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Prevention: The Continuing Challenge The epidemiological data presented in the first chapter enable researchers and program planners to identify shifts in the epidemic and in the sub- populations being affected. Although such data are vital for targeting programs to populations at nsk, they say little about how to stop the spread of infection. Given that there is no convincing evidence that AIDS or HIV infection is abating and that there are no cures or vaccines on the immediate horizon, the need for effective behavioral intervention will persist into the second decade of the epidemic. Many intervention efforts of the first decade were designed and implemented quickly in response to a new health problem that in some areas took on the char- acteristics of a crisis. As the United States enters the second decade of efforts to contain the spread of disease, the committee believes that the time has come to view behavioral intervention from a more long-term perspective. This view of AIDS calls for a commitment to the careful and systematic accrual of information capable of identifying those strategies that will facilitate change In risk-associated behaviors, maintain safer behaviors, and thus alter the course of the epidemic. 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. The committee further recommended that knowledge about the efficacy of intervention programs be built system- atically through the use of planned variations of key program elements with subsequent rigorous evaluation. The committee reiterates these rec- ommendations and notes that the need for well-designed, carefully 81

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82 ~ AIDS: THE SECOND DECADE implemented, and thoughtfully evaluated intervention efforts and good behavioral research continues today. Although there are many projects currently in place whose goal is to educate people about the threat of AIDS, few of these programs have been sufficiently well designed to pro- vide the data needed to assess the eject of their efforts especially their effects on changing the behaviors associated with transmission. More- over, as the first decade of the epidemic draws to a close, it is apparent that, although data have accrued from a range of behavioral research activities, those data are of varying quality. Consequently, it is often dif- ficult to draw firm conclusions from such studies or to reach consensus about the next set of issues to be studied. The first three sections of this chapter consider intervent~on-related issues pertaining to gay men (among whom the greatest share of the burden of disease continues to reside), IV drug users, and women. 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. Today, the focus of AIDS prevention requires expansion once again to accommodate the changing epidemiological patterns noted in the previous chapter and the changing character of the disease. IMPACT OF INTERVENTIONS AMONG GAY MEN Studies of gay men since the first years of the epidemic have indicated considerable behavioral change among some members of this popula- tion, especially men living in large urban areas (e.g., San Francisco, Los Angeles, New York City) (Becker and Joseph, 1988; Stall, Coates, and Hoff, 1988; Catania et al., 19894. This change is largely reflected in the decreased frequency of unprotected anal intercourse and fewer sexual partners. More recent data from the epicenters or focal points of the epi- demic have shown Hat gay men are continuing to alter risky behaviors. 1 For example, at recruitment into the AIDS Behavioral Research Project in 1983 and 1984, 45.3 per- cent of subjects reported practicing unprotected insertive anal intercourse, and 32.8 percent reported unprotected receptive anal intercourse. However, only 12 percent of the 435 nonmonogamous men who continue to participate in this longitudinal study reported unprotected anal intercourse at their last assessment in 1988 (McKusick et al., in press). Similarly, among participants in the San Francisco Men's Health Study, prevalence rates for insertive and receptive anal intercourse dropped from 37.4 and 33.9 percent in 1985 to 1.7 and 4.2 percent, respectively, in 1988. In 1988 only 8.5 percent of par- ticipants in this study reported one or more episodes of relapse (i.e., reman to risk-associated behavior after safer behavior had been initiated) during the previous year (Ekstrand and Coates, in press).

