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AIDS: The Second Decade (1990)

Chapter: 2 Prevention: The Continuing Challenge

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Suggested Citation:"2 Prevention: The Continuing Challenge." National Research Council. 1990. AIDS: The Second Decade. Washington, DC: The National Academies Press. doi: 10.17226/1534.
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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

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).

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).

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.

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).

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.

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.

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.

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).

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.

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

92 ~ AIDS: THE SECOND DECADE drugs and to ensure that those who do start injecting will practice "safer" injection should be allowed to proceed without constraints that have little grounding in current scientific knowledge. (A more detailed discussion of these issues is presented at the end of this chapter.) If one considers the changes made by individuals who already use drugs, the extent to which IV drug users have altered their behavior to reduce the risks of AIDS has been impressive, going well beyond what many experts in the field would have predicted. To say that the prob- lem has been solved, however, is to overlook the substantial difficulties involved in maintaining any kind of behavioral change. 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 main- taining 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 im- plies the need for greater attention to prevention efforts for this population. Programs designed to block the acquisition or transmission of infection include efforts to reach women at risk, help them to assess their level of susceptibility, and facilitate the process of changing risky behaviors and supporting healthy ones. Programs that focus on preventing transmission address two general transmission patterns: horizontal Transmission of the virus through sexual contact or shared injection equipment with art infected partner) and vertical (from a woman to her infant). Prevention programs addressing these pattems of transmission, as well as acquisition of the virus among women, ale discussed below. Preventing Horizontal Transmission in the Context of Drug Use As noted earlier, women are at risk of horizontal transmission of HIV in the context of drug use Trough two routes: clirectly, through IV drug use itself (e.g., sharing injection equipment with an infected person) and 16For a review of behavioral changes reported among IV drug users since the beginning of the AIDS epidemic, see Turner, Miller, and Moses (1989:202-211). 17In a survey of 401 IV drug users from New York City, the majority (79 percent) reported behavioral change. However, more than a third (36 percent) of this group indicated that they were unable to maintain such changes (Des Jarlais et al., l989b).

PREVENTION ~ 93 indirectly, through unprotected sex with a male infected IV drug user. Delivering interventions to either of these groups of women has proved difficult in the past, and such efforts loom large on the list of unresolved issues for the future. For example, female sexual partners of IV drug users may not readily identify themselves as being affiliated with an injector. (Alternatively, they may not know about their partner's drug use and thus may be unaware of their own risk.) Attempts to reach female sexual partners of IV drug users through men in treatment or through street outreach activities have met with very little success (Sterk et al., 1989). 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. Advocating treatment as a strategy, however, carries with it the requirement that policy makers confront O O the factors that prevent women from accessing such services and that lead to relapse and treatment failure. Many women report difficulties gaining entrance to treatment programs; moreover, surveys of existing Mug programs have found that drug and alcohol services for women are lacking in their availability, in the types and quality of support services they provide, and in the adequacy of referral and fo'1ow-up facilities (Reed, 19871.~9 Therefore, because many female IV drug users are neither recruited into treatment nor served by it, the scope of outreach efforts must be widened to cover a broader spectrum of this population. Additional outreach methods may also be needed for female sexual partners of {V Mug users. Some recent approaches have used mobile vans to reach geographically diverse and mobile groups. Organizations that serve these women (e.g., community clinics, shelters for the homeless, emergency rooms of inner-city hospitals, family planning and prenatal care clinics, local churches, women's organizations, sexually transmitted disease clinics, beauty parlors, laundromats, prisons) are also potential points of contact, as are door-to-door efforts. Upon closer scrutiny, however, it is clear that there are factors beyond the control of many women that affect access to needed services. Often, ~ sit should be noted, however, that one episode of treatment is generally insufficient to eliminate drug use. A survey of 220 women in drug treatment programs in San Francisco found that women reported a median of five episodes of previous treatment (Wolfe et al., 1989). 190nly two-thirds (67 percent) of the 736 female injectors participating in the NIDA demonstration projects (see Chapter 1) had ever been in a formal drug treatment program; less than a quarter (23 percent) of the noninjectors in those' projects reported participation in any foal treatment (Sowder, Weissman, and Young, 1989).

94 ~ AIDS: THE SECOND DECADE taking advantage of AIDS prevention programs requires transportation, child care, and a program in an accessible location at an affordable cost. Strategies that propose the use of health care facilities to deliver such pro- grams need to take into account the barriers that have inhibited women's access to other medical services, such as prenatal care.20 Women report lack of money most frequently as an obstacle to prenatal care (Institute of Medicine, 1985~. 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) than women who receive such care (Mattel et al., 1989~. Female drug users who are pregnant often have difficulties finding a treatment program that will accept them. Even when they are accepted for drug treatment, in many cases the program will not arrange for prenatal care (Chavkin, Dnver, and Forman, 199.2 In the opinion of the committee, fragmentary services for high-nsk populations are inconsistent with sound public health policies. All women of childbeanng age who wish to cease drug use should have access to treatment without undue delay, and all pregnant women who use drugs should have access to appropriate prenatal care. At a minimum, effective referral networks should be established. There is some evidence that intervention programs have reached particular subsets of women. For example, there are indications that female IV drug users have received AIDS prevention messages that describe the routes of HIV transmission (Selwyn et al., 1987~. The evidence also suggests that these women are aware of the effectiveness of bleach for stenlizing injection equipment and that they have taken preventive action (Wolfe et al., 19891.22 Studies performed in New York 20A report from the Institute of Medicine (1988) on prenatal care identified several significant baITiers for women: inadequate third-party coverage of medical benefits, inadequate capacity of the existing maternity care system, and lack of coordination between health and social services for low-income women. 21A recent survey of drug treatment programs in New York City found that more than half (54 per- cent) categorically excluded pregnant women, 67 percent rejected pregnant Medicaid patients, and 87 percent denied service to pregnant crack addicts who were Medicaid recipients. Of the programs that did accept pregnant women, fewer than half (44 percent) made any effort to arrange for prenatal care (Chavkin, 1990). 22Among 220 women recruited from methadone and detoxification treatment programs in San Fran- cisco, more than half (117) reported using bleach to sterilize their "works" (Wolfe et al., 1989). The longer Me period of time for which women reported bleach sterilization, the less likely they were to be infected. Of the 18 women who reported bleach use for two or more years, none was found to be

PREVENTION | 95 City indicate that some women who have altered their injection practices have also altered risky sexual behaviors.23 Nevertheless, there remain many potential baIners to change in this population, including problems with withdrawal for those women who are currently injecting drugs, the lack of sterile injection equipment, uncertainty about the risk associated with sharing injection equipment with one friend or a sexual partner, lack of confidence in the protection afforded by condoms, and general fear of HTV testing (Williams, 19891. Some studies have reported that brief but intensive counseling with IV drug users and their sexual partners has been effective in improving attitudes about AIDS risk reduction and condom use (D. R. Gibson et al., 1988~; conventional teaching methods, on the other hand, have been found to have little or no effect on increasing knowledge about AIDS or changing risk-associated behaviors (Arenson and Finnegan, 1989~. Several new intervention strategies that utilize lectures, videotapes, and support groups are being tested for women who use drugs. To date, no evaluation data are available on these programs. Another potential barrier to change may be a lack of perception of being at risk.24 The perception of being at risk, which is crucial to the initiation of behavioral change, is particularly important for women who are the sexual partners of {V drug users. Many of these women may not know about the drug use practices of their partners, practices that might affect individual attitudes toward or insistence on condom use and therefore their risk of exposure to the virus through unprotected intercourse. Even if they do know about their partner's drug use, there may still be obstacles that inhibit protective action. Studies have indicated that it may be more difficult to facilitate change in risky sexual behaviors among IV drug users than to facilitate change in risky injection behaviors (Celentano et al., 1989; Chitwood et al., 1989; Fariey et al., 1989; Sunita et al., 19891. Consequently, although a number of TV drug users have infected. However, 11 percent of the 47 women who said they had used bleach for one to two years and 17 percent of the 52 women who reported using bleach for less than a year were seropositive. 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); and (2) had friends who were sexual risk reducers (Tross et al., 1989). One explanation for this finding is that a shift in injection nods may have occurred, and norms that were supportive of safer practices had diffused through friendship networks and thus led to the adoption by individuals of a cluster of new health behaviors. 24For more information on motivating behavioral change, see Turner, Miller, and Moses ( 1989: Chap- ter4).

96 ~ AIDS: THE SECOND DECADE reported changing injection practices in response to the AIDS epidemic,25 fewer report changes in sexual behavior.26 One of the obstacles women confront in relation to condoms may be their lack of information regarding appropriate usage. Training to teach women the skills for proper condom use may be helpful, but there are no evaluation data to show how such programs can best be delivered. Moreover, simply reaming the skills involved in condom use may not be the critical change that must be made to enable these women to protect themselves.27 Intervention programs to help this gTOUp of women take protective action must also pay careful attention to outreach problems and to the psychosocial characteristics of the population and their partners. For women who deny their risk either the risk attributable to their own drug use or to that of their sexual partner additional interventions may be necessary. 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). Preventing Vertical Transmission Efforts to prevent vertical transmission of the AIDS virus generally try to identify high-risk and infected women prior to or during the early stages of pregnancy and counsel them about the likelihood of transmitting HIV to the fetus. They also discuss the options related to continuing or terminating the pregnancy and the impact of HIV infection on newborns. Studies have shown that there is a 40 to 60 percent chance that an infected woman will pass on the virus (as opposed to only her antibodies) to her infant (Danow, laffee, and Curran, 1988~. AIDS prevention thus 25A survey of 7,660 IV drug users recruited through two detoxification clinics in the San Francisco area between April 1986 and September 1988 found significant decreases in reported needle-sharing (Guydish et al., 1989). The proportions of injectors sharing injection equipment dropped from 55 and 48 percent for the two clinic populations to 28 and 27 percent. 26For example, a survey of 298 IV drug users recruited from methadone programs in New York City found that 68 percent of sexually active clients reported no condom use (Magura et al., 1989). 27 Powerlessness, low self-esteem. isolation, and a low perception of the risk of becoming infected with HIV were common characteristics found throughout a sample of 80 female sexual parmers of IV drug users recruited for an ethnographic survey conducted by Arguelles and colleagues (1989). A separate ethnographic suIvey of sexual partners of drug users found substantial numbers of women who reported emotional and economic dependency, social isolation, and denial of their partners' drug use (Sterk et al., 1989).

PREVENTION 97 depends on reaching two groups of women of childbeanng age: women who are at risk of acquiring HIV but are not yet pregnant and pregnant infected women. Because a substantial portion of childbearing women seek care for gynecological and obstetrical problems at some time during the childbearing years, this segment of the health care delivery system has the potential to reach out to these groups of women with interventions to interrupt the vertical transmission of HIV (CDC, 1985; Landesman, Minkoff, and Willoughby, 19891. Some programs are already in place. HIV testing and counseling services, for example, are offered in local health departments and in clinics for sexually transmitted disease (STIR, family planning, and prenatal care. 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~. They recruit participants through a variety of sources: prenatal and family planning clinics, methadone maintenance programs, STD clinics, and hospitals, as well as through street and storefront outreach stations. Some of the projects use focus groups30 and ethnographic interviews to elicit information from participants to incorporate into intervention strategies, which include individual and group counseling and education, safer sex parties, peer-led (versus professionally-led) HIV counseling groups, skills Gaining, and empowerment messages. One activity of this multisite study involves an investigation of the role of counseling and testing in changing high-risk behaviors and increasing the use of condoms. Every six months, participants receive a standardized questionnaire that elicits information 28Indeed, IV drug users, the women at highest risk for acquiring and transmitting the virus, may be the least likely to seek preventive health care (Dattel et al., 1989; Sweeney et al., 1989). 29The committee's panel on evaluation recently recommended a process evaluation of CDC's HIV testing and counseling program to determine how well services are being provided and suggested gathering data from several sources on two important aspects of service delivery the accessibility of services and client-centered barriers to program participation (see Chapter 5, Coyle, Boruch, and Turner [1990]). The committee believes that such research would shed light on the development of potentially effective intervention strategies to reach a diverse population of women at risk. 30Focus groups were developed by market researchers to improve their understanding of how con- sumers perceive a product. (This method is also used in social marketing tests of intervention pro- grams.) A focus group is generally composed of 6 lo 10 people plus a trained interviewer; volunteers may be paid for their participation. They are invited to discuss a product or program for a few hours. Interviewing generally moves from broad questions to more specific issues (Kotler and Roberto, 1989).

