, craft a focused and intentional strategic plan, and pinpoint the necessary action steps to accomplish their SCOs. As the coalition approaches 2 years of work on this issue, its strategic plan has expanded to include 16 objectives focused within this area, 9 of which have been achieved toward their overall goal of preventing HIV transmission and acquisition among the detained juvenile population and reducing risk for their sexual partners within the community.

The local success has provided a bridge to push for similar statewide policy changes, a goal coalition members are currently exploring. In addition, they are pursuing local policies to codify the program and practice changes that have occurred at each of the three facilities. Finally, they are seeking to infuse greater sustainability into their accomplished SCOs by securing state-funded service providers (rather than community-based organizations with less secure funding) to conduct the ongoing testing and counseling at the Juvenile Assessment Center, and certify clinicians who work within the Department of Juvenile Justice to conduct the HIV testing and counseling using testing kits distributed by the Florida Department of Health at no cost to the state institution.

CONNECT TO PROTECT: TAMPA BAY

Background

The C2P: Tampa Bay coalition, facilitated by the University of South Florida’s Divisions of Infectious Diseases and Adolescent Medicine, identified central Tampa as its geographic area and young women of color as their population of focus. Strategic planning began in April 2006.

The coalition’s strategic plan honed in on four areas: (a) high STI rates and lack of access to health care among school-aged adolescents, (b) perceived stigma within the faith-based community related to HIV and mental health services, (c) risk of adolescent and young women being infected by male sexual partners released from correctional facilities, and (d) risk associated with minor females being targeted as sexual partners by older men. This last area has been a primary focus for the coalition and is described below.

Early on the coalition identified age-discordant relationships (e.g., older men and younger women) as being important in the HIV epidemic. Specifically, GIS mapping, which only shows those who are registered offenders, revealed 160 in the coalition’s geographic area of focus while a comparably sized area nearby had two known registered offenders. The coalition invited several speakers, including a psychology professor with expertise working with victims and perpetrators of sexual crimes, to coalition meetings to further understand this issue. Participants discussed the over-whelming scope of the problem and resultant tolerance of the practice within the community, including the prevalence of sexual abuse within the community (including within representative coalition members’ families), the implicit mistrust of law enforcement and fear of having children taken away, and the inability of the women to address the issue with their own daughters owing to their inability to face their own past abuse. Poverty issues weighed heavily; the male perpetrator might also be the means of financial support for the family, and public housing policies stipulate that families with felony conviction will be evicted. The coalition’s investigation of the issue indicated that young people exposed to rape and intergenerational cycles of violence lacked the knowledge of what constituted an appropriate relationship and frequently chose older partners with a history of high-risk sexual and social behaviors, such as crime or drug use, thereby repeating the cycle. In thinking about structural changes that could make an impact on this issue, the coalition felt that they would need to penetrate multiple systems and look at the infrastructure that was either supporting this cycle of abuse or hindering prevention efforts.

Approach

The coalition’s overarching strategy was to intentionally find ways to empower the community to address sexual abuse. Coalition members pursued this strategy with three goals in mind. The first goal was to improve the community’s relationship with law enforcement and empower the community to address the problem internally. Strategies included educating and creating awareness around the issues, garnering support from key players, bringing members from the community and law enforcement, such as the coordinator of Neighborhood Watch Program for the Tampa Police Department, to the same table, and offering technical assistance. To achieve these strategies, some action steps included presenting this issue and the coalition’s ideas to the Tampa Housing Authority’s (THA) Safety Commission and safety directors; publicly honoring the THA’s property director to garner her support; and linking the THA Safety Board with the Tampa Police Department and other community service organizations.

A second goal was to extend the efforts beyond the residential communities as a way to reach young women citywide. The coalition identified that education about sexual abuse should be provided to staff and volunteers of after-school and summer programs because these agencies and individuals are instrumental in the lives of young girls at risk. The coalition developed a SCO stating that the City of Tampa would establish a new policy requiring all city funded after-school and summer programs that serve youth to train staff and volunteers on ways to prevent and identify child sexual abuse, as well as learn how to appropriately link young women to needed social services. To achieve this SCO, the coalition conducted background research on state statutes governing child sexual abuse and city policies related to staff and volunteer training. The coalition held discussions with local agencies that conducted sexual abuse prevention trainings, such as Apple Services, and through ongoing networking found that the Girl Scouts of West Central Florida was interested in this issue. This proved to be an excellent connection given the Girl Scouts’ visibility in the community and capacity to take on a large initiative.

