AIDS The Second Decade (1990) / Chapter Skim
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Pages 1-37
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From page 1... ...
The formation of such a committee within the National Research Council reflected a growing awareness that understanding HIV transmission, facilitating behavioral change to prevent further spread of infection, and coping with the social consequences of the epidemic raise questions that properly lie within the domain of the social, behavioral, and statistical sciences. At the request of the Public Health Service (PHS)
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From page 2... ...
3 The committee also benefited from the work of a second panel, which reviewed methodologies for evaluating the effectiveness of AIDS prevention programs. The panel's report, Evaluating AIDS Prevention Programs, Expanded Edition (S.
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From page 3... ...
review three domains of particular interest: the ways in which HIV infection is affecting adolescents and female prostitutes, and the challenge of protecting the blood supply while simultaneously ensuring the adequacy of that supply. The final section of the report (Chapter 6)
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From page 4... ...
The stabilization of infection rates seen among drug users in some cities (e.g., New York, San Francisco, Amsterdam) affords some hope that interventions directed toward this population can be effective.4 Nevertheless, stable rates of infection in selected cities do not signify the elimination Of viral transmission.
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From page 5... ...
At present it is clear that crack use and its associated unsafe sexual activity represent a potentially important new mode of HIV transmission in the United States, but it is unclear how large an impact this mode might have. The committee recommends that the Public Health Service support additional research on crack use, including its epidemiology, its relationship to sexual behavior, strategies to reduce its occurrence (both initiation of use and continuance among lowand high-frequency users)
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From page 6... ...
The committee finds that ongoing efforts fall far short of the magnitude of intervention needed, given the current prevalence of infection and evidence of continued nsk-associated behavior among many of the groups at risk for AIDS. AIDS Prevention Challenges in the Coming Decade At the beginning of the epidemic, interventions to prevent the spread of HIV infection focused pr~manly on adult gay men; subsequent prevention efforts encompassed the population of IV Hug users.
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From page 7... ...
Behavioral interventions are still the only available means of disease containment, and the committee anticipates that the need for well-designed, carefully implemented, and thoughtfully evaluated intervention efforts will not decrease over the course of the next 10 years. Therefore, the committee reiterates its earlier recommendations and in addition recommends the following: · that the Public Health Service encourage and support behavioral research programs that study the behaviors that transmit HIV infection and that the PHS develop and evaluate mechanisms for facilitating and sustaining change in those behaviors; · that intervention programs incorporate planned variations that can be carefully evaluated to determine their relative effectiveness; · that the PHS regularly summarize the data derived from currently funded behavioral and epidemiological
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From page 8... ...
There is some indication that AIDS prevention activities to date have, at least In part, achieved their goal; significant risk reduction has been reported among subsets of gay adult mates and IV drug users. Yet segments of every at-r~sk group continue to practice unsafe behaviors.
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From page 9... ...
Impediments to Improved Intervention AIDS prevention programs must identify, contact, and help at-r~sk individuals to assess their level of risk and access appropriate services. Providing AIDS prevention also involves first facilitating and then sustaining behavioral change.
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A significant controversy has surrounded the appropriate level of sexual explicitness in AIDS prevention information and the degree to which these interventions should emphasize the erotic. Political debate abounds regarding the propriety of using public monies to support the development of sexually explicit matenals, despite preliminary evidence that, for some populations, they have a degree of effectiveness.
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ADOLESCENTS The committee finds no credible evidence that He AIDS epidemic will cease in the foreseeable future in this country. As a result, prevention efforts remain cntically important.
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Currently, tAhAe adolescent population contains pockets of adolescents whose behavior puts them at relativeAv high Nick for ~rn~lirin~ HIV infection. ~ ~ ~~ SAABS, Sexual Behaviors.