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PREVENTION ~ 83 Similar change has also been reported among gay men from other com- munities, such as Denver (Judson, Cohn, and Douglas, 1989; O' Reilly et al., 1989), Long Beach (California) and Dallas (O' Reilly et al., 1989~. Reports of behavioral change have coincided with stable HIV incidence rates and stable rates of other sexually transmitted diseases, which sug- gests that the intervention programs targeting these men have had some success (Linden et al., 1989~. Despite the encouragement provided by these data, however, other studies indicate that safer sex practices have not been universally instituted among gay men, and there appears to be substantial variation in the degree of behavioral change across geographic areas and across age and ethnic groups in the gay community (Office of Technology Assessment, 1988; Coates et al., l98Sa, 1989b; Kelly et al., l989c). 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, al- though 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 understand- ing of health education guidelines for the prevention of HIV infection (Stall, Coates, and Hoff, 1988~. Especially in the epicenters of the AIDS epidemic, the high prevalence of infection estimated to exist among ho- mosexually active men, combined with the increased infectivity believed to be associated with later stages of ir~fection,3 confers a substantial risk 2For example, about 21 percent of a sample of 270 gay men in Boston who were interviewed in 1987 (McCusker et al., 1988) reported engaging in unprotected anal intercourse in the previous month. In a study of 127 gay men in Atlanta, a high-incidence city, only 13 percent of the men reported unprotected anal intercourse in the previous two months; however, 35.4 percent of 163 men in low-prevalence cities (Birmingham, Alabama, and Tupelo, Mississippi) reported such activity, as did approximately one-quarter of 355 men interviewed in Hattiesburg and Biloxi, Mississippi, and Monroe, Louisiana (St. Lawrence et al., 1989; Kelly et al., 1990a). Among a cohort of 249 male sexual partners of HIV- seropositive men in Toronto, 43 percent reported practicing unprotected insertive anal intercourse, and 42 percent reported engaging in unprotected receptive anal intercourse in the previous month (Calzavara et al., 1989). In a study that involved four south Florida counties, half (51 percent) of the gay and bisexual men who participated (N = 586) had previously sought HIV testing and counseling (suggesting that they considered themselves to be possibly at risk for infection), but only 25 percent reported that they always used condoms during anal intercourse (Lieb et al., 1989). For reviews of changes in sexual behavior among gay men, see Becker and Joseph (1988); Coates, Stall, and Hoff (1988); Coates and coworkers (1988b); Office of Technology Assessment (1988); and Stall, Coates, and Hoff (1988). 3In studies of men with hemophilia and their female sexual partners, Goedert and coworkers found that the probability of HIV infection increased significantly for female partners of men with HIV p24 antigenemia or extreme immune deficiency (Dr. James Goedert, National Cancer Institute, personal communication, April 23, 1990).

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84 ~ AIDS: THE SECOND DECADE of disease transmission by any single homosexual contact. Thus, notwith- standing the number of AIDS prevention programs that have already been established for gay men, continuing intervention remains a high priority. Research to understand the distribution and determinants of behav- ioral change among gay men is currently in progress,4 but certain aspects of the studies limit their usefulness. Despite the tremendous diversity among homosexual men, most research to date has involved older, white, self-identified gay men in urban areas. Relatively little is known about other subgroups of gay men who may in fact be at highest risk (e.g., younger men, black and Hispanic men, men who have sex with other men but do not self-identify as gay). In addition, piecing together the findings from different projects presents certain difficulties. First, data are collected and reported in different ways by different investigators, making it difficult to compare rates of change and prevalences of high-risk behav- iors across studies. Second, the results are often reported in a piecemeal fashion, using a variety of publication channels (e.g., scientific journals, scientific conferences, government reports, technical reports, personal communications). It is an arduous and extremely time-consum~ng task to assemble and collate the entire set of studies to identify any patterns among the results. Third, behaviors are reported for varying time periods, ranging from 1 and 2 months to 6 and 12 months. Finally, the frag- mentation of funding sources provides little opportunity or incentive to communicate with other investigators whose efforts are being supported by other funders. Establishing standards for reporting on at least selected subsets of data would facilitate comparisons across studies. But quantifying change does not provide insight into why men alter their behavior. Developing a more coherent sense of what has been learned from studies of gay men supported by the PHS requires considerably more effort. Therefore, the committee recommends that the Public Health Service assemble and summarize data reported by gay men in PHS-funded studies regarding seroprevalence, seroconversion, and high-risk behavior and determine what conclusions can be drawn from the research. 4Studies of behavioral change among gay and bisexual men in San Francisco, Chicago, and New York are currently being supported by the National Institute of Mental Health. CDC sponsors demonstration and education projects among gay and bisexual men in six communities: Dallas, Denver, Albany and New York City, Seanle-King County, Chicago, and Long Beach, California. 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) has administered inter- views and physical examinations to cohorts of homosexual men in Baltimore, Chicago, Los Angeles, and Pittsburgh. The University of California, Berkeley, also conducts studies of gay men.