98 ~ AIDS: THE SECOND DECADE on changes in sexual and drug use behaviors, use of contraception and family planning services, referral efficacy, and pregnancy. Whereas these projects appear interesting and promising, no data have been presented as yet to indicate their impact on participating women. The media are another means being used to reach women who are not in touch with the medical establishment. Although few media interventions have been evaluated, there are already some indications that improvement is needed in crafting more effective messages and reaching the targeted audience. Behavioral theory suggests that warnings about health threats must be accompanied by info~-~ation on concrete actions that can be taken to avoid these threats (Turner, Miller, and Moses 1989~. In New York City, faces of female film stars now peer down from subway placards, asking "Pregnant? 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. At present, there are only limited evaluation data on this activity, which began in the summer of 198S, but they indicate that the program may have several problems.32 3lWritten materials, generally in pamphlet form, provide more detailed information for women than can be communicated through a poster. Information provided by the Michigan Department of Health, for example, describes the range of services it offers: from testing and counseling, to prenatal, abortion, and pediatric services. The materials note that the choice of the individual regarding the available options for dealing with the pregnancy will be respected (Michigan Department of Health, 1988). 32 Data from the National Health Interview Survey (a weekly suIvey of 800 U.S. adults) for January through March 1989 showed that only 24 percent of female respondents could recall a radio or televi- sion public service announcement called "America Responds to AIDS" in the previous month (Daw- son, 1989). However, 80 percent of women reported seeing other AIDS public service announcements on television and 40 percent reported hearing about AIDS from radio broadcasts in the month prior to interview. These data can only describe the penetration of the message within the targeted popula- tion and do not speak to the effect of such messages on women's beliefs and behaviors in response to AIDS. The need for research on the effectiveness of media campaigns was recently addressed by the committee's evaluation panel, which devoted a chapter of its report to specific guidance on assessing the outcomes of CDC's media intervention strategy (Chapter 3 in Coyle, Boruch, and Turner [19903).

PREVENTION ~ 99 The Role of Counseling and Testing in Women's Intervention Programs Intervention strategies to prevent the vertical transmission of HIV have relied heavily on testing and counseling. These approaches presume that women who discover they are infected will avoid conception, either through contraception or sterilization (Kaunitz et al., 1987~.33 Most stud- ies, however, rely on small samples of convenience of pregnant women and suffer from methodological problems that preclude drawing firm con- clusions about their effectiveness. Thus, the evidence regarding whether HIV testing is likely to reduce perinatal transmission significantly is in- conclusive. Research conducted by Kaplan and colleagues (1989), 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 re- peatedly 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. It is not clear why this group is different from others that have been studied. Often women find out that they are infected while receiving prenatal 33 Kaunitz and coworkers ( 1987) provided HIV counseling and testing to 299 women attending a prena- tal clinic in Jacksonville, Florida. Two women were found to be infected. After delivery, both women received additional counseling on contraceptive practices and pediatric care. One woman chose an injectable contraceptive (depot medroxy-progesterone acetate, 150 mg intramuscularly every three months); the other chose oral contraceptives. (This study did not provide information on condom use.) 34 Of the 11 pregnancies that occurred among these ten women, seven were terminated, three were carried to term, and there was one miscarriage. There did not appear to be substantial differences in pregnancy rates for women who reported IV drug use as their risk factor and those who reported het- erosexual contact. Of the 80 women in the study who reported IV drug use, 6 (7.5 percent) underwent one pregnancy, and 1 woman became pregnant two times. Of the 43 women who reported heterosexual contact as their risk factor, 3 (6.9 percent) became pregnant. 35In a study by Barbacci and colleagues (1989) that retrospectively studied the pregnancy decisions of women recruited from clinics in Baltimore, Maryland, 14 (16 percent) became pregnant after learning they were infected; none chose to terminate their pregnancy. In a subsequent pregnancy, however, one in this group chose abortion. In another study of 43 infected women in Newark, New Jersey, Schneck and coworkers (1989) found that 7 women (16 percent) became pregnant within 2 to 20 months after receiving their test results; 2 women became pregnant twice. Of the 9 pregnancies reported, 6 were terminated.

100 ~ AIDS: THE SECOND DECADE care. The rationale for using HIV testing to prevent vertical transmis- sion once a woman has become pregnant is not clearly enunciated in Public Health Service guidelines, which may reflect the controversy that surrounds the role of abortion in managing this problem (Grimes, 1987; Gunn, 19881. There is evidence to suggest that, in some subpopulations, HIV testing dunog pregnancy may not significantly reduce perinatal transmission of HIV.36 In many instances, knowledge of infection status occurs after 24 weeks' gestation, when legal abortion is no longer an option. For other women, abortion is an option they do not select. A variety of factors affect whether infected women will choose abortion for example, financial barriers to securing an abortion, or the religious beliefs or cultural objections of the woman, her partner, or the community. Other women may not understand the options available to them. In many current testing and counseling programs, recommenda- tions from counselors concerning what, if anything, pregnant women should do when they are found to be seropositive are often nebulous, instead of being even-handed presentations of the range of available options, including abortion. Some testing programs apparently inform women who are found to be infected that abortion is an option (Ruther- ford et al., 1987; Sachs, Tuomala, and Fr~goletto, 1987; Holman et al., 19891; however, because of the controversy surrounding abortion in this country (Grimes, 1987; Gunn, 1988), in some programs the option of abortion may not be offered or discussed. 36Holman and coworkers (1989) are currently following a group of 82 seropositive pregnant women and a matched seronegative control group from Brooklyn, New York, throughout their pregnancies and for four years thereafter. The women were recruited through several different kinds of obstetrical clinics (a clinic attached to a drug treatment program, one that provides services to Haitian women, and a referral network of clinics at municipal and state hospitals and HIV testing and counseling cen- ters). Between January 1986 and July 1988, 840 pregnant women were counseled about HIV, and 625 consented to undergo testing; 82 ( 13 percent) were found to be seropositive. Only 27 of the seropos- itive women learned of their serostatus early enough in the course of their pregnancy to make legal abortion an option; of these, 4 chose to abort. One woman tried to get an abortion but could not find an outpatient clinic that would accept a methadone patient at her dosage level. (Inpatient service was not a possibility because she did not want her family to know about the abortion.) Thirteen of the seropositive women went on to become pregnant again, and of the 10 women who continued this latter pregnancy, 5 already had children with AIDS. An additional 4 women became pregnant a third time, and all chose to abort. Similar findings were reported in a retrospective review of pregnancy decisions by 89 seropositive women in Baltimore, Maryland (Barbacci et al., 1989). The sample was recruited through a prenatal clinic and an HIV clinic for women. Of the 89 women tested, 36 (40 percent) found that they were infected after they had already become pregnant. Of the 10 infected women who had been pregnant for less than 20 weeks, 2 opted to abort the pregnancy, and 1 suffered a miscarriage. In Wiznia and colleagues' (1989) 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.

PREVENTION ~ 101 Moreover, even if legal abortion is presented as an option, ser- vices for infected women may not be available. For example, 82 per- cent of counties in the United States (50 percent of those classified as metropolitan and 91 percent of those classified as nonmetropolitan) lacked a provider of abortion services in 1985 (Henshaw, Forrest, and VanVort, 1987), and only 13 states have Medicaid plans that cover abortion (Gold, 19901. Even where services are available, women who choose to ter- minate their pregnancy may not be able to do so. In a survey of 25 abortion clinics in New York City, 16 (64 percent) refused to schedule an abortion for a woman who identified herself as infected France, 19891. Perhaps the most important reason women do not elect abortion, one that may be overlooked by strategies that do not attempt to consider the emotional factors that contribute to reproductive decision making, is the profound positive meanings many women associate with bearing children. For some women, having children is associated with self-worth and self-esteem, and it may represent one of the few creative options open to women who are or fee} deprived of economic and educational opportunities. In addition, for women with AIDS, the continuation of a pregnancy may reflect the desire to replace a child lost to death or foster care. For women who are asymptomatic, not electing abortion may be a conscious or unconscious attempt to deny the reality of their infection. Despite the inconclusiveness of the evidence noted above on reducing perinatal transmission, there may be other reasons as well to continue to offer testing to pregnant women. These include optimal medical management of the pregnancy (CDC, 1985; Minkoff and Landesman, 1988~; the opportunity to avoid a subsequent pregnancy (Rutherford et al., 1987~; the opportunity to begin therapeutic interventions that could benefit the mother and the fetus;37 and the early identification of newborns who may be infected, thus speeding special medical attention following bird (Krasinski et al., 1988~.38 It is unclear from the available data whether testing and counseling 37Recent improvements in treatment and the inclusion of pregnant women in drug trials may pro- vide women with new incentives to seek testing and counseling before pregnancy or during the first trimester. Studies are planned to test whether early detection of infection and prompt treatment with antiretroviral agents such as AZT could lessen the chance of transmission of the virus to the fetus. However, other drugs (e.g. pentamidine) 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. The committee notes the serious consequences of mv infection among children, and itS Panel on Monitoring the Social Impact of the AIDS Epidemic is currently considering a range of issues that affect u s social structures and institutions, including the family and foster care, and the ability of these structures to respond to the needs of infected children. The panel's report is expected to be available in 1991.

102 ~ AIDS: THE SECOND DECADE are effective in reducing risky behavior, preventing vertical transmission of the virus, or assisting women to make informed decisions concerning childbearing. In part because of the dearth of sound evaluation data, some have questioned the merit of testing and counseling, as a behavior- changing intervention (as opposed to a diagnostic service). Clearly, women who are offered such services need to understand the manner in which testing and counseling intervention is delivered and the information it can provide. For example, they need to understand the differences between confidential and anonymous testing,39 the significance of positive and negative test results for both themselves and their offspring, the implication of positive test results on future reproductive choices, and the limitations of testing in predicting disease progression or outcomes. The ideal time to test for antibodies to the virus and to course! 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. The committee recommends careful review of the goals of counseling and testing programs for women of chilclbearing age and the implementation of efforts to ascertain the effect of such programs on future risk-taking behavior. In its review of CDC's counseling and testing program,4~ the commit- tee's evaluation panel recommended strategies for assessing the relative effectiveness of various counseling approaches through well-con~olled studies that compare services (1) delivered in different settings, (2) with different content, duration, and intensity, and (3) accompanied by differ- ent types of supportive services (see Chapter 5 in Coyle, Boruch, and Turner El9901~. This strategy need not be limited to CDC's program 39Confidential testing links test results to an individual but protects the individual's identity. Anony- mous test results are free of all identifying information. 40For example, in a survey of 2,276 sexual partners of hemophilic men conducted by CDC in con- junction with the National Hemophilia Foundation and Hemophilia Treatment Centers, only one-third of the women had been tested (Nichols, 1989). Ten percent of the tested women were infected; 22 women who were seropositive reported a pregnancy in the two years prior to the study. 4iFor a description of CDC's testing and counseling program and resulting epidemiologic data, see CDC (1990).

PREVENTION ~ 103 but could also be applied to the evaluation of any counseling and testing project. As the epidemic enters its second decade, data to ascertain which testing and counseling formats are most effective are crucial to guide in- tervention planners in designing prevention strategies for the population of women at nsk. 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. Genetic counseling programs for adults at risk of transmitting genetic diseases to offspnug have been in place for many years. In addition, ethical guidelines for genetic screening have been proposed by a variety of groups, including the former U.S. Department of Health, Education, and Welfare, the Hastings Center, the National Institute for Child Health and Human Development, and the National Academy of Sciences. All of these groups stress nond~rective counseling, individual choice and autonomy, and respect for the moral ambiguities and complexities of decision making (Lappe, Gustafsen, and Roblin, 1972; Powledge and Fletcher, 19791.42 Such programs may provide helpful information about decision making In relation to current and future pregnancies and the facts and services that might be helpful to women who must make difficult reproductive decisions. Lessons from Genetic Counseling Knowing that one may be capable of passing on a genetic disease to one's offspring does not inevitably result in a decision not to have children. hndeed, research shows that the factors that contribute to reproductive de- cision making in the face of genetic disorders show substantial vanation. For example, early research on genetic counseling regarding pher~ylke- tonuria (PKU), a metabolic disorder that can result in mental retardation (Schild, 1964), found that information about health outcomes and the quality of life for the child appeared to be highly salient factors in the decisions made by families who already had a child with PKU to modify or restrict reproductive plans. In addition, other factors, such as the birth order of the child in question, the age of the parents, and the level of perceived risk to the child all showed some association with reproductive decisions related to PKU and other disorders (Carter et al., 1971; Emery, Watt, and Clack, 1972; Bums et al., 1984~. Somewhat later studies found 42For a discussion of this issue specifically related to AIDS, see Bayer (in press).

