AIDS The Second Decade (1990) / Chapter Skim
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2 Prevention: The Continuing Challenge
2 Prevention: The Continuing Challenge
Pages 81-146
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From page 81... ...
In its first report, the committee recommended that the Public Health Service (PHS) support basic research on human sexual behavior and give high priority to research on the social contexts of IV drug use to provide the data needed to design efficacious intervention strategies to prevent the spread of HIV infection.
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From page 82... ...
At the beginning of the epidemic, interventions to prevent the spread of HIV infection focused primarily on gay men, the population that showed the first evidence of disease. However, as evidence accumulated on the risks associated with other behaviors, intervention efforts began to expand, encompassing, for example, IV drug users and heterosexuals with multiple sexual partners.
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From page 83... ...
. In particular, reports of unprotected anal intercourse among men living in low-prevalence cities raise serious concerns about the future spread of the epidemic in these communities.2 The existing data on behavior change and HIV seroprevalence, although imperfect, are sufficient to provide a sense that a major risk for new HIV infection still exists among samples of self-identified gay men, despite the profound behavioral risk reductions that have occurred since the onset of the AIDS epidemic and despite widespread understanding of health education guidelines for the prevention of HIV infection (Stall, Coates, and Hoff, 1988~.
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From page 84... ...
The National Institute of Allergy and Infectious Diseases supports research on the epidemiology and natural history of AIDS in cohorts of homosexual men as well as studies on behavioral and other risk factors associated with the acquisition of HIV infection. The Multicenter AIDS Cohort Study (MACS)
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From page 85... ...
However, which risk reduction strategies are most likely to be effective remains in doubt. Community-leve} intervention programs have been implemented in several gay communities to reach a critical mass of individuals with ~nforrnation, motivation, and skills training and to foster changes in the norms that stipulate appropriate behavior (Coates and Greenblatt, in press)
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From page 86... ...
indicated that gay men felt helplessly caught between the growing enormity of the AIDS epidemic and the sexual values and expectations of the gay community. The Stop AIDS program used a variety of strategies to elicit personal commitments to safer sex, encourage participation in intervention activities, empower individuals to take appropriate action, hasten the adoption of safer sex as a community norm, build peer support for safer sex activities, and create peer pressure against activities that would spread the virus.
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From page 87... ...
Participants in the expenmental group reported fewer episodes of unprotected anal intercourse and higher rates of condom use than control subjects at a follow-up assessment.9 An intervention conducted by Coates and colleagues (1989a) also showed risk reduction following an eightweek program.
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From page 88... ...
are more likely to report unprotected sexual behaviors than those who do not use drugs has important implications for the development of intervention programs. Men who combine drugs with sex are less likely than those who do not to have changed the frequency of engaging in unsafe anal intercourse and more likely to engage in sexual behaviors that cany a high risk of HIV transmission (Stall et al., 1986; Communication Technologies, 1987; Beeker and Zielinski, 1988; Robertson and Plant, 1988; Valdisem et al., 1988; Stall and Ostrow, 1989; Martin, 1990; Martin and Hasin, in press)
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From page 89... ...
INTERVENTIONS FOR INTRAVENOUS DRUG USERS HIV infection has been present among IV drug users in the United States for more than a decade now (Des JarIais et al., 1989a) , and the number of studies investigating behavioral change in this population has increased greatly since the early years of the epidemic.
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From page 90... ...
have been associated with self-reported behavioral change among IV Hug users, methadone maintenance treatment programs have been associated with reduced levels of HIV infection (Abdul-Quader et al., 1987; Blix and Gronbladh, 1988; Brown et al., 1989; Novick et al., 1989; Truman et al., 1989; and Schoenbaum et al., i5 Beliefs about effectiveness may serve as important cognitive reinforcement for AIDS risk reduction messages. In a study of street-recruited IV drug users in New York City (Des Jarlais et al., l989b)
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From page 91... ...
Targeting new injectors for intervention thus appears to be a reasonable strategy for preventing further spread of HIV infection. AIDS prevention efforts related to the initiation of injection have been stymied in some instances by political barriers.
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From page 92... ...
In the treatment of drug abuse, achieving abstinence from the use of drugs is relatively easy for at least short periods of time; the greater challenge is to maintain abstinence over longer penods, particularly in cases in which individuals must continue to live in the same social and economic environment in which the drug problem developed.~7 The problems involved in maintaining AIDS risk reduction affect all of the groups at risk for infection and are discussed later in this chapter. AIDS PREVENTION STRATEGIES FOR WOMEN The recent recognition of increased risk for women in this epidemic implies the need for greater attention to prevention efforts for this population.
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From page 93... ...
