Journal of Urban Health

, Volume 83, Issue 3, pp 506–522 | Cite as

Laying the Foundation for Connect to Protect ®: A Multi-Site Community Mobilization Intervention to Reduce HIV/AIDS Incidence and Prevalence among Urban Youth

  • Mauri A. Ziff
  • Gary W. Harper
  • Kate S. Chutuape
  • Bethany Griffin Deeds
  • Donna Futterman
  • Vincent T. Francisco
  • Larry R. Muenz
  • Jonathan M. Ellen
  • Adolescent Medicine Trials Network for HIV/AIDS Intervention


Despite the considerable resources that have been dedicated to HIV prevention interventions and services over the past decade, HIV incidence among young people in the United States remains alarmingly high. One reason is that the majority of prevention efforts continue to focus solely on modifying individual behavior, even though public health research strongly suggests that changes to a community's structural elements, such as their programs, practices, and laws or policies, may result in more effective and sustainable outcomes. Connect to Protect is a multi-city community mobilization intervention that focuses on altering or creating community structural elements in ways that will ultimately reduce youth HIV incidence and prevalence. The project, which spans 6 years, is sponsored by the Adolescent Medicine Trials Network for HIV/AIDS Interventions at multiple urban clinical research sites. This paper provides an overview of the study's three phases and describes key factors in setting a firm foundation for the initiation and execution of this type of undertaking. Connect to Protect's community mobilization approach to achieving structural change represents a relatively new and broad direction in HIV prevention research. To optimize opportunities for its success, time and resources must be initially placed into laying the groundwork. This includes activities such as building a strong overarching study infrastructure to ensure protocol tasks can be met across sites; tapping into local site and community expertise and knowledge; forming collaborative relationships between sites and community organizations and members; and fostering community input on and support for changes at a structural level. Failing to take steps such as these may lead to insurmountable implementation problems for an intervention of this kind.


Community mobilization HIV Structural change Youth 



The Adolescent Medicine Trials Network for HIV/AIDS Interventions (ATN) and Connect to Protect are funded by grant No. U01 HD40506-01 from the National Institutes of Health through the National Institute of Child Health and Human Development (Audrey Smith Rogers, PhD; MPH; Robert Nugent, PhD; Leslie Serchuck, MD), with supplemental funding from the National Institutes on Drug Abuse (Nicolette Borek, PhD), Mental Health (Andrew Forsyth, PhD; Pim Brouwers, PhD), and Alcohol Abuse and Alcoholism (Kendall Bryant, PhD). Connect to Protect has been scientifically reviewed by the ATN's Behavioral and Community Prevention Leadership Groups. The authors would like to acknowledge Connect to Protect's National Coordinating Center staff members and consultants: Audrey Bangi, PhD; Matthew Bowdy, MA; Shayna Cunningham, MHS; Mimi Doll, PhD; Jason Johnson, BA; Rachel Lynch, MPH; Suzanne Maman, PhD; Danish Meherally, BS; Grisel Robles-Schrader, BA; Marizaida Sánchez-Cesáreo, PhD; Nancy Willard, BA; and Stephanie Witt, MPH. The authors also acknowledge support of: DePaul University's Quality Assurance Team member Leah Neubauer, BA; individuals from the ATN Data and Operations Center (Westat, Inc.) including Jim Korelitz, PhD; Barbara Driver, RN, MS; Lori Perez, PhD; Rick Mitchell, MS; Stephanie Sierkierka, BA; and Dina Monte, BSN; and individuals from the ATN Coordinating Center at the University of Alabama including Craig Wilson, MD; Cindy Partlow, MEd; Marcia Berck, BA; and Pam Gore. The following ATN sites have participated in the study: University of South Florida: Patricia Emmanuel, MD; Diane Straub, MD; Shannon Cho, BS; Georgette King, MPA; Mellita Mills Kendrick, BS; and Chodaesessie Morgan, MPH. Childrens Hospital of Los Angeles: Marvin Belzer, MD; Miguel Martinez, MSW/MPH; Veronica Montenegro, Ana Quiran, Angele Santiago, Gabriela Segura, BA; and George Weiss, BA. Children's Hospital National Medical Center: Lawrence D'Angelo, MD; William Barnes, PhD; Bendu Cooper, MPH; and Cassandra McFerson, BA. The Children's Hospital of Philadelphia: Brett Rudy, MD; Antonio Cardoso, ABD; and Marne Castillo, MEd. John H. Stroger Jr. Hospital and the CORE Center: Lisa Henry-Reid, MD; Jaime Martinez, MD; Zephyr Beason, MSW; and Draco Forte, MEd. University of Puerto Rico: Irma Febo, MD; Ileana Blasini, MD; Ibrahim Ramos-Pomales, MPHE; and Carmen Rivera-Torres, MPH. Montefiore Medical Center: Donna Futterman, MD; Sharon S. Kim, MPH; Lissette Marrero, Stephen Stafford, and Carol Tobkes, MPH. Mount Sinai Medical Center: Linda Levin, MD; Meg Jones, MPH; Christopher Moore, MPH and Kelly Sykes, PhD University of California at San Francisco: Barbara Moscicki, MD; Coco Auerswald, MD; Catherine Geanuracos, MSW; Kevin Sniecinski, BS. Tulane University Health Sciences Center: Sue Ellen Abdalian, MD; Lisa Doyle, Trimika Fernandez, MS; and Sybil Schroeder, PhD University of Maryland: Ligia Peralta, MD; Bethany Griffin Deeds, PhD; Sandra Hipszer, MPH; Maria Metcalf, MPH; and Kalima Young, BA. University of Miami School of Medicine: Lawrence Friedman, MD; Angie Lee; Kenia Sanchez, MSW; Benjamin Quiles, BSW; and Shirleta Reid. Children's Diagnostic and Treatment Center: Ana Puga, MD; Dianne Batchelder, RN; Jamie Blood, MSW; Pam Ford, MS;and Jessica Roy, MSW. Children's Hospital Boston: Cathryn Samples, MD; Wanda Allen, BA; Khari Farrell, PhD; Lisa Heughan, BA; Meqdes Mesfin, MPH; and Judith Palmer-Castor, PhD University of California at San Diego: Stephen Spector, MD; Rolando Viani, MD; Stephanie Lehman, PhD; and Mauricio Perez. We would also like to acknowledge staff members who provided data from local public health departments, police departments, state agencies, and other institutions. Finally, we recognize the thoughtful input given by participants of our national and local Youth Community Advisory Boards.