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Thus, AIDS prevention programs for teenagers and adults properly discourage drug use among all persons. From a public health perspective, for persons who do use drugs, AIDS prevention programs have the goals of (1)
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Given the disjunctures in public opinion on this topic, federal AIDS education efforts have stumbled for several years over disputes about the need to offer "realistic" advice to young people about the protective value of condoms versus counterclaims that the AIDS epidemic requires moral education to promote abstinence from sex prior to marriage and sexual fidelity within marnage. The committee believes that, in the context of a deadly, sexually transmitted epidemic, AIDS prevention programs must heed the data on risk-associated behavior reported by the adolescents themselves and not be sidetracked by wishful thinking about patterns of behavior some might hope teenagers would follow.
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Families and other adult social institutions have a major responsibility for educating adolescents about health risks. Yet the available evidence indicates that parent-child communication about sexual behavior is often insufficient and it frequently does not occur until after initiation of sexual activity.
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There are many venues in which AIDS prevention programs for adolescents can be delivered. CDC has developed and funded prevention programs in schools and other organizations that serve youth, and it has recommended guidelines for AIDS education to help school personnel set the scope and content of their programs.
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From page 17... ...
The committee also wishes to reiterate that the diversity of the adolescent population requires a multiplicity of venues and formats to deliver AIDS prevention messages effectively. For some adolescents, intervention may be most effective if it is provided by AIDS prevention programs in the school systems at an early age—before students initiate the behaviors that can threaten their futures.
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From page 18... ...
often constitute additional hurdles to the dissemination of AIDS prevention information and training. Risk Factors Data from the CDC study indicate that rates of HIV infection among female prostitutes vary greatly from site to site (ranging from zero to 47.5 percent)
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Thus far, the number of cases of AIDS ascnbed to contact with female sex workers has been small, and the available data, although limited, suggest that there is little danger that female prostitutes will be a "bridge" of infection to the general population. Indeed, as noted earlier, it appears that female prostitutes ale more at risk of acquiring HIV than they are of transmitting it.
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From page 20... ...
Interventions Various types of AIDS prevention programs for female prostitutes have been implemented, including street outreach to teach safer drug use and safer sex techniques, similar types of outreach and workshops for organized sites, and voluntary HIV testing and counseling. Many of the outreach programs involve peer-led interventions delivered by exprostitutes or current sex workers to facilitate the location and recruitment of prostitutes into the programs and to improve communication between the research community and the targeted population.
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In 1985, blood collection organizations began using a new serologic test to screen blood donations for antibody to the AIDS virus. Although this technological innovation dramatically reduced the incidence of transfusion-related infection, it was not (nor is it yet)
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pressured by peers or coworkers to donate blood, blood collection organizations have instituted the confidential unit exclusion, or CUE, procedure to lessen the chance that an infected individual will give blood. CUE uses a form that allows the donor to select one of two options for handling the donated unit of blood: (1)
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From page 23... ...
clear and accurate information concerning both the need for donation and the absence of health risks from donation; · the National Heart, Lung, and Blood Institute support research on the design, systematic testing, and implementation of new methods for attracting healthy firsttime donors, retaining and encouraging repeat donations, and enlisting the aid of repeat donors in donor recruitment; · blood collection organizations undertake to make the actual donation process as comfortable, friendly, and efficient as possible through changes in scheduling procedures, physical accommodations, donor processing, and staff training; o blood collection agencies, Public Health Service agencies, and community leaders employ innovative recruitment approaches among populations such as minority and certain age groups that traditionally have not been represented in the donor pool; and · physicians and blood banks encourage autologous donation (i.e., predeposit of an individual's own blood) in cases in which surgery is anticipated (see later section on the appropriate use of blood)
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From page 24... ...
One strategy to increase participation of safe donors involves the use of members of a targeted group as role models for prospective donors and as staff for donor recruitment and blood collection. Seeing known or similar people involved in the process seems to increase the perception among potential donors that blood donation is something individuals in
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To improve the safety of the blood supply, the committee recommends that: · blood collection agencies strive for clearer communication of the exclusion criteria to potential and actual donors; · blood collection agencies work to increase donation by those who can safely give and abstention by those who are at even minimal risk through recruitment approaches that stress altruistic appeals rather than the use of competitions, incentives, and social pressure; and · the National Heart, Lung, and Blood Institute continue its support for research to investigate why some donors with identifiable risk factors continue to donate while others without risk factors inappropriately exclude themselves.