. Women who are currently in treatment for drug use are an obvious and relatively accessible subpopulation to target for AIDS prevention efforts, and encouraging women who use drugs to enter treatment is a reasonable prevention strategy.
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From page 94... ...
It is estimated that 17 percent of reproductive-age women lack any form of health insurance, a factor that undoubtedly affects access to prenatal, family planning, gynecologic, and abortion services (Alan Guttmacher Institute, 19871. Unfortunately, women who receive no prenatal care may be more likely to report risk behaviors (e.g., IV drug use, multiple sexual partners, sex with an IV drug user)
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From page 95... ...
23 Paid interviews with 175 female IV drug users found that those who reported a reduction in risky sexual behavior had also (1) decreased risky drug use practices (i.e., reduced or ceased injecting drugs, reduced the use of nonsterile injection equipment or needle-sharing)
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From page 96... ...
Programs may wish to provide information on the local prevalence of HIV infection to help women personalize the risk of infection. By focusing on the risk to the community rather than the risk to one individual, information concerning a serious health problem may be delivered in a less threatening way that can help women to begin to perceive and assess the level of personal risk they face for acquiring or transmitting the virus (Worth, in press)
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From page 97... ...
Because not all women at risk will be reached through health care facilities, however,28 other venues and mechanisms will be needed to deliver prevention services to the broader population of susceptible women.29 CDC is currently sponsoring a series of community demonstration projects that employ several mechanisms for improving programs to prevent perinatal transmission of HIV infection. The projects target childbear~ng-age women at risk who are not yet infected as well as women who are already infected and wish to avoid pregnancy (Berman, 1989~.
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From page 98... ...
Get a test for the AIDS virus." Unfortunately, such a message does not tell its audience why such information is useful, which is that infected women need to know about the potential impact of their infection on the fetus, the possible impact of disease progression on their pregnancy and their own health, and the availability of counseling, abortion services, and prenatal care.3~ The second year of CDC's "America Responds to AIDS" media campaign has focused campaign messages on a broad range of women at risk, including women with multiple sexual partners, female partners of IV drug users, minority women, college students, single parents, and the newly divorced. The program's most visible component is a multimedia public service advertising campaign that consists of television and radio announcements, print advertisements, and public transit posters.
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From page 99... ...
, for example, shows that infected women do not always avoid conception. These researchers followed 134 women of childbearing age after He women were informed that they were HIV seropositive; they found that 7.5 percent became pregnant, despite the fact that the women were repeatedly counseled about the need to practice contraception and safer sex.34 Other studies also report pregnancies among women who have been found to be infected.35 On the other hand, a study of 24 infected women recruited from a university medical center in Rhode Island found that, although most of the women remained sexually active even after the diagnosis of AIDS was made, none became pregnant during the course of this 22-month study (CaIpenter et al., 19891.
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From page 100... ...
study of 33 infected pregnant women from the Bronx, the option of legal abortion was available to 22 of the women; 6 chose to abort. Seven of the 33 infected women had previously delivered children with HIV infection; only 1 woman in this group chose to terminate her pregnancy.
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From page 101... ...
are not offered to pregnant women because of unknown consequences to the fetus. SHIV infection and AIDS among children have engendered pressing problems related to medical treatment, day-to-day care, home and family life, and social support.
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From page 102... ...
women about the risk of passing HIV infection to a child is before conception occurs; yet many women do not seek testing prior to conception.40 Moreover, to assume that positive test results will automatically lead a woman to forgo pregnancy either temporarily or permanently is to ignore the complex meaning that childbearing brings to the lives of women. Clearly, interventions to prevent vertical transmission of HIV must go beyond the means used during the first decade of the epidemic and employ new me~ods that take into account both the population to be served and the help that can realistically be offered.
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From page 103... ...
In reconsidenng the role of testing and counseling for women of childbeanug age, it might be useful to explore other similar counseling efforts. Preventing vertical transmission of a disease is not a problem unique to the AIDS epidemic; other disorders, including genetically determined conditions, are also passed from parent to child.
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From page 104... ...
In addition, the substantial likelihood that an infected mother will pass on HIV infection to her newborn child (Darrow, Jaffe, and Curran, 1988) emphasizes the need to identify any factors that may make counseling an effective tool for infected women who face reproductive decisions.
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From page 105... ...
review AIDS prevention efforts for Asian-American communities. 46CDC currently funds a variety of community-based HIV interventions aimed at promoting behavioral change among these high-risk groups.
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From page 106... ...
was greater than the proportion of whites but smaller than the proportion of Hispanics. Only 60 percent of blacks and Hispanics and 66 percent of white non-Hispanics knew that a person could be infected with HIV and not have AIDS, and even fewer realized that a person with HIV infection could look and feel healthy.
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From page 107... ...