104 ~ AIDS: THE SECOND DECADE a different pattem. Advances in the treatment of PKU and the diminished consequences of the disease (through such techniques as improving the diet of children with PKU to prevent retardation), together with readily available counseling, have resulted in decisions not to limit reproduction even when families know there is a 25 percent chance of having another child with the disease (Burns et al., 1984~. It appears that the availability of a treatment or remedy that improves the health status of the child increases the likelihood that other children will be conceived. For other types of genetic diseases, the impact of genetic counseling programs on reproductive decision making is unclear. Despite participa- tion in counseling, many couples who are at high risk of producing a child with sickle-cell anemia (Neal-Cooper and Scott, i988),43 cystic fibrosis (Leonard, Chase, and Childs, 1972; McCrae et al., 1973), or Down's syn- drome (Leonard, Chase, and Childs, 1972; Getting and Steele, 1982~44 go on to have children. These studies suggest either that some couples do not interpret the information provided by genetic counseling in a manner that leads to no further pregnancies or that the desire to have children outweighs the predicted risk. There also appears to be considerable van- ation in the effects of genetic counseling programs across the various subpopulations who seek such counseling, although the factors that ac- count for this vanability are not well understood (Evers-Kiebooms and van den Berghe, 1979; Murray et al., 1980), in part because of poor study design (Evers-Kiebooms and van den Berghe, 19791. What is clear is that information alone regarding a potential health problem in an unborn child does not necessanly result in postponement or relinquishment of child- beanng. When the disease in question is HIV infection, for which (unlike PKU, for example) there is no diagnostic procedure for the fetus and no prophylaxis for children who are born with the disease, He reproductive decision-making process is likely to be even more difficult. In addition, the substantial likelihood that an infected mother will pass on HIV infec- tion 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. Therefore, 43In their review of 25 couples at risk of having a child with sickle-cell anemia, Neal-Cooper and Scott (1988) reported 16 pregnancies among 10 couples, 4 pregnancies among 4 of the 5 couples with an unaffected child, and 5 pregnancies among 4 of the 9 couples with an affected child. 44Oetting and Steele (1982) found no significant differences between counseled and matched uncoun- seled couples who already had a child with Down's syndrome in terms of knowledge of genetics or recurrent risks, initiation of subsequent pregnancies, or utilization of prenatal diagnosis. Although 18 of 35 couples initiated at least one more pregnancy after the birth of a child with Down's syndrome, only 3 couples used prenatal diagnosis by amniocentesis to detains the presence or absence of the condition.

PREVENTION ~ 105 the committee recommends that the Public Health Service convene a symposium of experts in genetic counseling to consider the potential contribution of this field's expertise and experience to the design and implementation of counseling programs for HIV-infected women and to identify research opportunities in this area. In addition, more re- search is needed to understand cultural, religious, sociodemographic, and regional variations in responses to programs that deal with reproductive decision making, including the effects of these factors on the interpreta- tion of information, the counseling experience, medical interaction, and subsequent action. AIDS Prevention Challenges in the Coming Decade The clear indication that blacks and Hispanics are overrepresented in the AIDS epidemiological data has focused attention on the urgent need for AIDS prevention for these groups and for other minority subpopula- tions.45 Several intervention efforts are already under way, most of which have been directed toward minority subpopulations within traditional risk groups.46 For example, CDC has provided support for intervention pro- grams that target minority youth, both those in school and those who cannot be reached through educational institutions. In addition, the Na- tional Institute of Mental Health (NIMH) is currently supporting two studies of HIV risk among black men who engage in same-gender sex.47 Yet the committee finds that ongoing efforts fall far short of the magni- tude of intervention needed, given the prevalence of disease and evidence of continued risk taking among many of the populations currently at risk 45 For an overview of AIDS and Native Amencans, see Tafoya (1989); Aoki and colleagues (1989) review AIDS prevention efforts for Asian-American communities. 46CDC currently funds a variety of community-based HIV interventions aimed at promoting behav- ioral change among these high-risk groups. However, there is little in the way of currently available evaluation data to identify the most promising strategies. In its recent report, the evaluation panel recommended that randomized experiments be conducted to evaluate the effectiveness of a subset of these projects (see Chapter4, Coyle, Boruch, and Turner t19901). This committee endorses the panel's recommendation. 470ne of the NIMH studies is descriptive and focuses on the prevalence and determinants of risk behaviors in the group; the other implements and evaluates planned variations of "safer sex" workshops designed especially for black homosexual and bisexual men. Preliminary findings indicate that most men in the sample report high rates of risk-associated behavior. Of 50 black homosexual and 50 black bisexual mere recruited in 1988 in San Francisco, Oakland, and Berkeley, California, 60 percent of homosexual and 88 percent of bisexual men had engaged in unsafe sexual practices in the previous month with a partner other than their primary partner. Unsafe sexual practices with primary partners were reported by 50 percent of homosexual and 78 percent of bisexual men (Peterson et al, 1989). Predictors of safer sexual practices were a heightened sense of self-efficacy (i.e., a perceived ability to successfully enact such behaviors), enjoyment of safer sexual activities, close association with persons with AIDS, and media awareness of AIDS.

106 ~ AIDS: THE SECOND DECADE for AIDS, including minority men and women. Effective intervention strategies are needed to sustain healthy behavioral patterns in individuals who are not currently at risk and to facilitate change among individuals who are at risk. There is some recent evidence indicating that the basic facts about AIDS are reaching minority subpopulations. After controlling for ed- ucation, data from the 1988 National Health Interview Survey (NHIS) showed no differences between Hispanics and white non-Hispanics or be- tween black and white survey participants in patterns of AIDS knowledge (Dawson and Hardy, 1989a,b).48 For all groups, however, misconceptions and gaps in knowledge remain, indicating that the job of delivering use- fu] information is far from complete. One important factor that must be considered in planning further interventions for minority subpopulations is the diversity of these groups. For example, the term Hispanic may mask substantial cultural heterogeneity, given the groups that constitute this ethnic category (e.g., Puerto Ricans, Mexicans, Cubans, and individ- uals from Central and South American countries) (Amaro, 19881. The usefulness of AIDS prevention information to racial and ethnic minorities depends on the development of culturally and linguistically appropriate messages that are delivered through the venues and organizations deemed trustworthy by the targeted audience.49 Yet as the committee noted last year, for most at-risk individuals, regardless of their racial or ethnic background, information alone is 48Provisional data collected between May and October 1988 by the National Center for Health Statis- tics' NIBS were aggregated to provide sufficient numbers of respondents to examine differences in knowledge about AIDS in various subpopulations, including Hispanics (Dawson and Hardy, 1 989b). Unfortunately, the resulting sample of Hispanic adults was still small (N = 1,102) compared with the sample of white non-Hispanic participants (N = 19,963), making it difficult to detect subtle differences that could be statistically significant. In separate analyses (Dawson and Hardy, 1 989a), the responses of black participants (N = 3,066) were compared with those of whites (N = 17,355). Objective measures of knowledge about AIDS and HIV infection varied by education for Hispanics, white non-Hispanics, and blacks. After controlling for education, however, the responses of the groups were very similar: of respondents with more than 12 years of education, 89 percent of Hispanics, 90 percent of white non- Hispanics, and 82 percent of blacks knew that HIV could be transmitted through sexual intercourse, and 79 percent of Hispanics, 81 percent of white non-Hispanics, and 82 percent of blacks were aware of vertical transmission. However, the proportion of Hispanic participants who believed that condoms were not at all effective ( 10 percent) was twice as high as the proportion of white non-Hispanics hold- ing a similar belief (5 percent); the proportion of blacks with similar beliefs about condoms (8 percent) 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. In a separate telephone survey of 460 Hispanics from the San Francisco area, Marin and Marin (1990) found that knowledge about AIDS was strongly associated with acculturation, even after controlling for education. 49See, for example, Amaro (1988); MaIin (1990); Mann and Marin (in press).

PREVENTION ~ 107 unlikely to be sufficient to elicit change in risk-associated behaviors. Interventions that go beyond the provision of information for example, drug treatment programs or skills training to promote condom use are required and in the case of minority subpopulations must be tailored to reflect the cultures and languages of the individuals they seek to serve, as well as the socioeconomic and day-to-day realities of their lives. 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 ef- fective 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. Ac- cumulating the necessary data will require a Tong-term commitment to behavioral research targeted specifically toward these subgroups. Pre- vious attempts to gather high-quality data leave little doubt about the difficulty of conducting such research, and about limited information to illuminate current efforts. Careful ethnographic studies of the various mi- nority subpopulations and the social context of risk, in conjunction with demonstration projects, may offer an appropriate starting point for build- ing the knowledge base required to design effective interventions. Thus, the committee recommends 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 His- panic subpopulations, including men who have sex with men, drug users and their sexual partners, and youth. The committee further recommends that the PHS develop plans for appropriate interven- tions targeted toward these groups and support the implementation of intervention strategies (together with appropriate evaluation com- onents) in both demonstration projects and larger scale efforts. The committee anticipates that behavioral efforts to contain the epi- demic will not decrease over the course of the next 10 years. Indeed, as the only available means of disease containment, interventions to facili- tate change in risky behaviors must assume the lion's share of the burden to prevent further HIV infection. Therefore, the committee 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

108 ~ AIDS: THE SECOND DECADE anti evaluate mechanisms for facilitating and sustaining change in those behaviors; · that intervention programs incorporate planned varia- tions 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 anti 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 anti evaluation research regularly summarize the data derived from these studies to deter- mine which, if any, programs can be recommended for wider dissemination. These recommendations apply to the range of at-nsk populations described earlier in this chapter. For most of the subgroups who are now faced with the threat of AIDS, the existing knowledge base is deplorably limited. Specifically, in the case of women, there is a tremendous need for more and better information regarding the behaviors that transmit the virus as well as the determinants of those behaviors. The gender- specific differences in the distribution of these behaviors and the social and psychological factors that contribute to the initiation and continuance of bow nsk-taking and health-seeking behavioral patterns among women warrant significant attention in the coming decade. 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. In addition, several new factors related to AIDS may make relapse pre- vention even more important today than in the early years of the epidemic. The treatment of early-stage infection with AZT (as well as with other antiviral agents that are now being developed or that may be developed in the future) may lengthen the asymptomatic penod of the disease. It is not yet known whether individuals who are so treated remain infectious; it is also unclear how a more extended asymptomatic period will affect the initiation and maintenance of nsk-reducing practices. Given the rel- atively high background rates of infection In some communities and the

PREVENTION I 109 rise in infectivity that is suspected to occur in individuals who have been infected for some time, only the long-term and consistent practice of risk reduction by those who are infected will contain the further spread of HIV infection in these communities. If this premise is accepted, the need for long-term modification of behavior becomes even more crucial. Such an emphasis on the long term, however, may require certain reorientations in already-established AIDS prevention programs. The example of gay men offers a case in point. 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,. 19891. A plausible explanation for at least some new cases of infection is relapse or the inability to maintain safer sexual practices that had been initiated previously. Thus, prevention campaigns for gay men must now include additional efforts to prevent relapse from established risk reduction behaviors. After almost a decade of monitoring behavioral changes among gay men, there is some information about patterns of relapse in this population. Among participants in the San Francisco Men's Health Study, the frequency of risky sexual behaviors following the period of initial behavioral change in 1983 has dropped over the course of the study, and recent data from this sample indicate that behavioral change is remarkably stable (Ekstrand and Coates, in press). Nevertheless, a small proportion of men participating in this study continue to report high-nsk behavior. Each year between 1984 and 1988, roughly 3.5 percent of the sample reported engaging in unprotected anal intercourse. Moreover, 8.5 percent of subjects reported at least one episode of relapse following initial behavioral change. Other research from San Francisco presents a similar but no less cautionary picture (Stall, et al., 1990~; although only a small minority of men consistently reported unprotected anal intercourse, many more report initiating low-risk behavior only to relapse to high-risk behavior. Factors that predict relapse among gay men include a preference for unprotected anal intercourse and social support for high-risk behavior; reasons for relapse given (retrospectively) by gay men included being in love, knowing the sexual partner was seronegative, receiving a re- quest from the sexual partner for unprotected sex, using alcohol and drugs, and not having condoms available (Stall et al., 19901. Saltzman

110 ~ AIDS: THE SECOND DECADE and colleagues (1989) reported that relapsers tended to have higher lev- els of unsafe sexual behavior at baseline and reported perceptions that behavioral change would not offer protection from infection. Maintaining safer sex behavior over time is particularly problematic if people do not enjoy the physical result produced by the safer methods or find the psychological costs associated with change to be too great (Catania et al., 1989; Joseph et al., 1989~. The importance of the link between safer sex and pleasure is underscored by data indicating that the frequency of condom use is more strongly predicted by its perceived enjoyment ratings than by its health ratings (Catania et al., 1989~. Some researchers have proposed that the perception that safer sexual activities are less enjoyable than unsafe practices has hindered the adoption of such activities (Catania, Kegeles, and Coates, in press).50 Maintaining risk-reducing behavior also presents problems for IV drug users. In one study of 401 street-recruited TV drug users in New York City, almost 80 percent of the respondents reported that they had changed their drug use or sexual behavior, or both, since learning about AIDS. Yet more than one-third of those who had changed their behavior also reported that they had not been able to maintain those changes fully (Des Jarlais et al., l989b). Given the biases expected from self-reported data (see Chapter 6), this figure must be considered a low estimate of the percentage of drug injectors who will have difficulty maintaining risk reduction over time. A recent study of IV drug users in San Francisco reported some intriguing findings that also indicate some of the potential problems in maintaining AIDS risk reduction over long time periods. Sorenson and colleagues (1988) randomly assigned {V drug users to a six-hour "psycho- educational" experimental condition or an "information-only" control condition. Individuals who received the "psycho-educational" program scored significantly higher than those in the control group on a test of AIDS knowledge immediately following the intervention, but differences between the two groups had faded by the six-month follow-up interview. What is intriguing about the study are other program effects that were identified. Individuals who participated in the expenmental group showed increases in measures of self-efficacy, indicating a complex relationship among knowledge, attitudes, and beliefs that is not fully understood but that may have implications for AIDS relapse prevention. 50Another problem is the strong preference of some individuals for behaviors that are risky, a prefer- ence predictive of continued risk taking and relapse. 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).

