HIV Prevention among Men Who Have Sex with Men: Panel Discussion of Viewer Questions Archived
Moderator Rob Janssen and panelists Susan Kegeles, Alberto Santana, John Peterson, and Dwayne Jenkins respond to viewer questions received on May 17, 2007; then moderator Rob Janssen summarizes enhancements to CDC information online and mentions upcoming events such as World AIDS Day, National HIV/AIDS Testing Day, the National HIV Prevention Conference and the Nov 15, 2007 satellite broadcast/web cast "Current Challenges and Successes in HIV Prevention with Hispanics.". Created: 5/17/2007 by The National Center for HIV, STD, and TB Prevention (NCHSTP).
Date Released: 10/23/2007. Series Name: CDC Featured Podcasts.
[Announcer] This podcast is presented by the Centers for Disease Control and Prevention. CDC - safer, healthier people.
[Announcer] After the airing of this Satellite Broadcast in May 2007, CDC issued a revised 2005 HIV/AIDS Surveillance Report (June 2007). Some of the data sited in this broadcast have been updated. The revised report can be found at www.cdc.gov/HIV/datarevision.htm.
[Moderator/Dr. Rob Janssen] Our panelists have joined us now in the studio to take audience questions in a few moments. Dr. John Peterson is a professor in the Department of Psychology at Georgia State University in Atlanta. His research concentrates on HIV/AIDS prevention among African-American men, including socio-cultural and psychological factors that can impact men's lives. Dr. Peterson developed the first evidence based intervention for African-American MSM. Dr. Susan Kegeles is professor and co-director of The Center for AIDS Prevention Studies at The University of California-San Francisco. Her research focuses on two major areas first, developing, implementing and evaluating HIV prevention interventions with gay and bisexual men, especially men of color. And, secondly, collaboration with community-based organizations to improve implementation of evidence-based interventions. Mr. Alberto Santana is the Community Partnership Program Director for the Miami-Dade County Health Department and the Statewide Latino AIDS Coordinator for the Florida Department of Health. He’s also served on staff at The National Alliance of State and Territorial AIDS Directors and is currently on their Latino Advisory committee as the Representative from the state Florida. Dwayne Jenkins is the HIV Education coordinator of The Brothers United Program at Nashville Cares, the largest and oldest HIV/AIDS service organization in Tennessee. In this capacity, he coordinates an array of culturally sensitive counseling and educational programs and services locally, regionally and nationally for MSM, especially men of color. Thank you all for being with us today. Our first question is for everyone on the panel. We'd like, John, if you could start. Why are we still seeing new infections among MSM?
[Dr. John Peterson] The epidemic is not over and, as a result, there are men who have come into the population of MSM who are not reached earlier in the epidemic. These are younger men, men who are new generations of MSM who have to be reached. And there are many men who were in other populations, African-American and Latino populations, Asian populations, even, who were not reached earlier when most of the effort focused on white MSM.
[Moderator/Dr. Rob Janssen] Alberto.
[Alberto Santana] In addition to some of the co-factors that were mentioned earlier in the broadcast, I also think that the invisibility of HIV Prevention messages is also a contributing factor to the increases. As well as many of the men that are becoming infected now do not have the benefit of past prevention messages and massive prevention messages of the early 80’s and early 90’s.
[Moderator/Dr. Rob Janssen] Susan.
[Dr. Susan Kegeles] What’s changed is that in the last, since 11 years ago Anti-retrovirals came into existence. And so, there's no longer a sense of a crisis. People aren't seeing friends, brothers, sons dying of HIV and the fact is, is that unprotected sex is pleasurable. So, when you don't see the crisis any more and you're not so worried about it, people are reducing or increasing their risk behavior.
[Moderator/Dr. Rob Janssen] Dwayne.
[Dwayne Jenkins] Unfortunately, you know, as she said, people do like to have unprotected sex and most of the time that's the bottom line. They're still having unprotected sex. That's the basic point. I think.
[Moderator/Dr. Rob Janssen] Thanks. Here's a question for Alberto. Is HIV testing an effective strategy to preventing HIV transmission?
[Alberto Santana] Of course. HIV prevention is an important strategy in preventing further infections because people get to know their status. It’s also a point of entry to care services, as well as other prevention services. But the most important thing to note is that HIV testing is one strategy of a comprehensive prevention program.