  1. 1.
    Rosenberg PS, Goedert JJ, Biggar RJ. Effect of age at seroconversion on the natural AIDS incubation distribution. Multicenter Hemophilia Cohort Study and the International Registry of Seroconverters. AIDS. 1994;8(6):803–810.PubMedCrossRefGoogle Scholar
  2. 2.
    UNAIDS. 2004 report on the global HIV/AIDS epidemic: 4th global report. Joint United Nations Programme on HIV/AIDS and World Health Organization. Available at: Accessed January 10, 2006.Google Scholar
  3. 3.
    Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report, 2004. Atlanta: U.S. Department of Health and Human Services, CDC; 2005;16:1–46.Google Scholar
  4. 4.
    Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report, 2003. Atlanta: U.S. Department of Health and Human Services, CDC; 2004;15:1–40.Google Scholar
  5. 5.
    Diaz RM, Ayala G, Bein E. Sexual risk as an outcome of social oppression: data from a probability sample of Latino gay men in three U.S. cities. Cultur Divers Ethnic Minor Psychol. Aug 2004;10(3):255–267.CrossRefPubMedGoogle Scholar
  6. 6.
    Garofalo R, Harper GW. Not all adolescents are the same: addressing the unique needs of gay and bisexual male youth. Adolesc Med: State of the Art Reviews. 2003;14(3):595–611.Google Scholar
  7. 7.
    Gomez CA, Marin BV. Gender, culture, and power: barriers to HIV-prevention strategies for women. J Sex Res. 1996;33(4):355–362.CrossRefGoogle Scholar
  8. 8.
    Harper GW. Contextual factors that perpetuate statutory rape: the influence of gender roles, sexual socialization, and sociocultural factors. DePaul Law Rev. 1996;50(3):897–918.Google Scholar
  9. 9.
    Harper GW, Schneider M. Oppression and discrimination among lesbian, gay, bisexual, and transgendered people and communities: a challenge for community psychology. Am J Community Psychol. 2003;31(3–4):243–252.CrossRefPubMedGoogle Scholar
  10. 10.
    Centers for Disease Control and Prevention. HIV incidence among young men who have sex with men—seven U.S. cities, 1994–2000. MMWR. 2001;50:440–444.Google Scholar
  11. 11.
    Valleroy LA, MacKellar DA, Karon JM, Rosen DH. HIV prevalence and associated risks in young men who have sex with men. JAMA. 2000;284(2):198–204.CrossRefPubMedGoogle Scholar
  12. 12.
    Harawa NT, Greenland S, Bingham TA, Johnson DF, Cochran SD, Cunningham WE, Celentano DD, Koblin BA, LaLota M, et al. Associations of race/ethnicity with HIV prevalence and HIV-related behaviors among young men who have sex with men in 7 urban centers in the United States. J Acquir Immune Defic Syndr. 2004;35(5):526–536.PubMedCrossRefGoogle Scholar
  13. 13.
    Celentano DD, Sifakis F, Hylton J, Torian LV, Guillin V, Koblin BA. Race/ethnic differences in HIV prevalence and risks among adolescent and young adult men who have sex with men. J Urban Health. 2005;82(4):610–621.PubMedGoogle Scholar
  14. 14.
    Kim N, Stanton B, Li X, Dickersin K, Galbraith J. Effectiveness of the 40 adolescent AIDS-risk reduction interventions: a quantitative review. J Adolesc Health. 1997; 20(3):204–215.CrossRefPubMedGoogle Scholar
  15. 15.
    Jemmott JB III, Jemmott LS. HIV behavioral interventions for adolescents in community settings. In: Peterson JL, DiClemente RJ, eds. Handbook of HIV Prevention. AIDS Prevention and Mental Health. Dordrecht, Netherlands: Kluwer; 2000:103–127.Google Scholar
  16. 16.
    Johnson BT, Carey MP, Marsh KL, Levin KD, Scott-Sheldon LA. Interventions to reduce sexual risk for the human immunodeficiency virus in adolescents, 1985–2000: a research synthesis. Arch Pediatr Adolesc Med. 2003;157(4):381–388.CrossRefPubMedGoogle Scholar
