York and other cities where needle exchange programs have been proposed protest vehemently against their implementation, contending that the supply of clean needles actively encourages and perpetuates the very drug trade and drug addiction that community leaders are trying to eradicate among the local population. In this instance, observance of cultural sensitivity to one group may prevent implementation of proven HIV reduction measures for another. Balancing concern for cultural sensitivity with concern for HIV prevention is a delicate act.

The issue of cultural sensitivity in HIV prevention is also bound up with a larger social-structural problem affecting the ability to design effective interventions: the problematic dynamics of race and ethnicity in American culture and society. Just as it is important to understand stigma and antipathy against gays and lesbians in the HIV context, it also is important to understand racial and ethnic bigotry and the ways in which these may be institutionalized. Some scholars contend that continued inattention to the legacy of racism in governmental health research, particularly with regard to the infamous Tuskegee study, will necessarily undermine HIV prevention efforts directed to the African American community (Dalton, 1989; Thomas and Quinn, 1991). The deep suspicion engendered by this and other negative experiences, such as CDC's announcement in the early 1980s that AIDS came from Haiti and that Haitians were a highrisk group (Farmer, 1992) and past practices of sterilization of poor, African American, Hispanic/Latina, and Native American women without their knowledge or consent, has fueled the way in which racial/ethnic communities perceive the representation of the HIV epidemic. Until and unless these concerns are directly addressed—at least by open discussion—efforts at HIV related behavioral change in racial/ethnic communities likely will be met with continued resistance.

Women and Gender Dynamics

A growing number of investigators are recognizing that gender differences influence HIV risk factors and barriers to behavior change (Fullilove, Fullilove, Haynes, et al., 1990; Gomez and Marin, 1993; Grinstead et al., 1993; Icovics and Rodin, 1992; Mondanaro, 1990; Schilling, El-Bassel, and Gilbert, 1993; Schneider, 1992; Seidman, Mosher, and Aral, 1992; Solomon et al., 1993; Soskolne, Aral, Magder, et al., 1991; Weinstock et al., 1993). However, these studies have been based on theoretical models that do not provide an explanation for expected and observed gender differences.



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