Without careful attention to these factors, intervention programs for minorities hold little promise of success In preventing further spread of HIV infection (Worth and Rodriguez, 1987; Amaro, 1988; Mays and Cochran, 1988; Marin, 1989; Schilling et al., 1989~. The broad base of information required to develop potentially effective interventions for diverse minority subpopulations, information concerning the variation and distribution of behaviors as well as the contexts in which they are enacted, clearly does not currently exist.
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From page 108... ...
MAINTAINING RISK REDUCTION BEHAVIOR Relapse prevention is a necessary component of any AIDS intervention program because maintaining risk reduction is often more difficult than initiating it. Given that AIDS prevention for some individuals requires life-Ion" change, a significant challenge for the second decade lies in helping individuals who have initiated safer behaviors to maintain them.
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From page 109... ...
AIDS prevention programs for gay men have focused primarily on the adoption of safer sex techniques, and many communities have reported extensive modification of high-risk behaviors. Nevertheless, seroconversions have continued among gay and bisexual men in cities such as San Francisco (Lifson et al,.
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From page 110... ...
Men who report that unprotected anal intercourse is their favorite sexual activity are less likely to adopt safer sex practices and more likely to relapse than men who favor less risky activities (Stall et al., 1990; McKusick et al., in press)
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From page 111... ...
Maintaining risk-reducing behavioral change is also a problem for the diverse population of at-risk women. Prostitutes, female IV drug users, sexual partners of IV drug users, and sexual partners of hemophiliacs all report intermittent unprotected intercourse and thus continued exposure despite counseling and education (CDC, 1987; Cohen, 1989; Jackson et al., 1989; Sowder, Weissman, and Young, 1989; Turner, l989:Table 1~.
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From page 112... ...
Talking about sexual practices and introducing safer methods is at the heart of a great deal of AIDS prevention. Yet traditional sex roles for women in most cultures do not encourage them to talk about sex, to initiate sexual practices, or otherwise control an intimate heterosexual encounter.
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From page 113... ...
As the epidemic enters its second decade, it is clear that sexual transmission of the disease continues to be a major route of infection. Behavioral interventions focused on the consistent use of condoms are currently the most effective AIDS prevention strategy for this type of 54Problems with consistent condom use have been reported in other developed countries, including Norway (Sundet et al., 1989; Traeen, Rise, and Kraft, 1989)
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From page 114... ...
Thus, the committee relied on a more basic analysis of intervention strategies, using principles of human behavior established through empincal research and the theories of the social and behavioral sciences.s6 While a systematic review of the theories of human health behavior and the relevant research on the prevention of other, related diseases can assist efforts to design programs that hold the most promise of being successful,57 accumulating sound evaluation data on planned variations of intervention strategies is perhaps the most important task for the next decade of this epidemic. Reliable data on the behaviors that transmit the virus as well as on the prevalence of HIV infection in the population are needed to pack the movement of the epidemic and to target intervention resources to the diverse groups at highest risk.
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From page 115... ...
Sound evaluation data can ensure that prevention efforts receive a reasonable share of available resources and that those resources are allocated to the most effective programs. Successful AIDS prevention strategies will also need to look beyond the individual to the social forces that make it difficult to provide effective interventions to those at highest risk.
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From page 116... ...
That discrimination has occurred against persons with AIDS and HIV infection is not in question' but its extent is far from clear, for there is only limited empirical evidence. Questions remain about how 58The stigma associated with AIDS and HIV infection was a principal focus of Chapter 7, "Social Barriers to Intervention," in Turner, Miller, and Moses ( 1989)
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From page 117... ...
PREVENTION | 117 the burgeoning numbers of cases and the enduring nature of the epidemic are shaping individual and social reactions to persons with AIDS and HIV infection. Appropnate means for safeguarding the infected against discrimination have been the subject of continuing political debate regarding the forms such protection should take and whether responsibility should be lodged at the federal, state, or local level.
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From page 118... ...
Its scope was extended somewhat by the Fair Housing Amendment Act of 198S, Public Law 100-430 passed by the 100th Congress, which extends protections against discrimination to the private sector. (The Fair Housing Amendments make it illegal for private landlords to discriminate on the basis of HIV infection.)
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From page 119... ...
A number of states have enacted HIV-specific measures to prevent discrimination in the workplace. Most of these provisions relate to information generated in the course of HIV testing and prohibit the use of that information as a precondition of employment or in a determination of continued employability.
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From page 120... ...
A few crude barometers of AIDS discrimination have been cited in policy debates. The Presidential AIDS Commission cited testimony from officials of New York City's Commission on Human Rights that the number of complaints handled by its AIDS Discrimination Department has risen precipitously, from 3 in 1983 to more than 300 in 1986 and more than 600 in ~ 987 (City of New York Commission on Human Rights, 19881.