[Moderator/Dr. Rob Janssen] Here's a question I'd like both John and Susan to answer. John, how do we reach men on the down low?
[Dr. John Peterson] It’s extraordinarily difficult to reach a group of men who prefer not to be identified. And that's probably most likely to occur through sources like the internet, where you actually can contact men who will be invisible to the rest of the population at the time that they're seeking partners over the web. I think the internet poses a wonderful, valuable alternative to HIV prevention with this very, very unknown population.
[Dr. Susan Kegeles] An approach that a group that I'm working with, Cal Path, in Oakland, we're investigating is using enhanced counseling and testing as a method of reaching men. That we advertise counseling and testing to all black men in Oakland and then some of the men who will come in don't identify as having sex with men, but they’re coming in for testing and so this is an opportunity to talk to them about risk reduction without talking specifically about having sex with men.
[Moderator/Dr. Rob Janssen] Some important attempts to get to a very difficult population to reach. Duane, how can we support MSM to disclose their serostatus to potential partners?
[Dwayne Jenkins] What we've done in Nashville is try to bring couples and/or bring in friends at one time and actually use a thing called Positive Peer Pressure, if you want. We've taken a global look at what a successful gay male will be and that includes knowing your health status, knowing your HIV status and having a driver's license, having ID, having voter registration. So we take a whole health and wellness way of doing it and that way we can bring people in to get tested as well as using that positive peer pressure to go, “Hey I just got tested, isn't it your turn to get tested,” or, “Come with me to the agency.” And it really works out very well for us in Nashville.
[Moderator/Dr. Rob Janssen] Okay. John, what can be done to reduce the number of MSM who are unaware of their HIV infection?
[Dr. John Peterson] Critically important issue. One of our aspects may be to provide a convenient and safe place for men to be tested. It's critically important that men be able to go to a place to be tested where they won't have any fear of their results being disclosed to anyone outside of the staff. Being able to have real access to sensitive, caring staff who won’t judge them because of their sexual orientation or because of their sexual behavior. And being able to, if diagnosed with HIV, to get immediate access to care, which is critically important for men who may be low income, who may not have access to medical coverage. Being able to do something about their HIV infection is as important as them finding out about their HIV status.
[Dr. Susan Kegeles] Rob, if I could add something. I think it's also important that we continue to talk about the fact that treatment works. That there are side effects to be true. There are side effects and those can be difficult. But HIV treatments really save lives. And what I’ve been hearing out in the community is that oftentimes the men who don't get tested are fearful of getting tested because what would they do anyway if they found out they were positive? They distrust the treatments. And so, we need to get more information out there about the effectiveness of the treatments.
[Moderator/Dr. Rob Janssen] Sue, so you have a sense really that there just isn't enough knowledge yet in the community about treatments.
[Dr. Susan Kegeles] Absolutely.
[Moderator/Dr. Rob Janssen] Okay. On the other hand, is there a concern that the treatment works so well that HIV isn't a threat?
[Dr. Susan Kegeles] Well, I think that is a concern with many men, as well. But we're talking about men who are at different educational abilities, for example, who read different kind of magazines, access different kinds of resources. So, some men believe that HIV is no longer an enormous threat. Other men, though, think that HIV is very, very scary and that it's a death sentence and you're even more quickly to die, quicker to die if you get on the treatments because of the side effects.
[Dr. John Peterson] Rob, may I add one other point to that, I agree with Susan, for some men that’s an issue, but also for many men, they are completely unaware of the cocktail. Many men don't know about the new retroviral therapy and in fact among those men who are at most risk of being HIV infected there is very little information among those communities about the access to the new treatment.
[Moderator/Dr. Rob Janssen] Are there data on the characteristics of those men, John? For example, are they more likely to be young African-American MSM?
[Dr. John Peterson] The study that we have conducted that showed among 1,000 men, that 800 of the men were unaware of the cocktails. They knew nothing about them.
[Moderator/Dr. Rob Janssen] Okay. Alberto, what are the predictors of risk for Latino MSMs?
[Alberto Santana] Rob Well, one of the predictors, which is emerging and a lot of recent studies have been contributing to this is the use of crystal meth, methamphetamine. That is one predictor among Latinos. A second one is acculturation. Many Latino men feel that acculturating and being part of main stream society is also engaging in high-risk behavior such as drug use and unprotected sex.