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PREVENTION | 85 Such a summary would be extremely useful in formulating a research agenda that could direct intervention efforts that are likely to be effective toward gay men who continue to require intensive attention. One group of particular concern is young gay men. Numerous studies have found that young gay men engage in higher rates of risk taking than older gay menS (Joseph et al., 1988; VaIdisem et al., 1988; Ekstrand and Coates, in press; Kelly et al., 1990b). Indeed, according to data collected in the San Francisco Men's Health Study, young homosexual men were significantly more likely than older men to engage in unprotected anal intercourse and to do so with more partners (Ekstrand and Coates, in press).6 These results indicate the dynamic nature of the gay population and highlight the need for continuing intervention and the identification of particular subgroups whose risk behaviors may warrant increased efforts. Community-Level and Individual Intervention Efforts It is clear that behavioral change has been occurring among some groups of gay males in this country. Yet there is also evidence that some sub- populations of men who have sex with other men have not initiated or maintained nsk-reducing behavior. These findings argue for continuing intervention to prevent further spread of infection among men who en- gage in same-gender sex. However, which risk reduction strategies are most likely to be effective remains in doubt. Community-leve} inter- vention 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). In its first report, the com- mittee recognized the importance of this mechanism for reaching many high-risk groups. However, additional strategies that focus on individual gay men are also needed. Community-leve] strategies are based on the assumption that an in- dividual is much more likely to initiate and maintain healthful behavior when a variety of avenues are used to inform and motivate, specific strategies are used to teach skills needed for low-nsk activities, specific S The ages that constitute the '~young" male population, however, appear to vary across studies and are rarely defined. 6 Other studies have also reported differential risk taking among younger gay men. In a survey of 526 bar patrons in Seattle, Tampa, and Mobile, young men were more likely than older men to engage in unprotected anal intercourse (Kelly et al., 1990b). In a 1989 survey of 100 homosexual men between the ages of 18 and 25 in three West Coast communities (Santa Cruz, Santa Barbara, and Eugene, Oregon), 43 reported engaging in unprotected anal intercourse in the previous two months (Hays, Kegeles, and Coates, in press).

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86 i AIDS: THE SECOND DECADE health-diminishing behaviors become less socially accepted in a commu- nity, and social sanctions regarding unhealthy behaviors are perceived as persistent and inescapable (Coates and Greenblatt, in press). Programs conducted to date reflect a diversity in design and venues for delivery: educational sessions offered in homes and in bars, antibody testing and counseling in public health clinics and alternative test sites, newspaper coverage, pamphlets, and safer-sex videos (Catania et al., 19891. Preven- tion strategies that seek to influence entire communities have been widely advocated but less frequently implemented and rarely evaluated. One such program, the Stop AIDS Project, was developed in San Francisco and capitalized on community mobilization, using influential members of the local gay population to provide risk reduction information and skills to other gay men 7 There are indications that the Stop AIDS Project met some of its objectives,8 but data to determine its specific impact on behavior are lacking. The Stop AIDS mode] reportedly has been imple- mented in areas other than San Francisco (Becker and Rose, 1989; Miller et al., 1989) and in one case has shown encouraging results (Miller et al., 1989~. Without rigorous evaluation, however, conclusions about the effectiveness of this strategy cannot be drawn. Activities for gay men in a variety of communities around the country are exploring variations of community-level interventions. For example, researchers at the University of Mississippi are recruiting groups of so- cially influential gay males in each of three medium-sized cities for a series of training sessions. The sessions provide detailed educational materials on HIV transmission and social skills training to teach partic- ipants how to communicate risk reduction information to others (Kelly et al., 1989b). A second project at the University of Califomia, San Francisco, plans to implement and evaluate a peer-led, community-level intervention in three medium-sized West Coast cities to assist young ho- mosexual men to reduce AIDS-related high-risk behaviors (S. Kegeles, University of California, San Francisco, personal communication, lan- uary 19901. The project's community mobilization strategy will include 7 Initial analyses by the originators of this project (Puckett and Bye, 1987) indicated that gay men felt helplessly caught between the growing enormity of the AIDS epidemic and the sexual values and ex- pectations 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. For a detailed description of this project, see Turner, Miller, and Moses ( 1989:Chapter 4). 8Following its fourth survey (in 1986) of gay men in San Francisco, Communication Technologies (1987) reported that 51 percent (as compared with 27 percent in 1985) said that they had heard of the project, and 20 percent said that they had attended a meeting. Stop AIDS records showed that more than 7,000 men in San Francisco attended at least one meeting.