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From page 121... ...
Social Attitudes and Public Policy: Obstacles to Continued Progress Throughout this chapter, the committee has noted that effective intervention to prevent further spread of HIV infection requires knowing more about the people who are at risk the behaviors that transmit the AIDS 7 virus, and the conditions that have facilitated change in those behaviors. Gathering such information has been difficult; methodological problems have stymied efforts to understand these factors, and public policies and opinions have created impediments to acquiring knowledge.
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From page 122... ...
Political debate abounds regarding the appropriateness of using public monies to support the development of such materials;64 only now, however, are objective data accumulating on the effects of a sexually explicit approach to the prevention of sexually transmitted HIV infection. Eroticizing safer sex messages makes considerable sense, given that adults at high risk for HIV and other sexually transmitted infections are those who engage in sex often and with multiple partners (e.g., Bell and Weinberg, 1978; Marmor et al., 1982; gaffe et al., 19831.
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From page 123... ...
The goal of sexually explicit programs is to promote widespread and rapid acceptance of safer sexual behaviors. The strategies described above that have attempted to achieve these goals have relied on the principles of the behavioral theory of adoption and diffusion of innovation.65 For example, existing networks of communication are employed to reach the targeted audience and to promote new ideas—in this case, by persuading individuals that new behavioral patterns are positive and pleasant.
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From page 124... ...
Evaluations of ongoing efforts abroad have found that participation in syringe exchange programs is associated with the reduction but not the elimination of HIV risk behavior and that syringe exchanges do not lead to any detectable increase in illicit Hug injection, either among current users or new injectors. Program characteristics associated with successful risk reduction include readily accessible programs for potential participants and linkages and referral networks to drug use treatment and other health and social services required by drug injectors.
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From page 125... ...
The committee strongly reiterates the recommendation made in its 67 Even before AIDS prevention programs were offered lo IV drug users in New York City, the mass media and informal communication networks among IV drug users reportedly had provided an awareness of AIDS and knowledge of the routes of transmission (Des Jarlais, Friedman, and Strug, 1986)
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From page 126... ...
This year the committee reiterates its recommendation that the Public Health Service implement programs to collect sound data on the prevalence and distribution of behaviors that transmit HIV infection. In addition, it affirms its support for empirical tests of promising behavioral intervention strategies that may involve sexually explicit information.
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From page 127... ...
(1988) Considerations for prevention of HIV infection among Hispanic women.
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From page 128... ...
(1989) Demographic, behavioral, and clinical features of HIV infection in New York City intravenous drug users (IVDUs)
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From page 129... ...
. Toward an understanding of risk behavior: An AIDS risk reduction model (ARRM)
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From page 130... ...
(1989) Incidence of HIV infection in Pay and bisexual men attending a counseling and testing site or an AlL,5 prevention program.
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From page 131... ...
(1987) HIV infection among intravenous drug users: Epidemiology and risk reduction (editorial review)
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From page 132... ...
Gay men in San Francisco are maintaining low-risk behaviors but young men continue to be at risk. American Journal of Public Health.
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From page 133... ...
(1989) Drug use and sexual behavior in male patients at an STD clinic: Implications for AIDS prevention.
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From page 134... ...
(1989) Sharing needles: Risk reduction among intravenous Snug users in San Francisco.
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From page 135... ...
(1988) Seroprevalence of human immunodeficiency virus among childbearing women.
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From page 136... ...
American Journal of Public Health 80:416 418. Kelly, J
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From page 137... ...
(1989) AIDS prevention among Hispanics: Needs, risk behaviors, and cultural values.
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From page 138... ...
Longitudinal predictors of unprotected anal intercourse in San Francisco gay men 198~1988: The AIDS Behavioral Research Project. American Journal of Public Health.
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From page 139... ...
(1989) Conference Proceedings: NIDA Conference on AIDS Intervention Strategies for Female Sexual Partners.
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From page 140... ...
(1988) Transfusion-associated HIV infection: Epidemiology, prevention, and public policy (editorial review)
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From page 141... ...
(1987) Guidelines for the control of perinatally transmitted HIV infection and care of infected mothers, infants, and children.
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From page 142... ...
(1989) Risk factors for human immunodeficiency virus infection in intravenous drug users.
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From page 143... ...
(1989) Intravenous drug use, the combination of drugs and sexual activity and HIV infection among gay and bisexual men: The San Francisco Men's Health Study.
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From page 144... ...
(1989) HIV infection among intravenous drug users (IVDUs)
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From page 145... ...
(1989) HIV infection in female intravenous drug users in San Francisco.
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From page 146... ...
(1989) Sexual behavior of young adults and the effects of AIDS-prevention campaigns in Switzerland.
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