[Moderator/Dr. Rob Janssen] Some important challenges. A question for everyone. What are the best ways to get MSMs of color to participate in research studies? And let Susan, how about if you start that.
[Dr. Susan Kegeles] Well, the starting point is that you need to involve the communities that the men are from. You need to involve the institutions that, if you're trying to get, for example, a young black man into studies, work with the institutions that work with African-Americans. Work with the NCAAP, for example. If there's AIDS organizations that focus on young black men, work with them. So, really work with the community in every way possible.
[Moderator/Dr. Rob Janssen] That leaves Duane seems like the next obvious answer after Susan’s.
[Dwayne Jenkins] Okay. I think it's important to use whatever research that you have at your disposal. So, if you can get e-mails, get newsletters out and also bring, as you said, bring community members together so they can meet these particular people. Have tours of the facilities. Do different things so people once they walk in won't feel so clinical and then they'll have a better understanding of how what they're going to do with the project can help them benefit the whole society.
[Moderator/Dr. Rob Janssen] Okay. Alberto.
[Alberto Santana] I would say, it's an experience we have in Florida, is having the researchers work with the men. Working with gay men, working with them to help design the intervention and bringing them at the very beginning of that intervention. That seems to work.
[Dr. John Peterson] I couldn't agree with Alberto more, it's called participatory research where you involve members of the community as research collaborators in the process. Most of my research has involved using members of the African-American community as research staff.
[Moderator/Dr. Rob Janssen] Question for Susan. Can you please explain the higher risk of young men who are having sex with older men?
[Dr. Susan Kegeles] Well, sometimes what we see is that it happens when younger men see that they can get resources from the older men. And so, if older men, for example, are willing to buy them clothes, pay for dates, bring them out to restaurants and so forth, this can be a way that younger men can gain those resources that they can't otherwise have. There also can be a power dynamic so that the older man is seen as more sophisticated, more attractive, more worldly and a younger man might want to have sex with a man like that.
[Moderator/Dr. Rob Janssen] Okay. Again, a question for everyone. About the internet. Are there any internet-based interventions that are currently under development for MSM? John, if you want to start.
[Dr. John Peterson] I don't know of any specifically for African-American MSM but there are ones that include African-American and Latino men among Asian, I mean European-American men, one study is being done from the University of Minnesota that is a major internet intervention that's funded by CDC.
[Moderator/Dr. Rob Janssen] Okay. Alberto.
[Alberto Santana] I know currently right now Dr. Isabel Fernandas from Nova South Eastern University, is currently working on a research project for Latino MSM and it's an intervention with Latino MSM (inaudible) and it’s an intervention with Latino MSM and the internet. Our office, Miami-Dade Health Department and the Florida Department of Health is also looking towards working with some of our researchers to see how we can implement internet-based interventions for all men.
[Moderator/Dr. Rob Janssen] Okay, Susan?
[Dr. Susan Kegeles] I know one internet study was just published within the last two months, by a researcher, at the University of Wyoming, I don’t remember her name, reaching rural MSM.
[Moderator/Dr. Rob Janssen] Okay, Dwayne?
[Dwayne Jenkins] Well in Nashville the two MSM, well three MSM programs have been doing internet outreach since 1996. And it's a very successful way to get men just to talk, just to find out about information. Again, word of mouth is really, really important to the MSM community, having word of mouth get out about different activities and events. But we’ve been using the internet, especially the chat room since 1996 and it’s worked in our favor to just get people to know about us and to still be anonymous but still understand that they can ask us anything and/or call our 800 or local numbers.
[Moderator/Dr. Rob Janssen] Question for Susan and John. What can be done to address social norms in the environment through structural interventions?
[Dr. Susan Kegeles] John?
[Dr. John Peterson] I think this is the, I think the cutting edge of AIDS research now. To begin to address the stigma towards MSM and all of the social and cultural factors that affect the lives of MSM, particularly African-American and Latino MSM structural of (inaudible) would be extraordinarily useful. One example I am interested in is a structural intervention that focuses on specifically stigma and how to reduce the evasive effect of anti-gay tolerance and an acceptance of MSM, particularly, in the African-American community.
[Dr. Susan Kegeles] One very important structural intervention that people are debating right now has to do with gay marriage. That there is no better way we can show that we accept our gay brothers and their relationships than to accept gay marriage and support gay marriage.