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PREVENTION I 87 three central elements: a system of peer outreach in formal and infor- mal settings to communicate the need for safer sex; peer-led HIV risk reduction workshops to discuss and overcome barriers to safer sex; and an ongoing publicity campaign about the intervention program within the gay community to establish the legitimacy of intervention activities for this subpopulation and provide a continual reminder of the norms for safer sex. New research directions for AIDS prevention strategies that target individual gay men include the use of clinical interventions. Clinical interventions are multisession, face-to-face strategies for individuals who require more intensive attention than can be afforded by community-level programs to achieve or sustain behavioral change. These interventions attempt to help gay men evaluate their personal risk for AIDS, gener- ate group norms supportive of safer behaviors, and provide information, skills, and feedback on how well recommended behaviors are performed. Clinical interventions can be delivered in small group or individual ses- sions and have been employed in a variety of settings, including health care establishments, worksites, and drug treatment centers. Several researchers have reported on promising variations of clini- cal interventions in samples of gay men. Kelly and coworkers (1989b, 1989c) recruited and randomized 104 homosexual men with a history of frequent high-nsk behavior into experimental or wait-list control groups. The experimental intervention consisted of 12 weekly group sessions that provided AIDS risk education, cognitive behavioral self- management training that focused on refusing coercion (self-management and assertiveness training), and steady and self-affirming social supports. Participants in the expenmental group reported fewer episodes of un- protected 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 eight- week program. The intervention consisted of weekly meetings plus one retreat emphasizing meditation, relaxation, positive health habits, and 9 after four months, men in the experimental group reported a mean of only 0.2 episodes of unprotected anal intercourse (compared with 1.2 at baseline) in the previous month. The control group reported a mean of 1.2 (compared with 0.9 at baseline). In addition, experimental subjects at follow-up reported using condoms in 70 percent of sexual contacts that involved intercourse, compared with 40 percent at baseline. Comparable rates for control subjects were 20 percent at follow-up and 32 percent at baseline.

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88 ~ AIDS: THE SECOND DECADE coping with the stress of being seropositive.~ In addition, a peer-led in- tervention effort by VaIdise~n and coworkers (1989a) reported increased condom use following a skills training components The results presented above point to a possible role for clinical interventions in AIDS prevention efforts for gay men. Additional research is needed, however, to determine whether clinical interventions can be modified for wider dissemination through different avenues (e.g., the media) and for other populations (e.g., minorities, IV drug users). The Impact of Drug Use on Behavior Change The disturbing finding that gay men who use drugs (including alcohol) 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).~3 Moreover, the use of noninfected drugs 10The 64 men recruited by Coates and colleagues (1989a) were evenly divided into an experimental group and a wait-list control group to study the effects of stress management on behavior and immune function. At posttreatment, the experimental group reported a mean of 0.5 sexual partners in the pre- vious month (compared with 1.41 at baseline), whereas the control group reported 2.29 partners in the previous month compared with 1.09 at baseline. 11Valdiserri and coworkers (1989a) randomized participants to one of two peer-led interventions. The intervention that provided a skills training component to discuss and rehearse the art of negotiating safer sex resulted in more condom use at 6- and 12-month follow-ups than the intervention that provided information only. 12KeIly and coworkers (199Ob) surveyed bar patrons in three cities (Seattle, Tampa, and Mobile) and found that 37 percent had engaged in unprotected anal intercourse at least once in the past three months. In addition, Stall and colleagues (in press) described the sexual risks for HIV infection reported by a convenience sample of 1,344 homosexual male and heterosexual male and female bar patrons in San Francisco. More than one-third (37.3 percent) of the homosexual males in the sample (N = 593) had engaged in unprotected intercourse in the previous month, but approximately twice as many hetero- sexuals (61 percent of 314 heterosexual males and 63.8 percent of 437 heterosexual females) reported intercourse without a condom during the same time period. The rates in this study are much higher than those found in other samples of convenience (McKusick et al., in press) or in population-based samples (Ekstrand and Coates, in press). 13A longitudinal study of 604 gay men from New York City (Martin, in press) found that the strength of the association between drug use and high-risk sex has diminished over the course of the epidemic. Nevertheless, cessation of drug use was associated with lower rates of both receptive and insertive anal Intercourse.