  17. 17.
    Mullen PD, Ramirez G, Strouse D, Hedges LV, Sogolow E. Meta-analysis of the effects of behavioral HIV prevention interventions on the sexual risk behavior of sexually experienced adolescents in controlled studies in the United States. J Acquir Immune Defic Syndr. 2002;30(1):94–105.Google Scholar
  18. 18.
    Robin L, Dittus P, Whitaker D, et al. Behavioral interventions to reduce incidence of HIV, STD, and pregnancy among adolescents: a decade in review. J Adolesc Health. 2004;34(1):3–26.CrossRefPubMedGoogle Scholar
  19. 19.
    Altman D. Power and community: organizational and cultural responses to AIDS. In Book Series, Social Aspects of AIDS. Philadelphia, Pennsylvania: Taylor & Francis; 1994.Google Scholar
  20. 20.
    Adimora AA, Schoenbach VJ. Social context, sexual networks, and racial disparities in rates of sexually transmitted infections. J Infect Dis. 2005;191(Suppl 1):S112–S115.CrossRefGoogle Scholar
  21. 21.
    Parker RG. Empowerment, community mobilization and social change in the face of HIV/AIDS. AIDS. 1996;10:S27–S31.PubMedGoogle Scholar
  22. 22.
    Kelly JA, Murphy DA, Sikkema KJ, Kalichman SC. Psychological interventions to prevent HIV infection are urgently needed: new priorities for behavioral research in the second decade of AIDS. Am Psychol. 1993;48:1023–1034.CrossRefPubMedGoogle Scholar
  23. 23.
    Rotheram-Borus, MJ. Expanding the range of interventions to reduce HIV among adolescents. AIDS. 2000;14(suppl 1):S33–S40.CrossRefPubMedGoogle Scholar
  24. 24.
    Sumartojo E, Doll L, Holtgrave D, Gayle H, Herson M. Enriching the mix: incorporating structural factors into HIV prevention. AIDS. 2000;14(suppl 1):S1–S2.CrossRefPubMedGoogle Scholar
  25. 25.
    Harper G, Contreras R, Bangi A, Pedraza A. Collaborative process evaluation: enhancing community relevance and cultural appropriateness in HIV prevention. J Prev Interv Community. 2003;26(2):53–71.CrossRefGoogle Scholar
  26. 26.
    O'Reilly KR, Piot P. International perspectives on individual and community approaches to the prevention of sexually transmitted disease and human immunodefiency virus infection. J Infect Dis. 1996;174(suppl 2):S214–S222.PubMedGoogle Scholar
  27. 27.
    Blankenship KM, Bray SJ, Merson MH. Structural interventions in public health. AIDS. 2000;14(1):S11–S21.CrossRefPubMedGoogle Scholar
  28. 28.
    Parker RG, Easton D, Klein CH. Structural barriers and facilitators in HIV prevention: a review of international research. AIDS. 2000;14(Suppl 1):S22–S32.CrossRefPubMedGoogle Scholar
  29. 29.
    Sumartojo E. Structural factors in HIV prevention: concepts, examples, and implications for research. AIDS. 2000;14(Suppl 1):S3–S10.CrossRefPubMedGoogle Scholar
  30. 30.
    Deaton A. Policy implications of the gradient of health and wealth. An economist asks, would redistributing income improve population health? Health Aff. 2002;21(2):13–30.CrossRefGoogle Scholar
  31. 31.
    Lurie N. What the federal government can do about the nonmedical determinants of health. Health Aff. 2002;21(2):94–106.CrossRefGoogle Scholar
  32. 32.
    Wallace R. Urban desertification, public health and public order: ‘planned shrinkage,’ violent death, substance abuse and AIDS in the Bronx. Soc Sci Med. 1990;31(7):801–813.CrossRefPubMedGoogle Scholar
  33. 33.
    Sweat MD, Denison JA. Reducing HIV incidence in developing countries with structural and environmental interventions. AIDS. 1995;9(suppl A):S251–S257.PubMedGoogle Scholar
