How Low Can You Go?
A Brave New Campaign in Bexar County, Texas, Aims High
by Chael Needle

Thanks in large part to grass-roots advocates, the Undetectable = Untransmissible message has been spreading far and wide. And although Treatment as Prevention has been a longstanding mode of stopping the virus, first gaining prominence in vertical transmission and then, for sexual transmission, bolstered by the Swiss Statement in 2008, which proclaimed that positive individuals on sustained treatment who achieve viral suprression for at least six months (and in the absence of STIs) cannot transmit HIV via sexual contact. Later, 2011’s HPTN 052 study showed early treatment was more effective in preventing onward transmission from the positive to the negative partner in mixed-status couples than delayed treatment, as well as conferred better health outcomes for the partner living with HIV. In 2014–2018, the PARTNER studies again provided solid evidence that viral suppression means that an individual cannot transmit HIV to partners through vaginal or anal sex.

But it was arguably Prevention Access Campaign’s U = U that framed the prevention tool in terms of empowerment, placing engagement in care, sexual health and sexual freedom in the hands of those living with HIV/AIDS. The campaign has provided a template for others to build upon and tweak.

For example, the empowerment vibe resonates throughout How Low Can You Go? The campaign was organized by Operation B.R.A.V.E. (Bexar County’s Response and Victory in Ending the Epidemic) and covers all of the Texas county in the title, including San Antonio. It seeks to engage more and more residents in HIV care in a county where more than a third people living with HIV have not achieved viral suppression. The U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA), HIV/AIDS Bureau (HAB) provides funding for the initiative.

At its heart, How Low Can You Go? encourages individuals living with HIV to embrace the fact that sustained treatment leads to viral suppression, and a virus lowered to undetectable means not only overall better health outcomes but also zero risk of onward transmission to negative partners. Biligual messaging in English and Spanish invites users to check out the website and/or smart phone apps (iOS and Android), which, in turn, helps individuals who may have never engaged in HIV care or who have fallen out of HIV care to navigate the first important steps. Vibrant graphics and storytelling humanizes the science and creates points of connection for users to see themselves as part of the larger movement to utilize the power of undetectability for good.

A&U recently had the chance to talk with the creative forces behind Operation B.R.A.V.E., corresponding via email with Jeff Daniel, founder and CEO of Collaborative Research, a strategic planning healthcare firm dedicated to supporting local public health, social-service, and community-based organizations in various states.

Chael Needle: In 2019, San Antonio was identified as one of ten cities with a rising HIV rate, with the CDC identifying it as the largest “hot spot” in the U.S. Young LGBTQ individuals, particularly Hispanic and Black men, were mentioned as particularly affected. Briefly, what realities do the numbers reflect?
Jeff Daniel: Bexar County, home of San Antonio, has had historically high HIV infection rates. The county is one of 48 identified in the Ending the HIV Epidemic (EtHE): A Plan for America. Based on 2018 data supplied by the Texas Department of State Health Services, 120 (34%) of the county’s total new HIV infections (356) were among Hispanic men who have sex with men (MSM). Additionally, 49 (33%) of the county’s total new AIDS [diagnoses] (149) were among Hispanic MSM. Furthermore, Black MSM accounted for 29 (8%) of the total new HIV infections and 6 (4%) of the total new AIDS [diagnoses]. Finally: 13% of new 2018 AIDS cases were between the ages of 13-24, representing a 100% increase from 2017 AIDS cases (6%); In 2018, 20% of new HIV cases were among the 13-24 age group.