[Moderator/Dr. Rob Janssen] Let me follow up, this is a follow up a bit on John's answer to that question. For both Duane and Alberto, but, Alberto, if you can answer first. How can we address issues of stigma such as low self-esteem and internalized homophobia?
[Alberto Santana] I think one strategy that we should be implementing are social marketing campaigns and campaigns that talk about stigma, homophobia in communities primarily where men feel um, stigmatized. Another strategy could be bringing men together to talk about issues around self-esteem and issues around homophobia and what are some of the things they go through as they live their daily lives.
[Moderator/Dr. Rob Janssen] Okay. Dwayne?
[Dwayne Jenkins] Listening to especially, well, the youth and the young people. When you're listening to how people grew up, where they grew up, how they feel about themselves if the were (inaudible) when they were young, they have any self-worth or any empowerment structure within their family unit and/or gay family unit is really been important to find that out when you're trying to get the community together and some of the things that we've done in Nashville is to try to bring them in and actually ask them questions, do surveys and then what we've tried to do, as Alberto said, our social marketing campaign is to actually use real people so they're not always chiseled, they wear glasses, they’re bald, they have locs. They're just a different variety of people. When you use local people, it actually helps to have that positive effect to go, “Oh, I didn't know you were involved in with that program. How can I help?” and, “I wanna be seen,” of course you’ve gotta go on the vainness of people too, but that really helps in a positive way to get people out there.
[Moderator/Dr. Rob Janssen] Good. John, is there a correlation between routine HIV testing and HIV risk behavior?
[Dr. John Peterson] Absolutely. People who are more likely to get tested and to learn their status are less likely to engage in unprotected intercourse, much less likely to engage in high-risk sex. So, by getting people tested and learning their results, you are much less likely to have people engaging in risk behavior.
[Moderator/Dr. Rob Janssen] Okay. Dwayne, how is HIV transmission different among MSM in rural areas?
[Dwayne Jenkins] I'm not sure of the, if it's different for people. I know that most people in rural areas get their information a little bit different than those in urban areas. So, at some points people in rural areas will use the internet a little bit more and they may travel into the larger cities, whichever is closer, so that they can find a community, find a local bar. And that may be the difference. But people are still getting infected because they're having unprotected sex in both rural and urban settings.
[Dr. John Peterson] May I add to that Rob? I think, also, it's critical to understand that in small towns and in rural areas where people are much more likely to know each other and be familiar with each other, there's a greater likelihood that people will be less likely to be involved in something like HIV prevention or get access to prevention in the same way they would in large urban cities where people are less likely to know each other. I think it’s critical to understand in small towns and in rural communities there has to be a different approach to it where people don't necessarily have to worry about confidentiality and disclosure about their HIV risk.
[Moderator/Dr. Rob Janssen] Anonymity just doesn't exist. Susan, how can we address bare-backing issues?
[Dr. Susan Kegeles] Well I think most research has indicated that bare-backing is really serosorting so that most men who deliberately want to have unprotected sex and that’s what bare-backing is, they’re making assumptions about their sex partner's serostatus. And as we saw from the data presented earlier, many, many men don't have an accurate sense of their serostatus and so I think that's a very important issue is to keep pushing that men need to be, need to keep actively knowing what their serostatus is so that if an HIV negative person is trying to bare-back and assumes that he’s gonna be doing it with an HIV negative person, he really makes sure that he knows. He doesn’t just assume that just because someone says, “I’m negative,” that they are negative. I think it's a risky proposition.
[Moderator/Dr. Rob Janssen] It seems that knowledge of serostatus, you saw on a number of the videos a discussion of serosorting. It seems knowledge of serostatus of ones partner could be very important. What do people think? Dwayne, what do you think?
[Dwayne Jenkins] I think it's very important for people to go but then you have to start at zero, not even one. You have to start at zero and talk about communication between partners and if they are going to be partners. It’s really important to know if you're going to get with someone and you don't know them and it's not going to be a long relationship, then you should assume that you want to use condoms and not go off general like “I’m okay, you're okay,”. And what we always say in Nashville is, don't wait until you're both naked to talk about if you're clean, the term they use, “Are you clean?” What do you think the person is going to say, you know?
