et al., 1993). Although these experiments effected short-term behavioral change among gay men as a result of community-level peer education, both long-term impact and generalizability to other risk groups remain to be demonstrated.
In a number of African countries, a combination of peer-led education with free condom distribution has been used to attempt to change behaviors among commercial sex workers and their clients (Lamptey, 1991; Welsh et al., 1992); however, so far, only a few programs have been evaluated for their effectiveness (Asamoah-Adu et al., 1994; Williams et al., 1992; Wilson et al., 1993). In the Nigerian state of Cross River, community-based interventions trained commercial sex workers, clients, and brothel owners and managers as peer educators, initiated community outreach by peer educators, and distributed condoms at brothels (Williams et al., 1992). A follow-up evaluation one year later found that consistent condom use had increased from 12 percent to 24 percent and, among clients, AIDS knowledge had improved and attitudes toward condom efficacy were more favorable. In Zimbabwe a similar community-level peer education and condom distribution program resulted in increased consistent condom use among sex workers (8.6 percent at baseline to 58.3 percent at 1-year follow-up) and clients (25.4 percent at baseline to 44.7 percent at follow-up) (Wilson et al., 1993). Consistent condom use by sex workers and their clients in Ghana rose from 6 percent in 1987 to 71 percent in 1988 and then fell back to 64 percent in 1991 (Asamoah-Adu et al., 1994). Condom distribution strategies have been widely used, but more careful study should be initiated to determine their efficacy in reducing HIV infections. Also, interventions should target steady partners of sex workers, since it appears that sex workers use condoms less frequently in their personal relationships than in their interactions with clients (Dorfman, Derish, and Cohen, 1992; NRC, 1990b).
The impact of AIDS education on other adult heterosexual has mostly come from mass media campaigns directed at the general public. Several studies have found evidence that these campaigns have had an impact on AIDS knowledge, attitudes, and behavior (Hausser et al., 1988; Izazola, Valdespino, and Sepulveda, 1988; Lehmann et al., 1987; Mills, Campbell, and Waters, 1986; Moatti et al., 1992; Wober, 1988). For example, media campaigns in Switzerland that included mail distribution of an AIDS informational booklet and multimedia advertisements promoting condom use, nonsharing of syringes, and monogamy resulted in a demonstrated increase in AIDS knowledge, condom sales, and condom use (Hausser et al., 1988; Lehmann et al., 1987).