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PREVENTION ~ 89 ultimately may confer greater risk for gay men than IV drug use (Stall and Ostrow, 19891. Several studies are currently under way in San Francisco to investi- gate the impact of drug use on risk-associated behaviors among gay men. The intervention strategies being used are designed to be implemented in bars and to deal with both drug use and sexual risk taking among adult gay men. These activities may provide much-needed insight into the connection between drug use and risk taking, as well as the connection between drug use and relapse. 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. Knowledge regarding the manifestation and spread of the infection within this population has been advancing incrementally. A nationwide program to reduce the spread of the virus among drug users has been in place over the past several years, arid there is a general consensus among researchers in this area that IV drug users as a group have reduced their risk of acquiring HIV and AIDS by adopting safer injection practices. Indeed, recent studies presented in June 1989 at the Fifth International Conference on AIDS in Montreali4 confirmed many of the conclusions offered by this committee in its first report: many IV drug users (usually a majority of those studied in any particular research project) have reported changes in their behavior to reduce their risk of contracting AIDS; behavioral change among IV drug users usually reflects risk reduction rather than complete risk elimination; there is no single "best" method for facilitating AIDS risk reduction among IV drug users, and consequently it is nec- essary to provide the means both to reduce drug use and to increase the use of"safer" injection practices; and more drug users report changes in drug injection behavior than changes in sexual behavior. It does not appear likely that these conclusions will be contradicted by new research findings in the near future. Yet as the AIDS epidemic i4See, for example, Connors and Lewis (1989), Corby, Rhodes, and Wolitski (1989), Skidmore and Robertson ( 1989), Sunita and coworkers ( 1989), Vlahov et al. ( 1989), and Wolfe and colleagues ( 1989).

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90 ~ AIDS: THE SECOND DECADE enters its second decade within the population of IV drug users, a shift in perspective is required. There is still great geographic variation in the ex- tent to which HIV has spread among drug injectors in local communities. This variation affords both the hope of preventing a more widespread problem in communities that currently report low seroprevalence rates and the need for new approaches in communities that already have sig- nificant infection rates. Some populations in the United States appear to have moved beyond the immediate crisis phase of the AIDS epidemic to a longer term endemic phase. Because neither a vaccine nor a cure for HIV infection appears likely in the near future, planning is needed for the long term to limit the spread of HIV among drug injectors, their sexual partners, and their potential offspring. The conclusions noted above point to the need for a two-pronged approach to intervention: (~) reduce drug use in general, including preventing the initiation of injection, and (2) facilitate risk reduction behavior in both injection and sexual practices. In designing programs to implement such a strategy, the knowledge gained from past efforts must be combined with new approaches geared to present needs. Many injectors have received basic information about AIDS and HIV infection, but there are indications that risk-associated be- haviors in this population are not affected by information alone, nor can much change be expected to occur in response to a single intervention episode (Des JarIais, Friedman, and Stoneburner, 19881. Rather, nsk- associated behaviors are dynamic and are affected by a variety of factors, including new information from within the IV drug-using community, changing social norms regarding risky behaviors, and accessibility of the means for risk reduction (e.g., sterile injection equipment, drug treatment programs). Findings of past behavioral research would predict that indi- viduals who have begun new, lower risk behavior would be less likely to revert to previous high-nsk patterns if He means for risk reduction were readily available and were believed to be effective by the targeted population.~5 Whereas most interventions (with the possible exception of"infor- mation-only" programs) have been associated with self-reported behav- ioral 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), an individual's belief that behavior change would successfully protect against HIV infection was one of the strongest predictors of maintaining risk-reducing behaviors. The importance of other beliefs in AIDS risk reduction is not as clear.