  34. 34.
    Cohen DA, Scribner R. An STD/HIV prevention intervention framework. AIDS Patient Care STDs. 2000;14(1):37–45.CrossRefPubMedGoogle Scholar
  35. 35.
    Community Tool Box. Criteria for Choosing Promising Practices and Community Iinterventions. Available at: Accessed June 14, 2005.Google Scholar
  36. 36.
    Burris S, Blankenship KM, Donoghoe M, et al. Addressing the “risk environment” for injection drug users: the mysterious case of the missing cop. Milbank Q. 2004;82(1):125–156.CrossRefPubMedGoogle Scholar
  37. 37.
    Treno AJ, Holder HD. Community mobilization, organization, and media advocacy: a discussion of methodological issues. Eval Rev. 1997;21(2):166–190.PubMedCrossRefGoogle Scholar
  38. 38.
    Minkler M. Improving health through community organization. In: Glanz K, Rimer BK, Lewis FM, eds. Health Behavior and Health Education: Theory, Research, and Practice. San Francisco, California: Jossey-Bass; 1990:257–287.Google Scholar
  39. 39.
    Babalola S, Sakolsky N, Vondrasek C, Mounlom, D, Brown, J, Tchupo J. The impact of a community mobilization project on health-related knowledge and practices in Cameroon. J Commun Health. 2001;26(6):459–477.CrossRefGoogle Scholar
  40. 40.
    Cheadle A, Wagner E, Anderman C, et al. Measuring community mobilization in the Seattle minority youth health project. Eval Rev. 1998;22(6):699–716.PubMedCrossRefGoogle Scholar
  41. 41.
    Harachi TW, Ayers CD, Hawkins JD, Catalano RF. Empowering communities to prevent adolescent substance abuse: process evaluation results from a risk- and protection-focused community mobilization effort. J Prim Prev. 1996;16(3):233–254.CrossRefGoogle Scholar
  42. 42.
    Johnson K, Bryant D, Strader T, Bucholtz G. Reducing alcohol and other drug use by strengthening community, family, and youth resiliency: an evaluation of the creating lasting connections program. J Adolesc Res. 1996;11(1):36–67.CrossRefGoogle Scholar
  43. 43.
    Kirsch HW. Taking the message to the streets: Graffiti campaigns and community mobilization. In: Kirsch HW, ed. Drug Lessons & Education Programs in Developing Countries. New Brunswick, New Jersey: Transaction; 1995:263–270.Google Scholar
  44. 44.
    Kirsch HW, Andrade SJ, Osterling J, Sherwood-Fabre L. Empowerment, participation, and prevention: use of the community promoter model in Northern Mexico. In: Kirsch HW, ed. Drug Lessons & Education Programs in Developing Countries. New Brunswick, New Jersey: Transaction; 1995:179–194.Google Scholar
  45. 45.
    Manger TH, Hawkins JD, Haggerty KP, Catalano RF. Mobilizing communities to reduce risks for drug abuse: lessons on using research to guide prevention practice. J Prim Prev. 1992;13(1):3–22.CrossRefGoogle Scholar
  46. 46.
    Strader TN, Collins DA, Noe TD. Building Healthy Individuals, Families, and Communities: Creating Lasting Connections. Council on Prevention & Education: Substances, Inc. Louisville, Kentucky; 2000.Google Scholar
  47. 47.
    Rogers T, Feighery EC, Tencati EM, Butler JL, Weiner L. Community mobilization to reduce point-of-purchase advertising of tobacco products. Health Educ Q. 1995; 22(4):427–442.PubMedGoogle Scholar
  48. 48.
    Snell-Johns J, Imm P, Wandersman A, Claypoole J. Roles assumed by a community coalition when creating environmental and policy-level changes. J Commun Psychol. 2003;31(6):661–670.CrossRefGoogle Scholar
  49. 49.
    Ellis GA, Reed DF, Scheider H. Mobilizing a low-income African American community tobacco control: a force field analysis. Health Educ Q. 1995;22(4):443–457.PubMedGoogle Scholar