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A drawback of this practice, however, is that two to four patients may be exposed to blood components from one contaminated donation. There is some evidence that blood utilization in the United States has been affected by concern over the risk of HIV transmission.
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SURVEY METHODS IN AIDS RESEARCH Surveys or, more generally, the method of asking questions and recording answers from a sample of a population of interest continue to be one of the most important techniques for obtaining essential information about the epidemiology of AIDS and HIV, the behaviors that spread HIV, and the effectiveness of AIDS prevention efforts. Given the important role that this information plays in understanding the AIDS epidemic, the committee has reviewed what is known about the quality of existing data on behaviors associated with HIV transmission and provides recommendations on steps that can be taken to improve this information.
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From page 28... ...
, the number of questions on sexual behavior in the interview, or, surprisingly, whether sample persons were asked to donate blood specimens for serologic testing. From the review conducted by the committee, it appeared that "piggybacking" a small number of questions about sexual behavior onto established large-scale surveys is a particularly feasible strategy for obtaining estimates of the prevalence of certain sk factors for sexual transmission Of HIV in general populations.
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From page 29... ...
. Experience with surveys of sexual behavior conducted by phone is too limited, however, to determine the levels of participation that can be achieved in such surveys and whether the somewhat lower response rates in the few available cases are a generic feature of telephone surveys or simply the result of early and somewhat idiosyncratic first attempts.
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is an important exception. In the GSS, nonresponse biases were found to be quite small among those variables most closely associated with differences in sexual behavior.
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Sexual Behavior There is only a very limited range of evidence that can be collected to provide independent corroboration of the validity of self-reported sexual behaviors. One type of evidence is the reports of sexual partners.
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As in measuring sexual behaviors, a major problem in measuring injection behaviors arises from the fact that researchers usually cannot directly observe the behaviors of interest and thus must rely on self-reports. Several studies have compared reports of drug use with the results of urinalysis.
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. Finally, there is a fairly large body of research addressing the consistency of responses over short periods of time in survey reports on various aspects of sexual behaviors.
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From page 34... ...
Therefore, the committee recommencIs that the agencies of the Public Health Service encourage and strengthen behavioral science research aimed at understanding the transmission of HIV in various black and Hispanic subpopulations, inclutiing men who have sex with men, drug users anti their sexual partners, and youth. The committee further recommends that the PHS develop plans for appropriate interventions targeted toward these groups and support the implementation of intervention strategies (together with appropriate evaluation components)
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From page 35... ...
Thus, the committee recommends: · that the Public Health Service encourage and support behavioral research programs that study the behaviors that transmit HIV infection and that the PHS develop and evaluate mechanisms for facilitating and sustaining change in those behaviors; · that intervention programs incorporate planned variations that can be carefully evaluated to determine their relative effectiveness; · that the PHS regularly summarize the data derived from currently funded behavioral and epidemiological research on AIDS (in terms of incidence of infection and high-risk behaviors) to determine intervention priorities for various subpopulations at risk; and · that all agencies of the PHS that are currently funding intervention programs and evaluation research regularly
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From page 36... ...
There has been substantial progress in reducing the risks of HIV transmission associated with the blood supply, progress achieved through technological solutions, augmented by behavioral interventions. Yet, as the risk of exposure to contaminated blood and blood products diminishes, the issue of maintaining an adequate supply of blood arises.
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From page 37... ...
Reducing the exposure of potential transfusion recipients to homologous blood can be accomplished in several ways, depending on the circumstances that prompt transfusion. Educating physicians and their patients, establishing guidelines for blood use, and modifying prescribing behavior are necessary to achieve this goal.
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