AIDS, Sexual Behavior, and Intravenous Drug Use (1989) / Chapter Skim
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Pages 1-28
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Some of the efforts under consideration including the future activities of our own committee and of the Institute of Medicine address topics that will be of concern to readers of this report, including drug and vaccine development, AIDS research policy, and the social impact of the AIDS epidemic.
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and on the patterns of sexual behavior and drug use (Chapters 2 and 3) that spread HIV infection.
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The threat of epidemic and endemic disease will be most serious for those groups that are most heavily seeded with HIV infection, including IV drug users and men who have sex with men, as well as for their sexual partners and offspring. Currently available data also inclicate that the black and Hispanic populations of the United States are experiencing a disproportionate burden of ATDS cases (in particular, cases associated with IV cirug-use, heterosexual, ant]
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A further step requires an understanding of the sexual and IV drug-use behaviors that spread HIV from one person to another and thereby produce changes in HIV prevalence and incidence. The committee believes that more reliable systems must be developed for tracking the course of the epidemic.
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The committee concludes, nonetheless, that more reliable data on HIV prevalence are needed. In recommending that reliable systems be developed for tracking the course of the HIV/AIDS epidemic, the committee wishes to reiterate its firm belief that such systems are prerequisites for mounting an effective and efficient national response to AIDS.
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CDC's Family of HIV Seroprevalence Surveys CDC has launched a program to survey HIV prevalence among several population groups, including clients of drug treatment centers, clinics for sexually transmitted diseases (STDs) , tuberculosis clinics, and clinics serving women of reproductive age; patients at general hospitals; and newborn infants.
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Supplementing the newborn survey with surveys of probability samples of women who have abortions would provide a more complete picture of HIV prevalence among sexually active women of reproductive age. The committee recommencIs instituting a continuing anonymous probability survey of the HIV serostatus of 7Chapter 1 of the main report discusses problems that affect the use of data from special populations (e.g., military recruits, blood donors, etc.)
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The greatest technical barrier to obtaining an accurate estimate of HIV prevalence is the possibility of bias from selective nonresponse. This kind of bias can plausibly occur if, for example, individuals who belong to groups with elevatecl HIV prevalence rates (e.g., gay men, {V drug users)
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Third, anonymous testing can be conducted so that the identity of the donor is neither known nor traceable to the blood specimen.9 The committee believes that each of these strategies should be vigorously pursued. Sexual Behavior and AIDS The need to control the spread of HIV infection has forced a recognition of the underdeveloped state of sex research in the United States.
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In the past, federal agencies have supported some behavioral research on sexual practices, but much of it has been focused on the sexual behavior of female adolescents, with the goal of preventing teenage pregnancies. The committee believes such research is a valuable ant} necessary part of the fecleral research portfolio, but basic knowledge of human sexual behavior is needed in many other areas as well.
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In acldition, significant declines in numbers of sexual partners have been reported in numerous studies of gay mate sexual behavior as it relates to AIDS. Unfortunately, changes in risk-associated behavior have not been universal: high rates of unprotected anal intercourse have been reported in areas that are not foci of the epidemic (e.g., upstate New York and New Mexico)
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Intercourse is no longer linked to marriage or to forming a permanent couple, and such intercourse is often undertaken with inadequate precautions to forestall unwanted pregnancies or to prevent sexually transmitted diseases. Increases in sexual activity and in the number of heterosexual partners among teenagers have been paralleled by similar changes in sexual activity among ogler indivicluals.
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The committee recommencIs that local public health authorities ensure that treatment for all sexually transmitter! diseases is readily available to all persons who may seek such treatment.
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Although it is seldom possible to disentangle completely the effects of sexual transmission from drug-relatec3 transmission, the fact that there are relatively few women with HIV infection who are not IV drug users suggests that shared injection equipment rather than sexual activity has been the most significant transmission factor among female prostitutes. Research and Data bleeds The committee finals that the long history of unfunded and underfunded research on human sexual behavior in this country has resulte(1 in deficiencies in substantive knowledge, in the appropriate tools for scientific investigation of this topic, and in researchers who are expert in this area.