  50. 50.
    Holder HD. Community prevention of alcohol problems. Addict Behav. 2000; 25(6):843–859.CrossRefPubMedGoogle Scholar
  51. 51.
    Fawcett SB, Francisco VT, Hyra D, et al. Building healthy communities. In: Tarlov A, St. Peter R, eds. The Society and Population Health Reader: A State and Community Perspective. New York: New Press; 2000:75–93.Google Scholar
  52. 52.
    Roussos ST, Fawcett SB. A review of collaborative partnerships as a strategy for improving community health. Annu Rev Public Health. 2000;21:369–402.CrossRefPubMedGoogle Scholar
  53. 53.
    Institute of Medicine. The Future of the Public's Health in the 21st Century. Washington, District of Columbia: National Academies; 2003.Google Scholar
  54. 54.
    Anderson RM, May RM. Infectious Diseases of Humans: Dynamics and Control. England: Oxford University Press, Inc; 1991.Google Scholar
  55. 55.
    Community Tool Box. An Overview of Strategic Planning or “VMOSA” (Vision, Mission, Objectives, Strategies, and Action Plans). Part D, Chapter 8, Section 1: Available at: Accessed June 14, 2005.Google Scholar
  56. 56.
    Fawcett SB, Francisco VT, Paine-Andrews A, Schultz JA. Working together for healthier communities: a research-based memorandum of collaboration. Public Health Rep. 2000;115:174–179.CrossRefPubMedGoogle Scholar
  57. 57.
    Francisco VT, Fawcett SB, Schultz, JS, Paine-Andrews A. A model of health promotion and community development. In: Balcazar FB, Montero M, Newbrough JR, eds. Health Promotion in the Americas: Theory and Practice. Washington, District of Columbia: Pan American Health Organization; 2000:17–34.Google Scholar
  58. 58.
    Centers for Disease Control and Prevention, HIV/AIDS Prevention Research Synthesis Project. Compendium of HIV Prevention Interventions with Evidence of Effectiveness. Atlanta, Georgia: Centers for Disease Control and Prevention; November 1999 [revised].Google Scholar
  59. 59.
    Brown L, Macintyre K, Trujillo L. Interventions to reduce HIV/AIDS stigma: what have we learned? AIDS Educ Prev. 2003;15:49–69.CrossRefPubMedGoogle Scholar
  60. 60.
    Klein SJ, Karchner WD, O'Connell DA. Interventions to prevent HIV-related stigma and discrimination: findings and recommendations for public health practice. J Public Health Manag Pract. 2002;8:44–53.PubMedGoogle Scholar
  61. 61.
    Herek GM, Capitanio JP, Widaman KF. HIV-related stigma and knowledge in the United States: prevalence and trends, 1991–1999. Am J Public Health. 2002;92:371–377.PubMedGoogle Scholar
  62. 62.
    Skrondal A, Rabe-Hesketh S. Generalized Latent Variable Modelings: Multilevel, Longitudinal, and Structural Equation Models. Boca Raton, Florida: Chapman & Hall/CRC; 2004.Google Scholar
  63. 63.
    Sullivan LM, Dukes KA, Losina E. Tutorial in biostatistics. An introduction to hierarchical linear modeling. Stat Med. Apr 15 1999;18(7):855–888.CrossRefPubMedGoogle Scholar
  64. 64.
    Leviton LC, Snell E, McGinnis M. Urban issues in health promotion strategies. Am J Public Health. 2000;90(6):863–866.PubMedCrossRefGoogle Scholar

Copyright information

© The New York Academy of Medicine 2006

Authors and Affiliations

  • Mauri A. Ziff
  • Gary W. Harper
  • Kate S. Chutuape
  • Bethany Griffin Deeds
  • Donna Futterman
  • Vincent T. Francisco
  • Larry R. Muenz
  • Jonathan M. Ellen
    • 1
  • Adolescent Medicine Trials Network for HIV/AIDS Intervention
  1. 1.BaltimoreUSA

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