[Moderator/Dr. Rob Janssen] Um hm. Susan, do you want to add more to that?
[Dr. Susan Kegeles] And I think the building on that is when someone says, “I'm clean” but that means that they got tested three years ago and I've had lots of unsafe sex since then. So I think that's very risky. I think that serosorting can be an important approach, but it has to be entered in to very carefully. You need to know what your own serostatus is and what your partner's serostatus is.
[Moderator/Dr. Rob Janssen] And serosorting, really whether its people who are living with HIV having sex, with people living with HIV, or people who are uninfected having sex with people who are truly uninfected, there's still an issue about sexually transmitted diseases. So, unprotected sex isn’t just a risk with respect to HIV but other STDs, as well. Alberto, you want to answer that?
[Alberto Santana] I agree with Duane and Susan.
[Moderator/Dr. Rob Janssen] Okay. John?
[Dr. John Peterson] Yes, I think I agree with them.
[Moderator/Dr. Rob Janssen] Another question for Alberto now. How are budget priorities set locally regarding interventions and other HIV prevention efforts?
[Alberto Santana] Well, budget priorities are set through our local community planning process where community planning groups develop a HIV prevention plan. They prioritize populations and they also prioritize prevention interventions. But the other thing that jurisdictions like my jurisdiction of Florida is that we have a statewide Black and Latino MSM work group and through our work group we're able to solicit recommendations that have really helped us in developing some of our MSM projects. Most recently our statewide media campaign and most recently the release of competitive resources for MSM prevention projects.
[Moderator/Dr. Rob Janssen] Now, a question for John and Susan. Are there other interventions that you're aware of currently being researched and designed specifically for African-American MSM?
[Dr. John Peterson] Well, one in particular comes to mind and that's the one that Susan and I are doing with our colleague, Greg Rupture, that CDC recently funded in the last round of applications.
[Moderator/Dr. Rob Janssen] Does this sound like a set up? (Laughing)
[Dr. John Peterson] But, this is an actual adaptation of the Mpowerment Project which has been enormously successful and one of the few, actually, one of two community level interventions that have been shown effective with MSM. We are hopeful that the results of this trial will prove that the effects can be shown with African-American MSM.
[Dr. Susan Kegeles] In addition, I'm involved in another study focusing on African-American men who identify as heterosexual, but have sex with men. And in that study I described a little bit earlier where we're using enhanced counseling methods to try to reach these men.
[Moderator/Dr. Rob Janssen] Susan, another question. Why and how should interventions be adapted for different MSM groups or for any group regardless of age, gender or orientation?
[Dr. Susan Kegeles] I think almost every intervention, every evidence-based intervention has to be adapted for the population that you're focusing on. Whether it's the ethnic racial population or regional, geographic differences, the first thing that you have to do in adapting it is get to know the intervention well. You need to go to a training, read the manual, really understand what the core elements are of an intervention find out what the processes are that you're trying to get going in the intervention and then think about the cultural issues that you need to address. Talk to the community, have focus groups bring in a community collaborator to talk about the cultural issues. You almost never, when you adapt an intervention, drop components of it, instead you usually add components to it that address the cultural issues.
[Moderator/Dr. Rob Janssen] Let's ask a question for everyone now. Are drug use patterns different for different groups of MSM? Dwayne?
[Dwayne Jenkins] Definitely so, definitely. Depending upon where you are, of course, in the region, some people may just drink and some may actually just smoke. So, it really depends on where you are and how many drinks or how many cocktails you may have that would allow you to not know your triggers and have unprotected sex. So, that's a definite. Definite.
[Moderator/Dr. Rob Janssen] Susan?
[Dr. Susan Kegeles] I'll defer to Alberto.
[Moderator/Dr. Rob Janssen] Okay, Alberto?
[Alberto Santana] Yes, and I’m gonna speak specifically to Latino men. For Latino men who have are acculturated and a part of main stream society who go to the circuit parties and so forth. Many of them are using designer drugs such as ecstasy, crystal meth and so forth, but for men who maintain some of their cultural, some of them are still engaging in cocaine and alcohol use and then there's other resiliency factors where there are men who are not engaging in drug and substance use and are still becoming infected because they're engaging in high-risk behaviors.
[Moderator/Dr. Rob Janssen] Okay, John?
