An estimated 40,000 persons in the United States become infected with HIV every year
(1). Of the one million persons living with HIV in the United States, approximately 250,000 are
not aware of their infection and their risk for transmitting HIV to others. Of those who are
unaware, many are diagnosed late in the course of their infection, after a prolonged
asymptomatic period during which further transmission may have occurred. Persons who are
diagnosed late in their infection miss a valuable opportunity to start HIV care and are at greater
risk for AIDS-related complications (than those diagnosed earlier). Therefore, it is a national
priority to identify HIV-infected persons and link them to medical, prevention, and other services
as soon as possible after they become infected.
CDC currently funds health departments and community-based organizations (CBOs) to
conduct HIV counseling, testing, and referral (CTR) in a variety of settings. These publicly
funded sites, which perform approximately two million HIV tests yearly, account for
approximately 30 percent of positive tests in the US (2). The prevalence of positive tests in these
sites is highly variable, but is often very low (less than 1%), suggesting a need for more efficient
targeting strategies that will reach persons not being reached with current strategies.
One strategy for reaching and providing HIV CTR to persons with undiagnosed HIV
infection is the use of social networks. Enlisting HIV-positive or high-risk HIV-negative persons
(i.e., recruiters) to encourage people in their network (i.e., network associates) to be tested for
HIV may provide an efficient and effective route to accessing individuals who are infected, or at
very high risk for becoming infected, with HIV and linking them to services [originally
developed by Jordan and colleagues (3)]. The social network approach has proven to be a viable
recruitment strategy for reaching people beyond current partners.
In CDC’s Social Networks Demonstration Program (2003 – 2005), social
network strategies were used to identify people who were unaware of their HIV
infection in communities of color. Across nine sites funded for the program,
approximately 6% of people tested were newly diagnosed with HIV (4). This
prevalence rate is six times higher than the average of most HIV CTR
programs, illustrating the great value of using social networks to reach people
at risk for HIV infection.
Introduction to the Social Networks Strategy for HIV CTR
The use of social networks is a recruitment strategy whereby public health services (e.g.,
HIV CTR) are disseminated through the community by taking advantage of the social networks
of persons who are members of the community. The strategy is based on the concept that
individuals are linked together to form large social networks, and that infectious diseases often
spread through these networks. The social network approach and ethnographic assessment
provide a broader understanding of HIV transmission in the community and the role of all
members of the network, whether infected or not, in transmission and its prevention.
Although similar in some ways, the social networks strategy is not partner counseling and
referral services (PCRS), partner notification, outreach, health education, or risk education—and
it is not intended to replace these services. It is a programmatic, peer-driven, recruitment strategy
to reach the highest risk persons who may be infected but unaware of their status. This technique
is accomplished by enlisting newly and previously diagnosed HIV-positive and high-risk HIVnegative
recruiters on an ongoing basis and providing HIV CTR to people in their networks. This
type of strategy facilitates expansion and penetration of testing within networks.
Participating as a recruiter in a social networks testing project gives people living with
HIV the chance to help protect others in their community. In addition, if people in their networks
are infected, it gives them the opportunity to get medical care and treatment. Most people living
with HIV understand the importance of getting tested and can be powerful allies in this type of
HIV prevention effort.
Below is an illustration of a network diagram (Figure 1). In this figure, an HIV-positive
recruiter (large solid black square) was responsible for the ultimate identification of eight
different individuals who were diagnosed with HIV and previously unaware of their infection
(big and small black solid circles). Six of these eight individuals were directly identified by the
recruiter and are considered to be part of the recruiter’s network; the remaining two were
identified by a network associate who later decided to enlist as a recruiter himself (bottom right).
|| ||Network associates|
Black node|| ||HIV-positive|
White node|| ||HIV-negative|
Figure1- Example social network of an HIV-positive recruiter and his network associates
The primary goal of a program using a social network strategy is to identify persons
with undiagnosed HIV infection within various networks and link them to medical care
and prevention services.
Purpose of this document
This guide is intended to provide an overall description of a social networks strategy to
identify persons for HIV CTR and, also, to guide the development of protocols, policies, and
procedures for agency’s planning to use this strategy. Lessons learned from the field (from sites
funded for CDC’s Social Networks Demonstration Program) are highlighted throughout this
document so that future program managers can learn from past social network experiences.
We would like to thank all the staff of the nine CBO sites that took part in the Social
Networks Demonstration Program. Because of their hard work, dedication, and valuable input,
we are able to disseminate the social networks testing toolkit to CBOs and health departments
nationwide. In addition, we would like to acknowledge Wilbert Jordan’s seminal research in the
area of social networks (3). Without his early work identifying HIV-positive patients in
networks, the development of this social networks testing strategy would not have been possible.
—CDC, Division of HIV/AIDS Prevention, Social Networks Team
“Social Networks is all about breaking from the old model of just doing outreach. A main goal of social networking is to prevent HIV. What is put into the community in terms of knowledge and awareness is better than just random testing of people.”|