PREVENTION ~ ~ ~ ~ Most research and intervention activities conducted during the first decade of the epidemic have been directed toward facilitating change in risky sexual and drug use behaviors. There is some indication that these activities have, at least in part, achieved their goal because significant change has been reported among subsets of gay adult males and IV drug users. Yet segments of every at-risk group continue to practice unsafe behaviors. In some instances, the reason for such continuance may be that certain subgroups (e.g., young gay males, female sexual partners of drug users, minority men and women) may not have been aware of their risk for HIV infection and thus may not have adopted the appropriate protective behaviors. In other instances, individuals may not have been able to sustain changes they had initiated, thus relapsing into previous patterns of risk. Because the threat of AIDS does not appear to be declining and because the only available strategies to prevent this disease involve changing behaviors perhaps for a lifetime the committee finds the problem of relapse prevention to be a serious concern. Therefore, the committee recommends that the Alcohol, Drug Abuse, and Mental Health Administration focus research efforts on AIDS-related relapse prevention, including the determinants of such relapse and the role that alcohol and other drugs play in the return to unsafe sexual and injection practices. 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~. The poor rates of condom use reported among hemophilic and other couples have prompted some investigators to call for"comprehensive education and counseling" programs (Smiley et al., 1988~. Yet it appears from data reported by such couples (Jackson et al., 1989; Sotheran et al., 1989), as well as data reported by individuals from other subpopulations, that it is not yet known how best to reach the diverse female population or how to provide effective education and counseling that promote the consistent use of condoms. As contraceptive options have become fewer,5i many women find it increasingly difficult to identify a method of contraception they consider appropriate and effective. Now. women are being asked in addition to 5rA recent report of the National Academy of Sciences, Developing New Contraceptives: Obstacles and Opportunities (Mastroianni, Donaldson, and Kane, 1990), considers the organizational, policy, and research constraints on the development of new contraceptives.

112 ~ AIDS: THE SECOND DECADE look beyond fertility control to disease prevention. Condoms plus the use of a spermicide, which currently appear to be the most effective means for accomplishing both functions, pose considerable problems for women. Not only does condom use require the cooperation of the male partner, but it may also require substantial changes in the attitudes and behaviors of women. A survey of 759 women attending birth control clinics found that attitudes about condoms were the best predictor of their use (Valdisern et al., l989b). Positive attitudes, however, must be converted into effective and appropriate action, which VaIdiserri and coworkers have suggested is also predicated on a perceived need for protection or a sense of vulnerability. Therefore, additional measures are required for example, informative messages52 that build positive attitudes toward condoms while providing accurate information on their use or training in the skills needed to ensure proper usage. To circumvent cultural barriers to the adoption of condoms, intervention programs that stress condom use should also incorporate different ethnic and racial perspectives. 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. Intervention efforts that rely on women to introduce condoms into a sexual union ask that women assume new roles in what is already an emotionally charged area, roles that in some cultures or among some groups may be construed as controlling men's sexuality. "Indeed, what is being asked of women could be dangerous to them since it raises the possibility of domestic, if not cultural, conflict .... No one knows in any systematic way what women face when they introduce condoms into a sexual scene or talk about changing sexual practices" (Schneider, 1988:991. Women who must take upon themselves the burden of both contraception and disease prevention need more options that are within them control arid that do not depend for their effectiveness on the co- operation or consent of others.53 The committee recommends that the Public Health Service support research to develop protective mea- sures other than condoms for preventing HIV transmission cluring sexual contact specifically, methods that can be used unilaterally by 52More than one~uarter (26 percent) of the sample in this study conducted by Valdiserri and colleagues (1989b) considered Vaseline the best lubricant for condoms. A petroleum-based substance, Vaseline is, in fact, a very poor choice because it can compromise the integrity of latex condoms and cause them to rupture. 53See, for example, Sakondhavat (1990) and Stein (1990).

PREVENTION ~ 113 women and methods that will be acceptable to both men and women who do not currently use condoms. In fact, the inconsistent use of condoms is a common theme that cuts across all risk groups in the epidemic.s4 Gay men, IV drug users, and female sexual partners of infected or at-risk individuals have all reported inconsistent condom use despite clear evidence of perceived risk.55 Many discordant couples, for reasons that remain unclear, choose not to use condoms consistently to protect the uninfected partner. For some women, there remain important questions concerning the impact of domestic vio- lence on the initiation and regular use of condoms (Schneider, 1988~. In its first report, the committee urged widespread availability and promotion of the use of condoms (with spe~Tnicides) as the main means to reduce the risk of sexually transmitted HTV infection. The committee supported the presentation of condom advertisements in print and broadcast media and argued for wider distribution of condoms through a variety of retail outlets. Increasing the role of condoms in AIDS prevention, however, also requires a clearer understanding of the contexts in which they are used. Sexual conduct is influenced by a variety of factors, including opportunity, customs, and cultural norms and values. Last year the com- mittee recommended that funding be provided for longitudinal studies of sexual behavior and that high priority be given to studies of the social and societal contexts of sexual behaviors. Information on the dynamics of sexual interaction in dating and other social situations may enhance our understanding of the impediments to condom use and the potential opportunities for increasing this form of protection. 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), Denmark (Schmidt et al., 1989), and France (Moatti et al., 1989). On the other hand, national prospective surveys in Switzerland have found dramatic increases in the proportion of participants reporting consistent condom use—from 8 percent in February 1987 to 29 percent in October 1988 (Zeugin et al., 1989). 550ne reason for inconsistent condom use may be the enjoyment problems condoms pose for some people. It is not uncommon to hear men complain that condoms decrease penile sensitivity. It should be pointed out, however, that other men may derive benefits from condom use (e.g., delayed orgasm for men who typically achieve orgasm sooner than they want). It is not impossible that solutions to sensory problems could be found (for instance, better condom materials might be developed); however, at present, considerable work is needed to enhance both the acceptability of condom use as well as their physical characteristics.

114 ~ AIDS: THE SECOND DECADE transmission. Consequently, the committee recommends that the Pub- lic Health Service funs! research on condoms to achieve the following objectives: . understand the determinants of condom use for the di- verse populations at risk for sexually transmitted HIV infection; improve condom design and materials to make them more acceptable to users; and develop interventions to promote their consistent use. IMPEDIMENTS TO IMPROVED INTERVENTION In this chapter, and in the two chapters that follow, the committee de- scribes an array of intervention efforts that have been implemented to prevent further spread of HIV infection. Unfortunately, it is not possi- ble at this time to say which strategies will work best for the venous subpopulations at risk for HIV infection. Without well-designed, well- implemented, and well-evaluated programs, there is no rational basis for assessing the effectiveness of intervention efforts or for directing finite resources. In its first report, the committee found that the absence of rigorous evaluations of the major interventions undertaken at that time and the absence of empirical studies that compared the efficacy of AIDS prevention strategies made it virtually impossible to identify proven tech- niques for facilitating the behavioral change needed to retard the spread of HIV. Thus, the committee relied on a more basic analysis of intervention strategies, using principles of human behavior established through em- pincal 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. The evolving nature of the epidemic means 56See Chapter4 of Turner, Miller, and Moses (1989). 57See Mechanic and Alken (1989) for a review of lessons to apply to AIDS from the provision of care for the mentally ill, the elderly' and people with cancer.

PREVENTION ~ 1 15 that different intervention strategies provided in different contexts must be utilized to reach ever-changing at-risk populations. Understanding the best way to reach different subpopulations and to provide the most effective strategies will also require carefully designed and executed comparative studies and careful evaluation. Moreover, as the epidemic grows, there will be more groups, more programs, and more services competing for available resources. There- fore, comparative studies will need to take into account the cost-effect- iveness of the most promising intervention strategies. As Russell (1986) notes, making good choices requires a sound understanding of both the positive and negative aspects of prevention programs, and, as resources become more scarce, making good choices becomes more important. Sound evaluation data can ensure that prevention efforts receive a rea- sonable 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 effec- tive interventions to those at highest risk. The history of AIDS-related discrimination provides a promising example of social evolution com- patible with public health goals. For example, when HIV antibody tests first became available, many individuals eschewed this service, fearing loss of job, insurance, housing, and even family if they were found to be infected. Now, however, antidiscrimination legislation has been put into place, thus providing a social structure to deal with this problem. Nevertheless, other impediments remain that continue to block the pro- vision of additional intervention activities. In this final section of the chapter, the committee reviews the current status of antidiscrimination legislation to protect infected individuals and those with AIDS. It also considers the effect of restrictive social attitudes and public policies in impeding the implementation of innovative intervention programs (e.g., sexually explicit information and needle exchange programs) for those at highest risk and the collection of data on sensitive behaviors related to HIV transmission. AIDS-Related Discrimination Discrimination refers to the disadvantageous treatment, either overt or insidious, of individuals or groups that results in unequal treatment or the denial of opportunities afforded to others. Discrimination as a legal concept in the United States originated in the development of a body of law designed to protect the rights of blacks (Parmet, 1987~. In addi- tion to promoting equality, however, antidiscrimination laws and policies

Il6 ~ AIDS: THE SECOND DECADE have instrumental value as a bulwark in the fight against the spread of HIV, an advantage recognized by a number of governmental and policy groups (World Health Organization, 1988; U.S. Conference of Mayors, 1989~. Indeed, according to the Presidential Commission on the Human Immunodeficiency Virus Epidemic, discrimination has been one of the most significant barriers to reaching high-nsk groups and implement- ing effective interventions. According to the Presidential Commission (1988:119), "HIV-related discrimination is impairing this nation's ability to limit the spread of the epidemic .... As long as discrimination occurs, and no strong national policy with rapid and effective remedies against discrimination is established, individuals who are infected with HIV will be reluctant to come forward for testing, counseling, and care." The stigma associated with AIDS has prompted a wide spectrum of untoward reactions that are important to understand, monitor, and, ulti- mately, to counter.58 During the first decade of this epidemic, effective interventions and high-quality research were compromised by difficulties in identifying and reaching those most in need. Indeed, it is not known to what extent public health strategies designed to prevent further spread of infection have been impeded by fears of disclosure and stigma for example, strategies such as voluntary contact notification procedures to inform individuals who have had intimate contact with an HIV-infected person. Voluntary, confidential contact tracing is a prevention strategy that has provoked considerable debate and warrants further systematic study. Furthermore, the opportunities afforded by new modalities of care have conferred a new urgency on the need to reach and thus protect HIV- infected individuals from discrimination. The information now available on the potential benefits of prophylactic treatment of HIV-infected per- sons makes early diagnosis in asymptomatic individuals critical in at- tempts to forestall the progression of disease. Other critically important initiatives to halt the spread of the epidemic, such as surveillance to monitor the spread of HIV, are also affected by discriminatory policies (Fordyce, Sambula, and Stoneburner, 1989; Kegeles et al., 1989~. The committee thus finds that a review of the legal factors involved may shed some light on intervention issues. 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). Questions of stigma and discrimination will be taken up in greater depth by the comrniteee's Panel on Monitoring the Social Impact of the AIDS Epidemic, which is preparing a report for release in 1991.