[Dr. John Peterson] I would just say that the evidence is quite clear that crystal meth, for example, is not as evident and prevalent in among African-American MSM community as it is among other communities in particularly, white MSM communities. Now, that doesn't explain what the reason may be for this, but it does seem that as far as prevalence is concerned right now of use, that is not the case. So, there's a difference there in terms of this new effect of crystal meth in MSM communities.
[Alberto Santana] Can I just say for some of the research that has been conducted in South Florida has also indicated that a lot of the men that are Latino men that are engaging in crystal meth use they're engaging in crystal meth to feel accepted, to join, to be part of a gay main stream society and to be part of the in crowd and that's one of the things we're seeing. So one of the strategies that we need to be implementing is working with these men before they cross that line and are engaging in methamphetamine use.
[Moderator/Dr. Rob Janssen] Okay. We have one more question. And this is for everyone. What is the single most important approach that you think would improve HIV prevention among MSM? Dwayne, let's start with you.
[Dwayne Jenkins] /strong> Quickly, I think building self-worth, affirming our MSM communities and trying to empower them where they are and then to move them along in the process.
[Dr. Susan Kegeles] Helping to build strong communities that support each other, communities of MSM that support each other about risk reduction about getting in for testing and about following up with treatment.
[Alberto Santana] Bringing back the visibility of social marketing messages, moving away from depicting gay mean as lean, smooth bodies including men of color in messages and messages that build self-esteem and tackle homophobia.
[Dr. John Peterson] I would say using structural intervention approaches to affect these kinds of change that the other panelists mentioned. We really need to get massive community level interventions out to address these kind of issues.
[Moderator/Dr. Rob Janssen] Okay. That's all the time we have for our discussion segment. Thank you to our audience for your questions. And thank you to our panelists for your participation today. In just a few minutes, we'll have some important announcements about upcoming events and new CDC sources for HIV information, as well as how to order a DVD of today's program and the topic and date of the next satellite broadcast. So please stay with us a few more minutes. If you have feedback related to today's broadcast or questions we didn't get to, please send us an e-mail at CDCinfo@CDC.gov. Please put "HIV Satellite Broadcast" in the subject line. You can order a DVD of today's program by calling 1-800-458-5231. We’re very pleased to announce several new or enhanced sources of information. To receive automatic e-mail updates on resources and information on HIV/AIDS, please visit www.CDC.gov/emailupdates. And for the latest information and CDC resources for HIV prevention among MSM, including a new fact sheet of the most recent national data, please visit www.CDC.gov/HIV/topics/MSM. Recently, major enhancements were added to CDC's homepage, where you can now take a tour online and search by topic, resources or publication. The home page for HIV/AIDS at www.CDC.gov/HIV now includes a rotating features area, a daily news section, various fact sheets, slide sets and CDC reports and recommendations. Please mark your calendar for important upcoming events that include National HIV/AIDS testing day on June 27th, World AIDS Day on December 1st, and The National HIV Prevention Conference on December 2 through 5, 2007 here in Atlanta. CDC joins other governmental and nongovernmental prevention partners to host this conference. For more information about the National Conference, please visit www.2007nhpc.org. The next CDC satellite broadcast and webcast on HIV prevention is scheduled to air November 15, 2007 from 1:00 to 3:00 p.m. Eastern Standard Time. That broadcast will be on “Current Challenges and Successes in HIV Prevention with Hispanics." More information will be available after August 1st at the Satellite Broadcast website or by calling 1-800-458-5231. That brings us to the end of our broadcast. We sincerely hope that the information presented today will help you in your own efforts to prevent new HIV infections among Gay, Bisexual, and other Men Who Have Sex with Men. The HIV epidemic is far from over among MSM we must all do our part to ensure that we’re continuing to monitor the course of the epidemic among MSM, that we’re responding to emerging issues that affect MSM, and that we’re providing the best-possible interventions to those MSM who need them the most. Now is the time to re-evaluate and reinvigorate our HIV prevention efforts for MSM and to further strengthen our individual and shared commitments to doing all that we can to stop the spread of HIV and AIDS. On behalf of The Centers for Disease Control and Prevention, and the Public Health Training Network, thank you for joining us and we wish you many successes in your HIV prevention work. Good day from Atlanta.
[Announcer] To access the most accurate and relevant health information that affects you, your family and your community, please visit www.cdc.gov.