A third goal was to utilize the school system to teach youth about sexual abuse and appropriate relationships through a comprehensive sexuality education program. Florida state statutes mandate “comprehensive sexuality education,” yet the minimal amount provided in schools was an assortment of programs, many of which had serious methodological and ethical issues. Funding to support an HIV prevention program in the local schools had recently fallen through. The coalition worked to address this by developing a SCO that the Hillsborough County School District would require students to receive age and grade-level appropriate human sexuality education. The coalition engaged in grassroots efforts to gain community buy-in by hosting meetings and conducting surveys with parents and youth, as well as top-down efforts by meeting with high level administrative and medical staff affiliated with the school district. Each meeting involved educating the participants about the rates of STIs among youth, the prevalence of adolescent sexual activity, the state laws, and the current patchwork of school-based sex education. State-level technical assistance resources were also discussed, which proved compelling to the stakeholders being targeted because it added elements of legitimacy and sustainability to the effort.

Outcomes

Across all three goals, the coalition’s mobilization efforts have resulted in identifiable outcomes related to the community’s ability to address sexual abuse affecting young women through structural changes. Specifically, completed SCOs include the agreement by the THA to establish Neighborhood Watch Programs within the five public housing developments located within central Tampa; two programs have been created at this time. In response, two housing communities outside of central Tampa have decided to establish a watch program and the THA decided on its own accord to sign collaborative agreements with community agencies to provide tutoring for youth, classes to help parents teach sex to youth, and gun safety. To improve the monitoring of inappropriate behavior, the Tampa Police Department is working cooperatively with the THA’s Safety Commission and Safety Directors to establish accountability boards at the public housing communities in central Tampa. The accountability boards provide an alternative for first-time youth offenders who commit minor crimes to come before community members serving on the board, as well as the victim and victim’s family, and discuss an appropriate punishment. This approach is designed to hold the offender accountable and to aid in the youth’s return to good standing within the community, without the entanglement of legal intervention.

In addition, the coalition’s efforts resulted in the City of Tampa’s Parks and Recreation Department agreeing to implement a citywide policy change requiring training of after-school program staff and volunteers on sexual abuse. The local Girl Scouts chapter, in collaboration with Apple Services, agreed to develop the training materials, in the form of a video outlining the scope of the problem, prevention, signs, and appropriate responses, including referral for professional and legal services. Currently, the Girl Scouts of the USA is considering using this training resource for future Girls Scout leaders and volunteers nationally. Finally, the school district agreed to pilot a comprehensive sex education program in one of the highest risk schools in the Tampa Bay area with plans for further dissemination over time.

CONNECT TO PROTECT: PUERTO RICO

Background

Initiated by the Adolescent Medicine Trial Network (ATN) research staff affiliated with the Medical Sciences Campus of the University of Puerto Rico, the C2P: Puerto Rico coalition includes members from social services, faith-based organizations, education and schools, legal justice system, government, health care organizations, youth and parents, guardians, and family. The coalition identified San Juan as the geographic area of focus because it is consistently among the municipalities with the highest rates of syphilis, gonorrhea, and HIV among 12–24-year-olds. The epidemiological data showed that rates of HIV/AIDS were increasing among IV drug users and is the main HIV exposure category for adolescents and adults (Puerto Rico Department of Health, 2004). The coalition identified male and female drug users (12–24 years) as their population of focus.

The coalition started its strategic planning in March 2006 and quickly identified the problem of limited access to HIV testing and counseling for youth. One reason for this was Law 81, also known as the Law for the Prevention and Treatment of Sexually Transmitted Infections, which required parental consent for HIV testing if a medical doctor was not present and the individual was under 21 years. As a result of this law, HIV testing and counseling in community settings, where youth were frequently present, was significantly hindered. The coalition created a SCO to increase access to HIV testing by allowing professionals or representatives with appropriate certification to perform HIV testing and counseling without parental consent. Law 81, which others in the HIV community wanted to see amended, became a vehicle for achieving the coalition’s objective.

Approach

The coalition engaged in three primary strategies to achieve its objective: convening a diverse alliance of supporters, building the capacity of coalition members, and raising public awareness of the issue. Via formal and informal meetings, phone calls, and letters, the coalition reached out to individuals and groups from diverse spheres of influence (e.g., executive directors from the Division of STD/HIV/AIDS Prevention, Puerto Rico Health Department, organizations including PR CoNCRA and Iniciativa Comunitaria, and educators the University of Puerto Rico’s Graduate School of Public Health, School of Pharmacy and Bachelor Education Program, as well as youth, lawyers and public health officials), which helped to create linkages with key stakeholders both within and outside of the field of HIV. For example, forming a relationship with the advisor to Puerto Rico’s Secretary of Health on HIV/AIDS facilitated convening a meeting with the president of the Health Commission within the House of Representatives. Having the support of individuals outside the HIV field, such as the president of the Health Commission of Puerto Rico Senate, president of the Health Commission of Puerto Rico House of Representatives and Puerto Rico secretary of health, with decision-making authority proved to be critical. In addition, the coalition created linkages with interested community groups like the Community Planning Group for the Prevention of HIV in Puerto Rico, which had a larger network and could help to mobilize the community around HIV testing issues.