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 re- garding the forms such protection should take and whether responsibility should be lodged at the federal, state, or local level. One reason for the debate is that discrimination laws are not without costs. As Blendon and Donelan (1988) have observed, new antidiscr~mination laws may result in more litigation and may call for increased staff efforts at monitor- ing and enforcement. Federal legislation may draw the government into complex litigation and negotiations with employers, landlords, state and local agencies, about the line between reasonable accommodation and justifiable discrimination. Laws relating to AIDS, such as statutes enacted and cases reported (especially appellate cases that can set precedent), are only the most visible evidence of how U.S. society is dealing with HIV-related dis- crimination. Even this activity is considerable, as more than 170 state statutes specific to AIDS have been passed since the beginning of the epidemic (Gostin, 1989~. Already, litigation surrounding AIDS has re- sulted in more cases than for any other single disease in the history of American jurisprudence (Gostin, 1990~. Federal Protections Some protection from AIDS-related discrimination is afforded by the federal Rehabilitation Act of 1973, Public Law 93-112, Section 504. The act states that "no otherwise handicapped qualified individual . . . shall, solely by reason of his handicap, be excluded from the participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance." In a 1987 case, School Board of Nassau County v. Arline,s9 the U.S. Supreme Court held that the definition of a handicapped individual under Section 504 included a person with a contagious disease (in that case, tuberculosis). The court also delineated guidelines for defining whether an individual with a contagious disease would be "otherwise qualified," in terms of the accommodations that would have to be made to prevent risk to co-workers. A recent amendment to the Rehabilitation Act provides further clar- ification of this phrase by stating that a person with a contagious disease or infection is otherwise qualified if he or she does not "constitute a direct threat to the health or safety" of others and is able to perform the 59School Board of Nassau County v. Arline, 107 S.Ct. 1123 (1987).

II8 ~ AIDS: THE SECOND DECADE duties of the job. In addition, the Justice Department, reversing an earlier pronouncement, has advised that Section 504 encompasses discrimina- tion against infected individuals and prohibits discrimination based on unjustified fears of contagion. In recent years federal courts have used Section 504 to prohibit discrimination by employers or schools against individuals infected with HIV (e.g., Chalk v. Orange County Department of Education; Doe v. Centinela Hospital; Ray v. School District of DeSoto County). As the above quotation from the Rehabilitation Act of 1973 implies, its major failing is its limited reach; it applies only to programs receiving federal financial assistance. 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.) Notwithstanding this legislation, concerns about the limitations of extant federal antidiscrimination provisions and the patchwork of state and local laws (see below) prompted the drafting of a new federal bill known as the Americans with Disabilities Act,60 which passed the U.S. Senate on September 7, 1989, by a vote of 76-S (Congressional Record, l989a).6i Disability in the pending legislation is broadly defined as "a physical or mental impairment that substantially limits one or more of the major life activities of such individual" (Congressional Record, 1989b, S10954~. The definition thus includes both persons with AIDS and those infected with HIV. The legislation would prohibit labor organizations, employment agencies, and employers in both the private and public sectors from discriminating against qualified individuals with disabilities. The bill's sponsors estimate that as many as 43 million Americans with venous disabilities may be protected by its provisions. State and Local Protections In addition to federal protections, all 50 states and the District of Columbia have statutes that parallel the federal Rehabilitation Act pro- hibiting discrimination against handicapped persons.62 In all but five jurisdictions, protection from discrimination applies to some D~vate n~ r^^ ~. 60B. Lambert, "Federal policy against discrimination is sought for AIDS victims," New York Times September 22, 1988, A35. 6iAction on this bill is pending in the U.S. House of Representatives. For Senate debate on this issue, see the Congressional Record 135(112):S10701-S10723, S10734-S10763, September7, 1989. 62 Unfortunately, as Lambert's New York Times article notes, relatively less protection from discrim- ination is provided in states with lower prevalences of infection, ironically, in situations in which protection may be most needed. Furthermore, although the trend has been for state governments to

PREVENTION | 119 well as public employees. More than half of the states have extended previously enacted laws to cover persons with HIV infection; often, there are a variety of sources of legal protection in any one state. To but- tress statutory protections and avoid the delays inherent in enacting new laws, a number of states have used attorneys' general opinions and the statements of human rights commissions as vehicles for extending pro- tection to HIV-infected individuals. In addition, many states and some municipalities have enacted AIDS-specific antidiscnmination statutes or ordinances. 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. Protection from discrimination for simply taking an HIV test is increasingly important as more widespread testing is encouraged (Rhame and Maki, 1989), as more insurers screen potential policyholders, and as patients are tested with or without their knowledge. A major shift is now emerging in the nature of AIDS lawsuits that have been brought under the statutes described above. As Gostin, Porter, and Sandom~re (in press:45~6) observe: The early cases, still winding their way through the courts, often involve discriminatory practices by employers based upon prejudice or fears of transmission in the workplace. As CDC and OSHA guidelines continue to make clear that these fears are groundless, employers appear much less likely to exclude employees from ordinary workplaces. The new wave of cases involves workplace settings where there is likely to be some exposure to blood such as health care settings, laboratories, and forensic examiners. (pp. 45~6) Access for HTV-infected persons to public accommodations is also of concern, and lawsuits have been filed against establishments ranging from a manicure salon to a spiritual retreat for refusing to serve HIV-infected customers or clients. The question of such access takes on special urgency when the "accommodations" are health care institutions. The general antidiscnmination laws of most states cover public accommodations, but only a few explicitly, or even arguably, define public accommodations to include health care services. At least five states have enacted specific measures to prevent AIDS-related discrimination by health care providers. expand protections against AIDS-related discrimination, there have been moves in the opposite direc- tion. Tennessee, for example, amended its disability statutes because of AIDS to exclude contagious diseases; its human ri ,hts agency no longer investigates cases of AIDS-related discrimination.

120 ~ AIDS: THE SECOND DECADE These states prohibit refusal of admission to facilities based on HIV status or the use of HIV testing as a condition for receiving unrelated care. Enforcement of antidiscrimination provisions may vary tremendously among the states. Some larger states with significant caseloads, like New York and California, have been more aggressive than smaller, less affected states, imposing penalties, compensation, and punitive damages and providing provisions for civil suits and recovery of legal costs. In other states the remedies are more limited and procedures more protracted. Because all states prohibit at least certain manifestations of HTV- related discnmination, enforcement of statute provisions and the avail- ability of timely, equitable, and understandable procedures for pressing discrimination claims are cntical. Persons with AIDS may not have the wherewithal to sustain lengthy processes. In most states the process be- gins with a civil or human rights commission, and lawsuits can be filed only after administrative relief has been sought. In at least 20 states, an agency or attorney general may file a complaint on behalf of an indi- vidual alleging discrimination a critical procedure for people who wish to remain anonymous because of concerns about further discrimination from wider breaches in confidentiality. 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. It is impossible to tell how much the increase represents a growth in discriminatory incidents versus a greater awareness of their rights on behalf of victims, more vigorous enforcement, or some combination of these two factors. It is clear that many lawyers have been enlisted in the fight against AIDS discrimination, often on a pro bono basis. Increasingly, "AIDS law" is a legal speciality, with some lawyers in cities with large numbers of cases of AIDS engaged in full-time AIDS law practices. A number of law schools now operate AIDS law clinics, and the first major casebook on AIDS and the law has been published. The American Bar Association is undertaking a study to gauge the extent of the legal resources now being used in this area. . ~ . Another possible benchmark of AIDS-related discnmination is vio- lence against gay men and lesbians. Several studies have documented increases in reports of antigay violence. Herek (1989) reviews a num- ber of such unpublished reports by social and behavioral scientists. A

PREVENTION | 121 National Institute of Justice report notes that "homosexuals are probably the most frequent victims" of hate violence (Finn and McNeil, 1987~. Hate crimes, or bias crimes, are defined as threats of violence, intimi- dation, property crimes, or crimes of violence motivated by prejudice. Only recently have these crimes received the systematic attention of social scientists and policy makers. Several reports have attempted to document the extent of such crimes, and special units have been created within police forces to confront the problem. Legislative support for data collection efforts related to hate crimes is being sought at the state and federal level. These violent acts indicate a continued potential in U.S. society for stigmatizing actions and AIDS-related discrimination, despite the pro- tective measures that are currently in place. The committee is gratified to see that the antidiscrimination measures urged in its first report and recommended by the Presidential AIDS Commission are being instituted. It would point out, however, that this legislation alone is unlikely to ame- liorate all of the conditions associated with discrimination in this country. For example, such legislation protects the rights of HIV-infected children for education but does not necessarily prevent hostile encounters with the community. Other issues addressed in the committee's first report, how- ever, remain problematic, and their lack of resolution continues to impede efforts to contain the epidemic. These issues, which are discussed below, include the use of explicit sexual material in intervention programs, the implementation and evaluation of sterile needle programs, and the effects of public policies that restrict the acquisition of knowledge necessary to develop effective interventions. Social Attitudes and Public Policy: Obstacles to Continued Progress Throughout this chapter, the committee has noted that effective interven- tion 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. Drug re- searchers know, for example, that research that goes beyond the clinic or the jail to contact subjects in the settings in which the behaviors occur captures a crucial segment of the at-risk population. Although such efforts afford the important opportunity to observe subjects in their natural settings and to reach individuals who are not in drug treatment programs or other institutional settings, these efforts are more vulnerable

122 ~ AIDS: THE SECOND DECADE to community pressure than are cTinic-based programs. The committee notes, for example, that studies of syringe exchange pro grams in Great Britain were made more difficult than they might have been through picketing by members of the community (Stimson, 19881. In New York City, political opposition caused the syringe exchange pilot program to be operated from public health offices, a location distant (physically and psychologically) from major addict populations and drug use sites. Now, after a change in political administrations in New York City, the new mayor has announced the cancellation of the needle exchange program in that city.63 State and federal legislative action has afforded some protection to the populations these programs seek to reach. Nevertheless, constraints imposed by political opposition have limited the programs' ability to intervene and to collect much-needed surveillance data on risk behaviors. In the final section of this chapter, the committee reviews the public response to innovative and controversial intervention efforts. Sexually Explicit Information One of the significant controversies in intervention programs to prevent sexually transmitted HIV infection has surrounded the level of sexual explicitness of information and the degree to which interventions empha- size the erotic. 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. In Bullough's terms (1980), these individuals are highly "sex positive." To make safer sex messages appealing to such individuals, presentations of Hose mes- sages must capture and hold their attention. In addition, the messages may 63 See Todd S. Purdum, `'Dinkins tO End Needle Plan for Drug Users," New York Times, Feb. 14, 1990, B1, B4. 64Federally funded AIDS education efforts have historically had problems dealing with advice about the protective value of condoms, as well as the presentation of sexually explicit educational materi- als. For example, M. Gladwell reports in The Washington Post ("Publication of AIDS Pamphlet on Condoms Approved: FDA Sought Health and Human Services' Approval of Brochure in May 1988," April 5, 1990, A16) that a lack of consensus among federal officials on the effectiveness of condoms halted the production on an AIDS education pamphlet aimed at groups at highest risk for almost two years. (See also Chapter 6 in Turner, Miller, and Moses [1989].)