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PREVENTION | 91 19891. Individuals who enter and stay in methadone treatment programs are less likely to be seropositive than those who have not chosen to seek treatment or those who sought treatment but were unable to find it. This finding points to the importance of reducing drug use as a way of curbing the spread of the epidemic. Eliminating drug use among those who already inject drugs has so far proved very difficult. A more pragmatic and immediate approach raises another possibility for halting the spread of HIV: decrease the number of new drug injectors. Clearly, if HIV is present among IV drug users in a community, then it becomes critically important to reduce the number of new persons who might start injecting drugs, for it is during the initial period of use that individuals are most likely to share injection equipment (see the discussion on the progression of drug use in Chapter 31. Some have thought that the threat of AIDS In and of itself would be sufficient to deter individuals from using drugs, but the limited number of AIDS-era studies of persons beginning illicit drug injection suggest that fear of AIDS has not had any large-scale effect on whether individuals become IV drug users. This finding would be consistent with the limited effectiveness of fear arousal during drug prevention and safer injection campaigns of the past (Des lariats and Friedman, 1987; Ghodse, Tregenza, and Li, 19871. In fact, the United States and most other nations have given relatively little attention to new injectors or potential injectors, an oversight that may be attributable in part to the need to address simultaneously the multitude of other health and social problems associated with injecting illicit drugs. Recent data from a survey of 256 IV drug users in New York City, however, have shown infection to be less frequent among those who have been injecting for less than five years than among drug users who have been injecting for longer periods (Friedman et al., 19891. 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. Much attention has focused on vague fears of creating new injectors through the infor- mation and services offered in HTV prevention strategies (e.g., syringe exchanges), and untested hypotheses linking these services to new drug use have been used to oppose innovative approaches. Yet there is no evidence that any form of "safer injection" program is associated with an increase in the number of new drug injectors. Considering the importance of the research and public health aspects of these issues, the development of strategies to reduce the number of persons who start injecting illicit

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136 ~ AIDS: THE SECOND DECADE Kaback, M. M., Nathan, T. J., and Greenwald, S. (1977) Tay-Sachs disease: Heterozy- gote screening and prenatal diagnosis- U.S. experience and world perspective. In M. M. Kaback, ea., Tay-Sachs Disease: Screening and Prevention. New York: Alan Liss. Kamenga, M., Jihgu, K., Hassig, S., Ndilu, M., Behets. F., et al. (1989) Condom use and associated seroconversion following intensive HIV counseling of 122 mamed couples in Zaire with discordant HIV serology. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Kamps' B. S., Niese, D., Brackmann, H. H., Euler, P., van Loo, B., and Kamradt, T. (1989) No more seroconversions among spouses of patients of the Bonn hemophiliac cohort study. Presented at the Fifth Intemational Conference on AIDS, Montreal, June =9. Kanoff, A. B., Kietner, B., and Gordon, B. (1962) The impact of infantile amaurotic idiocy (ray-Sachs disease) on the family. Pediatrics 9:37~6. Kaplan, M. H., Farber, B., Hall, W. H., Mallow, C., O'Keefe, C., and Harper, R. G. (1989) Pregnancy arising in HIV infected women while being repetitively counseled about `'safe sex." Presented at the Fifth International Conference on AIDS, Montreal, June =9. Kaunitz' A. M., Brewer, J. L., Paryani, S. G., de Sausure, L., Sanchez-Ramos, L., and Harrington, P. (1987) Prenatal care and lIIV screening. Journal of the American Medical Association 258:2693. Kegeles, S. M., Coates, T. J;, Lo, B., and Catania, J. A. (1989) Mandatory reporting of HIV testing would deter men from being tested (letter). Journal of the American Medical Association 261:1275-1276. Kelly, J. A.' St. Lawrence, J. S., Smith, S., Hood, H. V., and Cook, D. J. (1987) Stigmatization of AIDS patients by physicians. American Journal of Public Health 77:789-79 1. Kelly, J. A., St. Lawrence, J. S., Hood, H. V., and Brasfield, T. L. (1989a) Behavioral intervention to reduce AIDS risk activities. Journal of Consulting and Clinical Psychology 57:60 67. Kelly, J. A., St. Lawrence, J. S., Stevenson, Y. L., Diaz, Y. E., Brasfield, T. L., and Hauth, A. C. (1989b) Changing peer norms to promote AIDS precautionary behavior: Training popular people to impact on the knowledge, attitudes, and behavior of their acquaintances. Presented at a symposium on Factors Influencing AIDS-Risk Behavior Reduction: Implications for Primary Prevention at the Annual Meeting of the Association for the Advancement of Behavior Therapy, Washington, D.C., November. ' Kelly, J. A., St. Lawrence, J. S., Brasfield, T. L., and Hood, H. V. (1989c) Group intervention to reduce AIDS risic behaviors in gay men: Applications of behavioral principles. In V. M. Mays, G. W. Albee, and S. F. Schneider, eds., Primary Prevention of AIDS: Psychological Approaches. Newbury Park, Calif.: Sage Publications. Kelly, J. A., St. Lawrence, J. S., Brasfield, T. L., Stevenson, L. Y., Diaz, Y. Y., and Hauth, A. C. (199Oa) AIDS risk behavior patterns among gay men in small southern cities. American Journal of Public Health 80:416 418. Kelly, J. A., St. Lawrence, J. S., Brasfield, T. L., Lemke, A., Amidei T., et al. (1990b) Psychological factors that predict AIDS high-nsk versus AIDS precautionary behavior. Journal of Consulting and Clinical Psychology 58:117-120.