Many of the allies formed a subcommittee within the coalition as a way to organize their planning and create a united front. Key participants within this subcommittee included a lawyer, members from community-based organizations, parents, youth, educators, and health care providers. Building the capacity of subcommittee members was a strategy that equipped each member to be stronger advocates around the issue of access to testing for youth. Rather than relying on one or two “experts” to carry the message into the community, subcommittee members participated in trainings related to the health and legal aspects of Law 81, as well as trainings about public health advocacy work. This elevated subcommittee members’ knowledge and confidence as they moved forward.

Having the necessary internal capacity provided a launching pad for the coalition’s strategy of raising public awareness around access to HIV testing. Specific tactics used included holding a press conference, which generated significant media coverage; circulating a petition; meeting with legislators; and testifying before Puerto Rico’s Senate Hetalth Commission regarding all aspects of HIV testing and counseling.

The coalition encountered challenges along the way, including being denied access to meetings with key individuals, maintaining the active participation of the diverse group assembled and ensuring that members engaged strictly in advocacy work, not lobbying. All of these challenges were overcome by employing the strategies described above.

Outcomes

The Senate and House approved the proposed amendment without further changes in November 2007 and March 2008, respectively. The governor signed amended Law 81, now referred to as Law 36, on April 4, 2008. Since then, community-based organizations and the Puerto Rico Department of Health have entered into an internal review process to assess their outreach procedures and to educate their staff about the new law and its implications. Health and social service providers anticipate seeing a considerable increase in the number of youth receiving HIV testing and counseling, as well as improved access to prevention and care for individuals affected by HIV.

DISCUSSION

The ability of community coalitions to serve as catalysts for making structural changes related to HIV determinants of risk is a promising frontier in the field of HIV prevention. The above case studies, summarized in Table 1, illustrate how several key strategies contribute to achieving critical milestones in a coalition’s quest to reduce HIV acquisition and transmission among youth within their community. In summary, the strategies that proved most beneficial for these three coalitions in achieving structural changes included the following: (a) forming strategic partnerships with diverse individuals who possess influence, knowledge or decision making authority and could help the coalition move their SCOs forward efficiently and effectively; (b) building the capacity of coalition members within relevant areas (e.g., government policy) so that all participants have the knowledge, skills, and confidence to serve as effective advocates and leaders; (c) raising public awareness of the issue to generate broad-based support and visibility; and (d) working closely with stakeholder’s most impacted by the issue and finding strategic ways for the community to “own” the issue.

TABLE 1
Summary of Community Mobilization Efforts and Outcomes

In pursuing the above strategies and seeking to accomplish SCOs, the coalitions learned several lessons. First, strategic partnerships do not happen by chance. All three coalitions found it necessary to have the “right people” at the table who knew how to navigate a system and connect with others in the system with influence. This often meant the coalition engaged in ongoing discussions in the community before identifying the change agents who could guide the SCO to the finish line. In the case of C2P: Miami, the coalition’s opening came after members toured a local juvenile correctional facility and met with the superintendent of Department of Juvenile Justice. Second, coalitions learned to be flexible and patient in their approach, especially when engaging stakeholders most impacted by an issue. Issues related to HIV, sexual behavior, and/or sexual abuse are sensitive and require skilled leaders to balance the drive of the coalition to achieve a SCO with the needs and concerns of the community to meet people where they are emotionally. For the Tampa coalition, the psychology professor was able to clearly distill the critical issues for the coalition while also recognizing the inherent cultural norms that affected the community. Her ability to help the coalition understand the dynamics proved beneficial to their efforts. In addition, knowing when to seize an opportunity and quickly mobilize and when to maintain a tempered pace with an eye on the long-term goal are important aspects of being flexible. Third, coalitions must be thoughtful in knowing when and how to raise public awareness of an issue. In Puerto Rico, the timing of the petition and media coverage related to expanding HIV testing (Law 81) came just prior to the legislature meeting to discuss the amendment. Had the publicity come too early, the momentum may have been lost. Finally, building diverse and distributive leadership within the coalition maximizes the capacity of the coalition to bring about changes. The coalitions learned how to broadly define leadership so that all coalition members were able to contribute. For example, C2P: Puerto Rico distributed tasks among their members, such as writing testimony to present in a public hearing, identifying and transporting youth to testify before Puerto Rico’s Senate Health Commission, distributing petitions and educating legislators. This, in turn, fueled a sense of purpose and pride among members as they took on action steps and worked toward the completion of SCOs. Providing appropriate training and technical assistance proved to be an effective mechanism for expanding leadership.