PREVENTION ~ ~ 23 need to make cognitive-affective associations between pleasurable sex and safer sex. Programs using sex-positive messages have been shown to increase favorable attitudes toward condom use among individuals attending an STD clinic and heterosexual couples (Tanner and Pollack, 1988; Solomon and DeJong, 1989) and have facilitated the initiation of safer sex activities among gay and bisexual men (D'Eramo et al., 19881. Early in the epidemic the Gay Men's Health Crisis in New York City developed workshops to promote the acceptance of safer sex by eroticizing these practices (Valdiserri, 1989~. The workshops also used conventional psychotherapeutic techniques to teach men how to negotiate safer sexual encounters. Extensions of this approach that were designed to reach a much larger audience relied on erotic films and comic books. The comic books in particular created intense controversy because some federal legislators perceived them as promoting homosexuality (Valdis- erri, 1989:152~. Despite such controversy, however, this approach shows promise in changing risk-associated behavior. Recently, D'Eramo and colleagues (1988) evaluated the efficacy of various sexually explicit materials by comparing four planned variations of an AIDS prevention education program that had been implemented in New York for 619 gay men. The variations included the following: (1) lectures and discussions about AIDS, how it is transmitted, and safer sex guidelines; (2) a program of eroticizing safer sex alternatives through verbal and print media; (3) the program described in (2) but with sexually explicit videos and slides; and (4) distribution of printed copies of safer sex guidelines (the comparison group). Investigators assessed the risk level of participant sexual behaviors before the application of the intervention and three months after the program ended. They concluded that the erotic program with audiovisuals (variation 3 above) was most effective in increasing the adoption of safer sex. 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 innova- tion.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. The use of a trusted communication system contributes to the perceived worthiness of the innovation and helps the adopter to overcome 65 For a detailed discussion of this theory, see Chapter 4, Turner, Miller, and Moses (1989)

124 ~ AIDS: THE SECOND DECADE motivational barners, thus accelerating the process of behavioral change (VaIdiserr~, 1989~. Sterile Needle Programs Previous reports on AIDS from the National Academy of Sciences (NAS) and the Institute of Medicine (IOM) recommended that the U.S. govern- ment sponsor research on needle and syringe exchange programs as a means for reducing the spread of HIV among drug injectors (IOM/NAS, 1988; Turner, Miller, and Moses, 19891. Yet syringe exchange programs remain controversial in the United States,66 currently operating on a very Ignited basis in only a few cities. Programs approved by local juris- dictions have been established in New York City; Tacoma and Seattle, Washington; and Portland, Oregon. The New York City program was cancelled in February 1990. Unofficial programs are operating publicly in San Francisco and Boston, and there may well be other such unofficial efforts. None of these programs receive federal support for either operational or research activities, and this policy has resulted in limited evaluation of the effectiveness of these efforts. The early findings on U.S. needle exchange programs, however, are quite similar to findings from Euro- pean and Australian studies (Buning et al., 1988; Hart et al., 198S, 1989; Ejungberg et al., 1988; van den Hoek et al., 1988; Des lariats et al., l989c; Hartgers et al., 1989; Stimson, 1989; van den Hock, van Haastrecht, and Coutinho, 19891. 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 character- istics 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. Despite these findings, many individuals making policy-level de- cisions on this matter express the general fear that explicit messages concerning sterile injection equipment will result in increased rates of IV drug use. As this committee previously noted (Turner, Miller, and Moses, 1989:Chapter 3), however, what evidence there is from various intervention programs suggests otherwise: having the information and the means to protect oneself from a deadly disease is likely to result in protective action against AIDS, as well as in generalized increases 66For an overview of this controversy, see Stryker ( 1989).

PREVENTION | 125 in healthy behaviors (e.:,., seekers drug treatment) amon:, people who are already engaging in risky activities.67 Furthermore, information aIld services do not appear to entice the uninitiated into nsk-associated ac- tions.68 Given the success of innovative interventions in other developed countries, the potential for spread of HIV to other subpopulations from individuals who inject drugs, and the seriousness of this disease, it makes sense to implement well-designed pilot studies of needle exchange pro- grams and to collect the data that would establish whether these strategies are effective in decreasing risky behaviors and the spread of AIDS. Con- tinued reliance on hunches and suspicions rather than on data regarding the impact of these programs gives too much credence to guesswork and may obstruct a promising path toward retarding the spread of HIV in the U.S. population. 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 aware- ness of AIDS and knowledge of the routes of transmission (Des Jarlais, Friedman, and Strug, 1986). However, more inflation was needed to identify and implement self-protective measures against HIV infection, and this information was provided through more formal and targeted programs. Ethno- graphic studies of the New York drug scene in 1985 found a substantial expansion in the illicit market for sterile injection equipment (Des Jarlais, Friedman, and Hopkins, 1985); the demand for new in- jection equipment was so great that counterfeit sterile needles and syringes were being sold. Later in 1985, outreach programs began to teach IV drug users about AIDS and sterilization techniques, such as boiling injection equipment in water or soaking it in bleach or alcohol (Jackson and Neshin, 1986; Jackson and Rotkiewicz, 1987). Not only did drug users report increased use of bleach and other sterilization techniques but when offered coupons for free drug treatment, drug users accepted in such numbers that more than 85 percent of the vouchers were redeemed. A similar outreach program to provide information about AIDS and bleach sterilization techniques was started in San Francisco. More than half of the subjects in one study (Chaisson et al., 1987) and two-thirds in another (Watters, 1987) reported adopting the use of bleach. Data from Amsterdam, where a needle exchange program was initiated prior to the AIDS epidemic, found that the number of subjects reporting daily injection decreased as the distribution rate for sterile injection equipment increased (van den Hoek et al., 1988). Other researchers (tuning et al., 1986, 1988; Stimson, 1988, 1989; Hartgers et al., 1989) have found higher rates of needle sharing and more frequent injection among users who were not participating in the needle exchange programs in Amsterdam and Great Britain than were found among program par- ticipants. The pilot study of the New York City needle exchange program, although limited in scope and longevity, was found to be an effective `'bridge to treatment" for IV drug users (New York City Department of Health, 1989). The data are far from perfect, but on balance they do provide some evidence indicating that individuals who participate in needle exchange programs are more amenable than individuals who do not participate in such programs to enrollment in drug treatment programs. 68For example, the Amsterdam syringe exchange program distributed 25~000 sterile needles and sy- ringes in 1984; in 1987, the number distributed increased greatly. In addition, during the period of expansion, there was no decrease in the number of persons entering methadone maintenance or drug- free treatment programs, and the number of heroin users held constant at approximately 7,000 to 8,000 (van den Hock, van Haastrecht, and Coutinho, 1989). During this time the average age of IV drug users increased, thus indicating little influx from younger age groups. More recent data find that individuals who receive sterile injection equipment from this program are no more likely to lend it to others than are individuals who do not participate in the program.

126 ~ AIDS: THE SECOND DECADE first report (Turner, Miller and Moses, 1989) that well-designed, staged trials of sterile needle programs, such as those requested in the 1986 TOM/NAS report Confronting AIDS, be implemented. Evaluation of these programs, if they were carefully implemented and monitored, could provide the evidence needed to resolve some of the questions regarding their impact. The committee notes, however, that the 101st Congress69 adopted legislation requiring that "Enjone of the funds appropriated under this Act shall be used to carry out any program of distributing sterile nee- dles for the hypodermic injection of any illegal drug unless the President of the United States certifies that such programs are effective in stopping the spread of HIV and do not encourage the use of illegal drugs." The committee observes that the evidence needed by the President to make such determinations about the effect of domestic needle exchange programs requires research that has also been held hostage to this con- troversy. The committee repeats its recommendation that this research be carried forward. The lack of current, valid, and reliable data, which provide the basis for sound public health policy decisions, appears to reflect a tendency to rely on intuition and hunches concerning sensitive issues rather than on empincally denved facts. Last year the committee recommended well-designed pilot tests of needle exchange programs accompanied by evaluation research to determine the effect of these efforts. It now appears unlikely that funds will be appropriated to evaluate the few pilot studies that have been executed over the past year. 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. The committee continues in its calls for these measures in the belief that, despite an apparent lack of appreciation for empirical approaches to understanding the behavioral underpinnings of the AIDS epidemic, certain recent examples of progress offer hope for the mutability of social structures. (For example, empirical evidence of AIDS-related discrimination has resulted in changes in laws to protect HIV-infected individuals and those with AIDS.) The committee thus finds that this country must redouble its efforts to identify and remove other impediments to change arid to affimn and support rational approaches to the resolution of controversial problems. 69Public Law 101-166 (H.R. 3566), Title V, Section 52O9 as finally approved by the House and Senate.

PREVENTION ~ 127 REFERENCES Abdul-Quader, A. S., Friedman, S. R., Des Jarlais, O., Marmor, M. M., Maslansky, R., and Bartelme, S. (1987) Methadone maintenance and behavior by intravenous drug users that can transmit HIV. Contemporary Drug Problems Fall:425~34. Abdul-Quader, A., Tross, S., Des Jarlais, D. C., Kouzi, A., and Friedman, S. R. (1989) Predictors of attempted sexual behavior change in a street sample of active male intravenous drug users in New York City. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Alan Guttmacher Institute. (1987) Blessed Events and the Bottom Line: Financing Maternity Care in the United States. New York: Alan Guttmacher Institute. Alldritt, L., Dolan, K., Donoghoe, M., and Stimson, G. V. (1988) HIV and the injecting drug user: Clients of syringe exchange schemes in England and Scotland. Presented at the Fourth International Conference on AIDS, Stockholm, June 12-16. Amaro, H. (1988) Considerations for prevention of HIV infection among Hispanic women. Psychology of Women Quarterly 12:429- 143. Aoki, B., Ngin, C. P., Mo, 13., and Ja, D. Y. (1989) AIDS prevention models in Asian-Amencan communities. In V. M. Mays, G. W. Albee, and S. F. Schneider, eds., Primary Prevention of AIDS: Psychological Approaches. Newbury Park, Calif.: Sage Publications. Arenson, C., and Finnegan, L. P. (1989) Prevention methodologies for women at risk for AIDS. Presented at the Fifth International Conference on AIDS, Montreal, June ~9. Arguelles, L., Rivero, A. M., Rehack' C. J., and Corby, N. H. (1989) Female sex partners of IV drug users: A study of socio-psychological characteristics and needs. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Barbacci, M., Chaisson, R., Anderson, J., and Horn, J. (1989) Knowledge of HIV serostatus and pregnancy decisions. Presented at the Fifth Intemational Conference on AIDS, Montreal, June =9. Baskin, J. (1983) Prenatal testing for Tay-Sachs disease in the light of Jewish views regarding abortion. Issues in Health Care of Women 4:41-56. Bayer, R. (In press) AIDS and the future of reproductive freedom. Milbank Quarterly (Special Supplement). Bayer, R., Lumey, L. H., and Wan, L. (In press) The American, British and Dutch responses to unlinked, anonymous, HIV seroprevalence studies: An international comparison of ethical, legal and political issues. AIDS. Becker, M. H., and Joseph, I. G. (1988) AIDS and behavioral change to reduce risk: A review. American Journal of Public Health 78:391 110. B,eeker, C., and Rose, T. (1989) The Stop AIDS model for community change: Acceptability in a low-incidence area for AIDS. Presented at the Fifth International Conference on AIDS, Montreal, June ~9. Beeker, C., and Zielinski, M. (1988) Drugs, alcohol and nsky sex among gay and bisexual men in a low-incidence area for AIDS. Presented at the Annual Meeting of the American Public Health Association, Boston, November 13-17. Bell, A. P., and Weinberg, M. S. (1978) Homosexualities: A Study of Diversity Among Men and Women. New York: Simon & Schuster.

128 AIDS: THE SECOND DECADE Berman, S. (1989) Prevention of perinatal transmission of HIV. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Beschner, G., and Thompson, P. (1981) Women and Drug Abuse Treatment: Needs and Services. Service Research Monograph Series. DHHS Publication No. (ADM) 81-1057. Rockville, Md.: National Institute on Drug Abuse. Biemacki, P., Mandel, J., and Aldrich, M. (1989) Gender differences in "maturing out" of intravenous drug use. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Blendon, R. J., and Donelan, K. (1988) Discrimination against people with AIDS: The public's perspective. New England Journal of Medicine 319:1022-1026. Blendon, R. J., and Donelan, K. (1989) AIDS, the public, and the "NIMBY" syndrome. In D. E. Rogers, and E. Ginzberg, eds., Public and Professional Aui~des Toward AIDS Patients: A National Dilemma. Boulder, Colo.: Westview Press. Blix, O., and Gronbladh, L. (1988) AIDS and IV heroin addicts: The preventive effects of methadone maintenance in Sweden. Presented at the Fourth International Conference on AIDS, Stockholm, June 12-16. Bradford, J., and Johnson, D. (1989) AIDS-related behavior change of gay men in Richmond, Va., 1985-1988. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Brown, L. S., Chu, A., Nemoto, T., and Primm, B. J. (1989) Demographic, behavioral, and clinical features of HIV infection in New York City intravenous drug users (IVDUs). Presented at the Fifth International Conference on AIDS, Montreal, June i9. Brundage, J. F., Burke, D. S., Gardner, L. I., Herbold, J., Voskovitch, J., and Redfield, R. R. (1987) Temporal trends of prevalence and incidence of HIV infection among civilian applicants for U.S. military service: Analysis of 18 months of serological screening. Presented at the Third International Conference on AIDS, Washington, D.C., June 1-5. Bullough, V. (1980) Sexual Variance in Society and History. Chicago, Ill.: The University of Chicago Press. Buning, E., Coutinho, R. A., and van Brussel, G. H. A. (1986) Preventing AIDS in drug addicts in Amsterdam. Lancet 1:1435-1436. Buning, E., Hartgers, C., Verster, A. D., van Santen, G. W., and Coutinho, R. A. (1988) The evaluation of the needle/syringe exchange in Amsterdam. Presented at the Fourth International Conference on AIDS, Stockholm, June 12-16. Burns, J. K., Azen, C. G., Rouse, B., and Vespa, H. (1984) Impact of PKU on the reproductive patterns in collaborative study families. American Journal of Medical Genetics 19:5 15-524. Calzavara, L., Coates, R., Read, S., Johnson, K., Farewell, V., et al. (1989) Sexual behaviour changes among male sexual contacts of men with HIV disease: A 3-year overview. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Carpenter, C. J., Mayer, K. H., Fisher, A., Desai, M. B., and Durand, L. (1989) Natural history of acquired immunodeficiency syndrome in women in Rhode Island. The American Journal of Medicine 86:771-775. Carter, C. O., Roberts, J. A. F., Evans, K. A., and Buck, A. R. (1971) Genetic clinic: A follow-up. Lancet 1 :281-285.

