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).

Recruiters   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.

Thanks
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