What was the impetus for starting Operation B.R.A.V.E.’s “How Low Can You Go”?
In October 2018, the U.S. Department of Health and Human Services, Health Resources & Services Administration’s HIV/AIDS Bureau released a funding opportunity notice entitled: “Building Capacity for HIV Elimination in Ryan White HIV/AIDS Program Part A Jurisdictions.” The application guidance encouraged jurisdictions to be innovative and creative in developing strategies to end their local epidemics. Having been born and raised in San Antonio (I still call San Antonio “my hometown”), I felt that this was a great opportunity to restart conversations about HIV. Viral suppression as HIV prevention (commonly called Undetectable = Untransmittable) is a positive, exciting message for everyone to hear—especially people living with HIV. I “pitched” the concept of a social media campaign to Ryan White Part A Recipient. They quickly committed to the initiative. With input from PLWH and other stakeholders in the community, we worked to develop a multi-tiered approach to ending the HIV epidemic in San Antonio that evolved into Operation B.R.A.V.E. (Bexar County’s Response and Victory in Ending the Epidemic). I wrote the grant and submitted it to HRSA. San Antonio was one of ten jurisdictions selected to be funded.

The press release states: “An estimated 37% of people living with HIV in Bexar County have not been able to reach an undetectable status. This may be due to other health issues, how often they take their meds or other socioeconomic factors. Operation B.R.A.V.E. has set an ambitious goal of having 90% of persons with HIV in Bexar County achieve a consistent undetectable level of HIV by 2030.“ What barriers need to be overcome for this to happen?
In 2018, we surveyed 167 non-virally suppressed PLWH and barriers they cited as not achieving viral suppression were: Stigma; Denial; Other Co-morbidity (Mental Health/Substance Use/Homelessness) and Uninsured. Texas is a non-expansion Medicaid State and in 2018, an estimated 4.7 million Texans, or 19% remain uninsured; the national estimate is 11% resulting in Texas being the “highest un-insurance rate of any state in the country” (Buettgens, 2018). In 2018, 93% of Ryan White clients were uninsured. The survey also revealed that one-third of survey respondents had never had an HIV test prior to their positive test.

To overcome these barriers, the community needs to collaborate to reduce stigma; expand HIV testing so that it’s a routine part of an individual’s health care; highlight and promote success stories that show managing an individual’s HIV is “quite doable” and that HIV does not define you as an individual. How Low Can You Go’s goals are to address these issues. It is also to celebrate individual accomplishments and reduce fear/stigma/denial.

How do you balance promoting an individual’s undetectable viral load as beneficial for their own health with undetectability as beneficial for their sexual partners?
To inform the campaign, we met with a variety of PLWH in San Antonio to learn about the care they receive, and what they knew about U=U. They told us that viral suppression to remain healthy is universally discussed by providers. The U=U prevention benefits, not so much. Some were just hearing the message for the first time. Based on this feedback, the campaign emphasizes the message of zero risk of passing HIV to others. Treatment adherence methods are shared to create a “roadmap” of how to reach a long-term undetectable status that protects you and your sexual partners.

Are you concerned about a divide between people living with HIV/AIDS who are detectable and those who are undetectable? Why or why not?
The goal of the campaign is to provide hope and encouragement for PLWH to achieve viral suppression. We know it will be harder for some to achieve viral suppression based on other factors (mental health/substance use/homelessness, etc.). However, we think the campaign is a much needed “Lighthouse of Hope” for a community that confronts stigma and shame. If we can get folks talking about HIV, shine a light on it, as it were, we hope we can increase willingness to get the appropriate care to live their best life.

Do you have any sense yet about how the initiative is being received or any measurable success?
We worked hard to make the site accessible, using plain language, bright colors, and diverse representation of San Antonio’s PLWH community. When we previewed the campaign to our PLWH focus groups and San Antonio’s Ryan White Part A Planning Council, the response was extremely positive. Several PLWH offered to be interviewed/quoted, and we were asked to create a range of images and messages that could be shared on personal Facebook and Instagram accounts.

Initially, the campaign has been implemented in six zip codes in San Antonio via online digital ads, Twitter and Facebook messages, and radio ads on Spotify and Pandora. In the first three weeks of the campaign (May 1 to 25), more than 1,500 people have visited An additional 550 people have visited, the Spanish-language website.

Given the highly targeted media placement, we are very happy with these results. The next phase of the campaign will extend into other parts of the city and include outdoor advertising.

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Chael Needle interviewed HIV advocates for their thoughts on how everyone could respond to COVID-19 for the May cover story. Follow him on Twitter @ChaelNeedle.