PREVENTION ~ 129 Catania, J., Kegeles, S., and Coates, T. (In press). Toward an understanding of risk behavior: An AIDS risk reduction model (ARRM). Health Education Quarterly. Catania, J. A., Coates, T. J., Kegeles, S. M., Ekstrand, M., Guydish, J. R., and Bye, L. L. (1989) Implications of the AIDS risk-reduction model for the gay community: The importance of perceived sexual enjoyment and help-seeking behaviors. In V. M. Mays, G. W. Albee' and S. F. Schneider' eds., Primary Prevention of AIDS: Psychological Approaches. Newbury Park, Calif.: Sage Publications. Celentano, D. D., McQueen, D. V., and Chee, E. (1980) Substance abuse by women: A review of the epidemiologic literature. Journal of Chronic Diseases 33:383-384. Celentano, D., Vlahov, D., Anthony, J. C., and Bestial, M. (1989) Is condom use an independent risk for HIV in IV drug users? Presented at the Fifth International Conference on AIDS, Montreal, June =9. Centers for Disease Control (CDC). (1985) Recommendations for assisting in the prevention of perinatal transmission of human T-lymphotropic virus type IIVlymph- adenopathy-associated virus and acquired immunodeficiency syndrome. Morbidity and Mortality Weekly Report 34:721-726, 731-732. Centers for Disease Control (CDC). (1987) Antibody to human immunodeficiency virus in female prostitutes. Morbidity and Mortality Weekly Report 36:157-161. Centers for Disease Control (CDC). (1988) Relationship of syphilis to drug use and prostitution~onnecticut and Philadelphia, Pennsylvania. Morbidity and Mortality Weekly Report 36:755-765. Centers for Disease Control (CDC). (1990) Publicly funded HIV counseling and testing United States, 1985-1989. Morbidity and Mortality Weekly Report 39: 137-140. Chavkin, W. (1990). Drug addiction and pregnancy: Policy crossroads. American Journal of Public Health 80:483~87. Chavkin, W., Driver, C. R., and Fonnan, P. (1989) The crisis in New York City's perinatal services. New York State Journc~l of Medicine 89:658~63. Chetwynd, J., Horn, J., and Kelleher, J. (1989) Safer sex amongst homosexual men: Meaning and motivation. Presented at the Fifth Intemational Conference on AIDS, Montreal, June =9. Chiasson, R. E., Osmond, D., Moss, A., Feldman, H., and Biemacki, P. (1987) HIV, bleach, and needle sharing (letter). Lancet 1:1430. Childs, B. (1979) Psychological consequences of genetic screening. In R. M. Goodman and A. G. Motulsky, eds., Genetic Diseases Among Ashkerzazi Jews. New York: Raven. Chimel, J., Detels, R., van Raden, M., Brookmeyer, R., Kingsley, L., and Kaslow, R. (1986) Prevention of LAV/HTL-III infection through modification of sexual practices. Presented at the Second International Conference on AIDS, Pans, June 25-26. Chitwood, D. D., McCoy, C. B., Comerford, M., and Trapido, E. J. (1989) Risk behaviors of IV cocaine users: Implications for intervention. Presented at the Fifth International Conference on AIDS, Montreal, June =9. City of New York Commission on Human Rights. (1988) Report on discnmination against people with AIDS and people perceived to have AIDS. Commission on Human Rights, New York.

130 ~ AIDS: THE SECOND DECADE Cleary, P. D., Barry, M. J., Mayer, K. H., Brarldt, A. M., Costin, L., and Fineberg, H.V. (1987) Compulsory premarital screening for the human immunodeficiency virus. Journal of the American Medical Association 258:1757-1762. Coates, T. J., and Greenblatt, R. M. (In press) Behavioral change using community- level interventions. In K. Holmes, ea., Sexually Transmitted Diseases. New York: McGraw-Hill. Coates, T. J., Stall, R. D., and Hoff, C. C. (1988) Changes in sexual behavior of homosexual and bisexual men since the beginning of the AIDS epidemic. Back- ground paper prepared for the Health Program, Office of Technology Assessment, Washington, D.C. Coates, T. J., Stall, R. D., Catania, J. A., and Kegeles, S. M. (1988a) Behavioral factors in the spread of HIV infection. AIDS 2(Supplement 11:S239-S246. Coates, T. J., Catania, J. A., Dolcini, M. M., and Hoff, C. C. (1988b) Changes in sexual behavior with the advent of the AIDS epidemic. Prepared for the Hudson Institute, Indianapolis, Ind. Coates, T. J., McKusick, L., Kuno, R., and Stiles, D. P. (1989a) Stress reduction training changed number of sexual partners but not immune function in men with HIV. American Journal of Public Health 79:885-887. Coates, T. J., Stall, R., Catania, J., Dolcini, P., and Hoff, C. (1989b) Prevention of HIV infection in high-risk groups. In P. Nlolderding and M. Jacobson, eds., 1988 AIDS Clinical Review. New York: Marcel-Dekker. Coates, T. J., Ekstrand, M. L., Kegeles, S. M., and Stall, R. D. (1989c) Knowledge of HIV antibody status, behavior change, and psychological distress in two cohorts of gay men in San Francisco. Unpublished paper. Center for AIDS Prevention Studies, University of California, San Francisco. Cohen, J. B. (1989) Condom promotion among prostitutes. In Condoms in the Prevention of Sexually Transmitted Diseases. Research Triangle Park, N.C.: American Social Health Association. Cohn, D., Koleis, J., Cooper, S., Cole, V., and Judson, F. (1989) Incidence of HIV infection in Pay and bisexual men attending a counseling and testing site or an AlL,5 prevention program. Presented at the forth lnternat~onal (conference on AIDS, Montreal, June =9. Communication Technologies. (1987) A Report on Designing an Effective AIDS Prevention Campaign Strategy for San Francisco: Results From the Fourth Probability Sample of an Urban Gay Male Community. San Francisco AIDS Foundation, San Francisco. Congressional Record. (1989a) Senate vote on Americans with Disabilities Act. Congressional Record 135(1131:S10765-S10803, September 8. Congressional Record. (1989b) Quote from text of proposed bill. Congressional Record 135(115~:S1095~10961, September 12. Connors, M. M., and Lewis, B. F. (1989) Anthropological and epidemiological obser- vations of changes in needle use and needle sharing practices following twelve months of bleach distribution. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Corby, N. H., Rhodes, F., and Wolitski, R. J. (1989) HIV serostatus and risk behaviors of street IVDUs. Presented at the Fifth International Conference on AIDS, Montreal June =9.

PREVENTION ~ 131 Coyle, S. C., Boruch, R. B., and Turner, C. F., eds. (1990) Evaluating AIDS Prevention Programs, Expanded Edition. Washington, D.C.: National Academy Press. Cuskey, W. R., merger, L. H., and Densen-Gerber, J. (1977) Issues in the treatment of female addiction: A review and critique of the literature. Contemporary Drug Problems 6:307-371. Dalton, H. L. (1989) AIDS in blackface. Daedalus 118:205-228. Darrow, W. W., Jaffe, H. W., and Curran, J. W. (1988) Behaviors associated with HIV-1 infection and the development of AIDS. In R. Kulstad, ea., AIDS 1988. Washington, D.C.: American Association for the Advancement of Science. Dattel, B. J., Hauer, L. B., Crombleholme, W., Landers, D. V., Edison, R., et al. (1989) HIV-1 seroprevalence and risk behavior are increased in pregnant women receiving no prenatal care. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Dawson, D. A. (1989) AIDS knowledge and attitudes for January—March 1989: Provisional data from the National Health Interview Survey. In Advance Data from Vital and Health Statistics of the National Center for Health Statistics, No. 176. DHHS Publ. No. (PHS) 89-1250. Hyattsville, Md.: National Center for Health Statistics. Dawson, D. A., and Hardy, A. M. (1989a) AIDS knowledge and attitudes of black Americans: Provisional data from the 1988 National Health Interview Survey. NCHS Advance Data 165:1-22. Dawson, D. A., and Hardy, A. M. (1989b) AIDS knowledge and attitudes of Hispanic Americans: Provisional data from the 1988 National Health Interview Survey. NCHS Advance Data 166:1-22. D'Eramo, J. E., Quadland, M. C., Shatts, W., Schuman, R., and Jacobs, R. (1988) The "800 men" project: A systematic evaluation of AIDS prevention programs demonstrating the efficacy of erotic, sexually explicit safer sex education on gay and bisexual men at risk for AIDS. Presented at the Fourth International Conference on AIDS, Stockholm, June 12-16. De Vroome, E. M. M., Sandfort, T. G. M., Paalman, M., and Tielman, R. A. P. (1989) AIDS and condom use in the Netherlands. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Des Jarlais, D. C., and Friedman, S. R. (1987) HIV infection among intravenous drug users: Epidemiology and risk reduction (editorial review). AIDS 1:67-76. Des Jarlais, D. C., Friedman, S. R., and Hopkins, W. (1985) Risk reduction for the acquired immunodeficiency syndrome among intravenous drug users. Annals of Internal Medicine 313:755-759. Des Jarlais, D. C., Friedman, S. R., and Strug, D. (1986) AIDS and needle sharing within the IV-drug use subculture. In D. A. Feldman and T. M. Johnson, eds., The Social Dimensions of AIDS: Method and Theory. New York: Praeger. Des Jarlais, D. C., Friedman, S. R., and Stonebumer, R. L. (1988) HIV infection and intravenous drug use: Cntical issues in transmission dynamics, infection outcomes, and prevention. Reviews of Infectious Disease 10:151-15 8. Des Jarlais, D. C., Friedman, S. R., Novick' D. M., Sotheran, J. L., Thomas, P., et al. (1989a) HIV-1 infection among intravenous drug users in Manhattan, New York City, from 1977 through 1987. Journal of the American Medical Association 261:1008-1012.

132 ~ AIDS: THE SECOND DECADE Des Jarlais, D. C., Tross, S., Abdul-Quader, A., Kouzi, A., and Friedman, S. R. (1989b) Intravenous drug users and maintenance of behavior change. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Des Jarlais, D. C., Hagan, H., Purchase, D., Reid, T., and Friedman, S. R. (1989c) Safer injection among participants in the first North American syringe exchange program. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Detels' R., English, P., Visscher, B. R., Jacobsen, L., Kingsley, L. A., et al. (1989) Seroconversion, sexual activity, and condom use among 2,915 seronegative men followed for up to two years. Journal of Acquired Immune Deficiency Syndromes 2:77-83. Distnct of Columbia Advisory Committee to the U.S. Commission on Civil Rights. (1989) Handicap protection for AIDS victims in Washington, D.C. Washington, D.C. Ekstrand, M., and Coates, T. J. (1988) Prevalence and change in AIDS high risk behavior among gay and bisexual men. Presented at the Fourth International Conference on AIDS, Stockholm, June 12-16. Ekstrand, M. L., and Coates, T. J. (In press) Gay men in San Francisco are maintaining low-risk behaviors but young men continue to be at risk. American Journal of Public Health. Ellerbrock, T., Chamberland, M. E., Bush, T. J., and Rogers, M. F. (1989) National surveillance of AIDS in women, 1981-1988: A report from the Centers for Disease Control. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Emery, A. E. H., Watt, M. S., and Clack, E. R. (1972) The effects of genetic counselling in Duchenne muscular dystrophy. Clinical Genetics 3:147-150. Eric, K., Drucker, E., Worth, D, Chabon, B., Pivnick, A., and Cochrane, K. (1989) The Women's Center: A model peer support program for high risk IV drug and crack using women in the Bronx. Presented at the Fifth International Conference on AIDS, Montreal, June 4-9. Eskenazi, B., Pies, C., Newstetter, A., Shepard, C., and Pearson, K. (1989) HIV serology in artificially inseminated lesbians. AIDS 2:187-193. Evers-Kiebooms, G., and van den Berghe, H. (1979) Impact of genetic counseling: A review of published follow-up studies. Clinical Genetics 15:465~74. Farley, T., Peterson, L., Cartter, M., and [Iadler, J. (1989) Trends in HIV prevalence and risk behavior among drug treatment program entrants. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Fehrs, L., Hill, D., Kerndt, P., Rose, T., and Henneman, C. (1989) HIV screening program at a Los Angeles prenatal/family planning center. Presented at the Fifth Intemational Conference on AIDS, Montreal, June ~9. Fineberg, H. V. (1988) Education to prevent AIDS: Prospects and obstacles. Science 239:592-596. Finn, P., and McNeil' T. (1987) The Response of the Criminal Justice System to Bias Crime: An Exploratory Review. Contract report submitted to the National Institute of Justice. Cambridge, Mass.: Abt Associates. Fordyce, E. J., Sambula, S., and Stoneburner, R. (1989) Mandatory reporting of human immunodeficiency virus testing would deter blacks and Hispanics from being tested (letter). Journal of the American Medical Association 262:349.