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PREVENTION I 143 Sotheran, J. L., Fnedman, S. R., Des Jarlais, D. C., Engel, S. D., Weber, J., et al. (1989) Condom use among heterosexual male IV drug users is affected by the nature of the social relationships. Presented at the Fifth International Conference on AIDS, Montreal, June 4-9. Sowder, B., Weissman, G., and Young, P. (1989) Working with women at risk in a national AIDS prevention program. Photocopied materials distributed at the Fifth International Conference on AIDS, Montreal, June =9. St. Lawrence, J. S., Hood, H. V., Brasfield, T. L., and Kelly, J. A. (1988) Patterns and predictors of risk knowledge and risk behavior across high-, medium-, and low-AIDS prevalence cities. Presented at the Fourth International Conference on AIDS, Stockholm, June 12-16. St. Lawrence, J. S., Hood, H. V., Brasfield, T. L., and Kelly, J. A. (1989) Differences in gay men's AIDS risk knowledge and behavior patterns in high and low AIDS prevalence cities. Public Health Reports 104:391-395. Stall, R. D., and Ostrow, D. (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. Journal of Drug Issues 19:57-73. Stall, R. D., Catania, I., and Pollack, L. (1988) AIDS as an age-defined epidemic. Report to the National Institute of Aging, April. Stall, R. D., Coates, T. J., and Hoff, C. (1988) Behavioral risk reduction for HIV infection among gay and bisexual men: A review of results from the United States. American Psychologist 43:878-885. Stall, R. D., McKusick, L., Wiley, J., Coates, T. J., and Ostrow, D. G. (1986) Alcohol and drug use during sexual activity and compliance with safe sex guidelines for AIDS: The AIDS Behavioral Research Project. Health Education Quarterly 13:359-371. Stall, R. D., McKusick, L., Hoff, C., Lang, S., and Coates, T. J. (1989) Sexual risk for HIV infection among bar patrons in San Francisco. Presented at the Fifth International Conference on AIDS, Montreal, June 4-9. Stall, R. D., Ekstrand, M., Pollack, L., McKusick, L., and Coates, T. J. (1990) Relapse from safer sex: The next challenge for AIDS prevention efforts. Unpublished manuscript. Center for AIDS Prevention Studies, University of California, San Francisco. Stall, R. D., Heurtun-Roberts, S., McKusick, L., Hoff, C., and Lange, S. (In press) Sexual risk for HIV transmission among singles-bar patrons in San Francisco. Medical Anthropology Quarterly. Steele, M. W. (1980) Lessons from the American Tay-Sachs experience. Lancet 2:914. Stein, Z. (1990) HIV prevention: The need for methods women can use (commentary). American Journal of Public Health 80:46~462. Sterk, C. E., Friedman, S. R., Sufian, M., Stepherson, B., and Des Jarlais, D. C. (1989) Barriers to AIDS interventions among sexual partners of IV drug users. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Stevens, R., Wethers, J., Berns, D., and Pass, K. (1989) Human immunodeficiency (HIV) and human T-lymphotropic (HTLV-1/2) viruses in childbearing women: Tests of 24,569 consecutive newboms. Presented at the Fifth International Conference on AIDS, Montreal, June ~9. Stimson, G. V. (1988) Injecting equipment exchange schemes: Final report. London: Monitoring Research Group, Sociology Department, Goldsmith's College.

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