Launched in 2004, Project ACXION is the Miami-Dade and Broward County arm of the National HIV Behavioral Surveillance system. The goal of this study, sponsored by the Centers for Disease Control and Prevention, is to reduce the number of new HIV cases in the United States by looking at behaviors that put different groups of people at high risk for HIV infection. Researchers also are following trends in these behaviors over time and monitoring people’s awareness and use of testing, counseling, and other prevention services. Miami-Dade and Broward Counties are among 25 Metropolitan Statistical Areas with a high prevalence of AIDS included in the national study.

“We need to understand what the people who get this disease have in common and how we can reach them,” says Marlene LaLota, program administrator in the Florida Department of Health’s Bureau of HIV/AIDS, which is administering the study in Florida and selected the University of Miami Miller School of Medicine as its partner in the task. “If we have a group of people who are at risk and providers who aren’t reaching them, we need to know that.”

Florida has the nation’s third largest AIDS population—almost 97,000 people—with the greatest concentrations in Miami and Fort Lauderdale. ACXION (for Assessing Characteristics of Population X in Ongoing Surveillance) was formed by the Department of Epidemiology and Public Health in the Miller School of Medicine to collect information about individuals in these areas who are at greatest risk of HIV. The department, particularly through its Drug Abuse and AIDS Research Center, played an early role in recognizing the AIDS threat and developed some of the first AIDS programs in the community. “We’ve been successful in large part,” says Clyde McCoy, epidemiology professor and department chair, “because we have maintained a strong relationship with community organizations.”

David Forrest, an anthropologist by training, is the director of operations for Project ACXION. He believes that his team has been particularly successful in obtaining honest and thorough information in this study because of the compassion and objectivity with which Project ACXION interviewers approach survey participants. This is also particularly important, he notes, because ACXION provides a rare opportunity to reach individuals who might otherwise not participate in prevention programs.

“One of the fantastic things about this is, because we don’t make any assumptions about people and the survey is anonymous, we get fairly open talk about people’s sexual behaviors,” Forrest says. “All our training is geared to being objective and nonjudgmental, from the way we carry ourselves to our facial expressions and tone of voice.”

At the end of each survey, people are invited to take an HIV screening test and, if they agree, receive HIV counseling and a personal risk assessment that goes well beyond that offered in most doctors’ offices or clinics. If a person turns out to be HIV-positive, they’re referred elsewhere for follow-up testing and treatment.

Why, more than 20 years after this devastating epidemic was identified, does controlling the spread of HIV remain such a challenge?

“I think one of the problems has been that when HIV went from being a fatal disease to a chronic disease in the mid-1990s, it led to some complacency,” says Lisa Metsch, associate professor in the Department of Epidemiology and Public Health and the Miller School of Medicine principal investigator in the study. In the mid-1990s, she explains, physicians began using HAART (Highly Active Anti-Retroviral Therapy), a combination drug therapy that suppresses the virus’s ability to multiply in the body and slows down the development of AIDS. This made it possible for HIV-positive people to survive for decades.

A second issue is the growing awareness of men who are known in the media as being “on the down low,” which Metsch describes as “men who are in heterosexual relationships but who also are carrying on secret lives, having sex with men.”

Finally, although the sharing of drug paraphernalia by injection drug users has long been a known risk factor for AIDS, the problem may be worsening with the growing popularity of crystal methamphetamine. This drug suffers the double curse of being highly addictive and ramping up one’s sex drive at a time when people are less apt to practice safe sex. The ACXION survey revealed that crystal methamphetamine users were more likely to have in excess of ten sexual partners, to engage in the riskiest types of sexual behavior, and to find sex partners on the Internet. “A lot of prevention strategy focuses on condom use,” Metsch adds, “and it’s pretty challenging to get people hooked on hard-core drugs to use a condom.”

Forrest explains that the nationwide study is investigating risk behaviors among three different groups: men who have sex with men, injection drug users, and at-risk heterosexuals.

In the first phase, which his team completed in early 2005, trained interviewers spoke with hundreds of men and administered a half- to full-hour anonymous survey exploring everything from sexual identification (homosexual, heterosexual, bisexual), to number of sexual partners, to whether the interviewee exchanged sex for money or drugs. Researchers drove the ACXION van—an oversized emergency medical vehicle with three soundproof rooms, a bathroom, and blood collection facilities—to multiple venues where they determined that men who have sex with men congregate. They asked random individuals at these sites to participate in the study.

The second phase, completed in early 2006, focused on risk behavior among men and women who use injection drugs. This phase used a respondent-driven sampling technique in which drug users who participated in the study located and recruited other drug users to take the survey for a small fee.

The third phase of the study will break new ground by becoming the first national study of HIV risk among heterosexuals. In Florida, 23 percent of men and 89 percent of women with HIV contracted it through heterosexual contact, according to data from 2004. ACXION staff will interview people in neighborhoods with a high incidence of HIV.

Once the heterosexual phase of the study is over, Metsch and her colleagues will begin the cycle anew, again interviewing people among the three groups. This will help local and national organizations track trends in risk behavior every three years and determine whether changes in prevention strategies have worked.

Although the study is still in its early stages, ACXION researchers have reported a number of notable findings. These include the discovery that almost half of the men (46 percent) who tested positive for HIV were unaware of their infection. This is particularly dangerous, Metsch notes, because individuals are most contagious during the early stages of the disease when they may not know they’re infecting others. Metsch and Forrest have presented these findings to numerous federal, state, and local organizations to help them design effective prevention strategies.

For people who visit the ACXION van, though, the trusting relationship they develop with the UM interviewers is the key. In many cases, the interviewer is the first person—or the first in many years—with whom they’ve openly discussed their concerns.

“The most powerful thing we can do by talking to people during the interview is to cause them to think about their behavior regarding risk for HIV and what they can do about it,” Forrest says. “Some people simply don’t think about the consequences.”

Joan Cochran is a freelance writer in Boca Raton, Florida.