In conclusion, the case studies illustrate the promising role of mobilized communities to bring about structural changes that have the potential to reduce rates of HIV among youth by preventing HIV/STI transmission and acquisition. An in-depth analysis of each C2P coalition will help to inform future HIV prevention efforts.

Acknowledgments

This work was supported by the Adolescent Trials Network for HIV/AIDS Interventions (ATN) from the National Institutes of Health (Grants U01 HD 040533 and U01 HD 040474) through the National Institute of Child Health and Human Development (B. Kapogiannis, L. Serchuck), with supplemental funding from the National Institutes on Drug Abuse (N. Borek) and Mental Health (P. Brouwers, S. Allison). Connect to Protect has been scientifically reviewed by ATN’s Behavioral and Community Prevention Leadership Groups.

The authors acknowledge the contributions of the following individuals: Alex Moreno, MPH, Adolescent Outreach & Educator, University of Miami, Miami, FL; Vershawn Berry, Superintendent, Miami Dade Regional Detention Center, Miami, FL; Wansley Walters, Director, Juvenile Services Department, Miami, FL; Morris Copeland, CPM, Deputy Director, Juvenile Services Department, Miami, FL; and Leigh Lin-hart BS, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD. The authors are grateful for the dedication and hard work of all community members who are part of Connect to Protect, and recognize members of the local youth community advisory boards.

The authors also acknowledge the contribution of the investigators and staff at the following ATN sites that participate in Connect to Protect: Children’s Diagnostic and Treatment Center (Ana Puga, MD, Jessica Roy, MSW, Jamie Blood, MSW); Childrens Hospital of Los Angeles (Marvin Belzer, MD, Miguel Martinez, MSW/MPH, Veronica Montenegro, Julia Dudek, MPH); John H. Stroger Jr. Hospital of Cook County and the CORE Center (Lisa Henry-Reid, MD, Jaime Martinez, MD, Ciuinal Lewis, MS, Antionette McFadden, BA); Children’s Hospital National Medical Center (Lawrence D’Angelo, MD, William Barnes, PhD, Stephanie Stines, MPH) Montefiore Medical Center (Donna Futterman, MD, Michelle Lyle, MPH, Bianca Lopez, MPH); Mount Sinai Medical Center (Linda Levin-Carmine, MD, Meg Jones, MPH, Michael Camacho, BA); Tulane University Health Sciences Center (Sue Ellen Abdalian, MD, Sybil Schroeder, PhD); University of Maryland (Ligia Peralta, MD, Bethany Griffin-Deeds, PhD, Kalima Young, BA); University of Miami School of Medicine (Lawrence Friedman, MD); Children’s Hospital of Philadelphia (Bret Rudy, MD, Marne Castillo, PhD, Alison Lyn, MPH); University of Puerto Rico (Irma Febo, MD), University of California at San Francisco (Barbara Moscicki, MD, Johanna Breyer, MSW, Kevin Sniecinski, MPH) and University of South Florida (Patricia Emmanuel, MD, Amanda Schall, MA, Rachel Stewart-Campbell, BA). Network, scientific and logistical support was provided by the ATN Coordinating Center (C. Wilson, C. Partlow) at The University of Alabama at Birmingham. Network operations and analytic support was provided by the ATN Data and Operations Center at Westat, Inc. (J. Korelitz, B. Driver, R. Mitchell, M. Alexander, D. Monte). Technical assistance, training and protocol support was provided by the National Coordinating Center at Johns Hopkins University and DePaul University.

Contributor Information

Kate S. Chutuape, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore.

Nancy Willard, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore.

Kenia Sanchez, Department of Adolescent Medicine, University of Miami, Miami, FL.

Diane M. Straub, Divisions of Adolescent Medicine and Pediatric Infectious Disease, University of South Florida, Tampa, FL.

Tara N. Ochoa, Divisions of Adolescent Medicine and Pediatric Infectious Disease, University of South Florida, Tampa, FL.

Kourtney Howell, Divisions of Adolescent Medicine and Pediatric Infectious Disease, University of South Florida, Tampa, FL.

Carmen Rivera, Medical Sciences Campus, University of Puerto Rico, San Juan, Puerto Rico.

Ibrahim Ramos, Medical Sciences Campus, University of Puerto Rico, San Juan, Puerto Rico.

Jonathan M. Ellen, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore.

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