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Research should include prostitutes and their clients, minorities, young gay men, gay men living outside the current epicenters of the epidemic, socially vulnerable adolescents, the different groups that make up the heterogeneous {V clrug-using population, and the sexual partners of IV drug users. It is particularly important to obtain information from the people in these groups because of their potential role as conduits for the spread of HIV through sexual activity from groups with higher rates of prevalence to groups with lower rates.
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Sharing occurs for a variety of economic, cultural, and practical reasons, but whatever the individual causes of the behavior, almost all {V drug users report "needle-sharing" is at some time during their drug-use "careers." HIV infection among IV drug users also poses a threat to their sexual partners and offspring, as well as to persons with whom they share injection equipment. Nearly 70 percent of the reported cases of heterosexually acquired AIDS in the United States have been associated with {V drug use, ant!
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Moreover, studies conducted during the AIDS era have shown that entering and remaining in drug treatment programs are factors associated with significant reductions in the rates of HTV infection among IV drug users. Second, the committee concludes that, regardless of the availability of treatment opportunities, a substantial number of people in the United States will continue to inject drugs, at least in the short run.
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The {V drug-using population is also at risk of acquiring and spreading HIV infection through unprotected sexual behaviors. Little is known about the sexual, contraceptive, and childbearing practices of IV drug users, although early studies indicate that more riskreclucing change has occurred in injection practices than in sexual behaviors.
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The mass media can play an important role in providing information about risk, as well as in molding both the skills and behavior of individuals and the norms of the community to support that behavior. The committee recommends that television networks present more public service messages on those behaviors associated with HIV transmission and practical measures for interrupting the spread of infection.
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AIDS prevention programs should also incorporate what is already known about the adoption and diffusion of new ideas. For example, opinion leaders of target populations should be identified and used to maximize a program's credibility and persuasiveness with the target audience and to shape more effective messages and programs.
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The committee recommends that anonymous HIV antibody testing with appropriate pre- ant} posttest counseling be made available on a voluntary basis for anyone desiring it. However, to maximize the usefulness of antibody testing in facilitating behavioral change, more knowledge is needed about why individuals seek testing, how testing affects behavioral change in different populations, and how it affects psychiatric morbidity.
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field experiments for evaluating new intervention programs on both individual and community levels. Resources for Evaluation Carrying out evaluations that produce reliable data about the effectiveness of interventions to stop the spread of HIV infection requires creative leadership on the part of the management of an organization ant!
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CDC (and any other agency that undertakes AIDS prevention programs) should assign to some administrative unit the responsibility for ensuring the use of planned variants of intervention programs and for overseeing a system of evaluation.
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The committee recommends that the CDC AIDS program increase its staff of persons knowIedgeable about survey sampling and survey clesign, and that it exploit the methodological expertise of the National Center for Health Statistics. Finally, in adclition to experienced survey scientists, CDC needs technical assistance to evaluate currently funded intervention programs.
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One creative mechanism that has been developed to foster collaboration is the multidisciplinary AIDS research center. Much of the needed behavioral and social research on AIDS prevention requires large, multidisciplinary teams of scientists with close working relationships with many of the different communities in which interventions must be conducted.
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AIDS education efforts provide a number of examples in which potentially effective prevention activities have become entangled in social conflicts that caused delays in their implementation or a weakening of their message. Specific controversies have involved restrictions on the use of explicit language in educational materials, conflict between providing scientific information or promoting particular moral values in AIDS prevention messages, and prohibitions against condom advertising on network television.
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to stigmatization since its beginning. The fact that the disease has been largely confined to mate homosexuals and IV drug users has made stigmatization almost inevitable, for these groups were already the objects to some degree of the deprecating judgments that constitute this phenomenon.
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From page 28... ...
Similarly, the struggle to retard the spread of HIV is likely to persist well into the next century. Improved understanding and prevention of the behaviors that spread HIV/AIDS will be needed not only in the short run, however many years that may be, but in the decades that follow any medical breakthrough as well.
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