PREVENTION ~ 133 Fox, R., Ostrow, D., Valdisem, R., Van Raden, M., Visscher, B., and Polk? B. F. (1987) Changes in sexual activities among participants in the Multicenter AIDS Cohort Study. Presented at the Third International Conference on AIDS, Washington, D.C., June 1-5. Franke, K. M. (1989) Discnmination against HIV positive women by abortion clinics in New York City. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Freeman, H., Lewis, C., Montgomery, K., and Corey, C. (1989) Recent changes in sexual behavior among men in Los Angeles. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Friedman, S. R., Rosenblum, A., Goldsmith, D., Des Jarlais, D. C., Sufian M., et al. (1989) Risk factors for HIV-1 infection among street-recruited intravenous drug users in New York City. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Frutchey, C., and Walsh, K. (1989) Marginalization of gay men in AIDS funding and programs. Presented at the Fifth International Conference on AIDS, Montreal, June ~9. Gaynor, S., Kessler, D., Andrews, S., and Berge, P. (1989) Lookback: An update on the New York experience. Presented at the Fifth International Conference on AIDS, Montreal, June =9. General Accounting Office (GAO). (1989) AIDS Forecasting: Undercount of Cases and Lack of Key Data Weaken Existing Estimates. Washington, D.C.: General Accounting Office. Gerbert, B. (1987) AIDS and infection control in dental practice: Dentists' attitudes, knowledge, and behavior. Journal of the American Dental Association 114:311- 314. Gerbert, B., and Maguire, B. (1989) Public acceptance of the Surgeon General's brochure on AIDS. Public Health Reports 104:13~133. Gerbert, B., Maguire, B., and Coates, T.J. (1989) Are patients getting the AIDS education they want from their physicians? Presented at the Fifth International Conference on AIDS, Montreal, June =9. Gerbert, B., Maguire, B., Badner, V., Greenspan, D., Greenspan, J., et al. (1988) Changing dentists' knowledge, attitudes, and behaviors related to AIDS: A con- trolled educational intervention. Journal of the American Dental Association 1 16:85 1-854. Ghodse, A. H., Tregenza, G., and Li, M. (1987) Effect of fear of AIDS on sharing of injection equipment among drug abusers. British Medical Journal 295:698~99. Gibson, D. R., Wermuth, L., Lovelle-Drache, J., Ergas, B., Ham, J., and Sorensen, J. L. (1988) Brief psychoeducational counseling to reduce AIDS risk in IV drug users and sexual partners. Presented at the Fourth International Conference on AIDS, Stockholm, June 12-16. Gibson, P., Kohn, R., and Bolan, G. (1989) Drug use and sexual behavior in male patients at an STD clinic: Implications for AIDS prevention. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Gold, R. B. (1990) Abortion and Women's Health: A Turnzng Point for America? New York: Alan Guttmacher Institute. Goodman, M. I., and Goodman, L. E. (1982) Overselling of genetic anxiety. Hastings Center Report October:2~27.

134 ~ AIDS: THE SECOND DECADE Gostin, L. O. (1989) Public health strategies for confronting AIDS: Legislative and reg- ulatory policy in the United States. Journal of the American Medical Association 261:1621-1630. Gostin, L. (1990) The AIDS litigation project, a national review of court and human rights commission decisions, Part I: The social impact of AIDS. Journal of the American Medical Association 263:1961-1970. Gostin, L., Porter, L., and Sandomire, H. (In press) Objective Description of Trends in AIDS Litigation: AIDS Litigation Project. U.S. Public Health ServicelAIDS Program Office. Washington, D.C.: U.S. Government Printing Office. Greatbatch, W., and Holmes, W. (1989) Evidence of a 1~18 year mean time between HIV viral infection and AIDS onset. Presented at the Fifth International Conference on AIDS, Montreal, June 09. Grimes, D. A. (1987) The CDC and abortion in HIV-positive women. Journal of the American Medical Association 258:1176. Gunn, A. E. (1988) The CDC and abortion in HlV-positive women. Journal of the American Medical Association 259:217. Guydish, J., Abramowitz, A., Woods, W., Newmeyer, J., Clark, W., and Sorensen, J. (1989) Sharing needles: Risk reduction among intravenous Snug users in San Francisco. Presented at the Fifth International Conference on AIDS, Montreal, June 4-9. Hargraves, M. A., Jason, J. M., Chorba, T. L., Holman, R. C., Dixon, G. R., et al. (1987) Hemophiliac patient's knowledge and educational needs concerning acquired immunodeficiency syndrome. American Journal of Hematology 26:115- 124. Harper, P. S., Tyler, A., Smith, S., and Jones, P. (1981) Decline in the predicted incidence of Huntington's Chorea associated with systematic genetic counseling and family support. Lancet 2:411-413. Hart, G. J., CarveIl, A., Johnson, A. M., Feinmann, C., Woodward, N., and Adler, M. W. (1988) Needle exchange in central London. Presented at the Fourth International Conference on AIDS, Stockholm, June 12-16. Hart, G. J., Carvell, A. L. M., Woodward, N., Johnson, A. M., Williams, P., and Parry, J. V. (1989) Evaluation of needle exchange in central London: Behaviour change and anti-HIV status over one year. AIDS 3:261-265. Hartgers, C., Buning, E. C., van Santen, G. W., Verster, A. D., and Coutinho, R. A. (1989) The impact of the needle and syringe-exchange programme in Amsterdam on injecting risk-behavior. AIDS 3:571-576. Haverkos, H. W., and Edelman, R. (1988) The epidemiology of acquired immun- odeficiency syndrome among heterosexuals. Journal of the American Medical Association 260:1922-1929. Hayes, R., Kegeles, S., and Coates, T. J. (In press) AIDS risk among young gay men. AIDS. Henshaw, S. K., and Wallisch, L. S. (1984) The medicaid cutoff and abortion services for the poor. Family Planning Perspectives 16:17~180. Henshaw, S. K., Forrest, J. D., and Van Vort, J. (1987) Abortion services in the United States, 198~1985. Family Planning Perspectives 19:63-70. Herek, G. M. (1989) Hate crimes against lesbians and gay men: Issues for research and policy. American Psychologist 44:948-955.

PREVENTION ~ 135 Herek, G. M., and Glunt, E. K. (1988) An epidemic of stigma: Public reactions to AIDS. American Psychologist 43:88~891. Hoff, R., Berardi, V. P., Weiblen, B. J., Mahoney-Trout, L., Mitchell, M. L., and Grady, G. F. (1988) Seroprevalence of human immunodeficiency virus among childbearing women. New England Journal of Medicine 318:525-530. Holman, S., Berthaud' M., Sunderland, A., Moroso, G., Cancellieri, F., et al. (1989) Women infected with human immunodeficiency virus: Counseling and testing during pregnancy. Seminars in Perinatology 13:7-15. Holt, K. S. (1958) The influence of the retarded child upon family limitation. Journal of Mental Deficiency Research 2:28-36. Hunter, N. (1988) Testimony on discrimination in access to clinical trials of AIDS drugs before the Human Resources and Intergovernmental Relations Subcommittee of The Committee on Government Operations. Washington, D.C., April 28. Institute of Medicine (IOM). (1985) Preventing Low Birthweight. Washington, D.C.: National Academy Press. Institute of Medicine (IOM). (1988) Prenatal Care: Reaching Mothers, Reaching Infants. Washington, D.C.: National Academy Press. Institute of Medicine/National Academy of Sciences (IOM/NAS). (1988) Confronting AIDS: Update 1988. Washington, O.C.: National Academy Press. Jackson, J., and Neshin, S. (1986) New Jersey Community Health Project: Impact of using ex-addict education to disseminate information on AIDS to intravenous drug users. Presented at the Second International Conference on AIDS, Paris, June 25-26. Jackson, J., and Rotkiewicz, L. (1987) A coupon program: AIDS education and drug treatment. Presented at the Third International Conference on AIDS, Washington, D.C., June 1-5. Jackson, J. B., Kwok, S. Y., Hopsicker, J. S., Sannerud, K. J., Sninsky, J. J., et al. (1989) Absence of HIV-1 infection in antibody-negative sexual partners of HIV-1 infected hemophiliacs. Transfusion 29:265-267. Jaffe, H. W., Choi, K., Thomas, P. A., Haverkos, H. W., Auerbach, D. M., et al. (1983) National case-control study of Kaposi's sarcoma and Pneumocystis carinii pneumonia in homosexual men. Part 1. Epidemiologic results. Annals of Internal Medicine 99:145-151. Johnson, A.M., Petherick, A., Davidson, S.J., Brettle, R., Hooker, M., et al. (1989) Transmission of HIV to heterosexual partners of infected men and women. AIDS 3:367-372. Joseph, J. G., Montgomery, S. B., Kessler, R. C., Os~ow, D. G., and Wortman, C. B. (1988) Determinants of high risk behavior and recidivism in gay men. Presented at the Fourth International Conference on AIDS, Stockholm, June 12-16. Joseph, J. G., Kessler, R. C., Wortman, C. B., Kirscht, J. P., Tal, M., et al. (1989) Are there psychological costs associated with changes in behavior to reduce AIDS risk? In V. M. Mays, G. W. Albee, and S. F. Schneider, eds., Primary Prevention of AIDS: Psychological Approaches. Newbury Park, Calif.: Sage Publications. Judson, F. N. (1989) What do we really know about AIDS control? American Journal of Public Health 79:878-882. Judson, F., Cohn, D., and Douglas, J. (1989) Fear of AIDS and incidence of gonorrhea, syphilis, and hepatitis B. Presented at the Fifth International Conference on AIDS, Montreal, June =9.

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.

PREVENTION ~ 137 Kenen, R. H., and Schmidt, R. M. (1978) Stigmatization of carrier status: Social implications of heterozygote genetic screening programs. American Journal of Public Health 68:111~1120. Kirp, D. L. (1989) Learning by Heart: AIDS and Schoolchildren in America's Commu- nities. New Brunswick, N.J.: Rutgers University Press. Kotler, P., and Roberto, E. L. (1989) Social Marketing: Strategies for Changing Public Behavior. New York: The Free Press. Krasinski, K., Borkowsky, W., Bebenroth, D., and Moore, T. (1988) Failure of voluntary testing for human immunodeficiency virus to identify infected parturient women in a high-risk population. New England Journal of Medicine 318:185. Landesman, S. H., Minkoff, H. L., and Willoughby, A. (1989) HIV disease in reproductive age women: A problem of the present. Journal of the American Medical Association 261:132~1327. Lappe, M., Gustafson, J. M., and Roblin, R. (1972) Ethical and social issues in screening for genetic disease. New England Journal of Medicine 286:1129-1132. Leonard, C. O., Chase, G. A., and Childs, B. (1972) Genetic counseling: A consumer's view. New England Journal of Medicine 287:433~39. Lewis, C., and Freeman, H. (1987) The sexual history-taking in counseling practices of primary care physicians. Western Journal of Medicine 147:165-167. Lieb, S., Zimmerman, R. S., Kuechler, M., Langer, L. M., Sims, J., and Witte, J. J. (1989) Trends in AIDS knowledge, attitudes and behaviors (KAB) in heterogeneous, high-nsk groups, Florida. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Lifson, A., O'Malley, P. M., Hessol, N. A., Doll, L. S., Cannon, L., and Rutherford, G. W. (1989) Recent HIV seroconverters (SC) in a San Francisco cohort of homosexual/bisexual men: Risk factors for new infection. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Lindan, C., Rutherford, G.W., Payne, S., Hearst, N., and Lemp, G. (1989) Decline in rate of new AIDS cases among homosexual and bisexual men in San Francisco. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Ljungberg, B., Andersson, B., Christensson, B., Hugo-Persson, M., Tunving, K., and Ursing, B. (1988) Distribution of sterile equipment to IV drug abusers as part of an HIV prevention program. Presented at the Fourth International Conference on AIDS, Stockholm, June 12-16. Lowden, J. A., and Davidson, J. (1977) Tay-Sachs screening and prevention: The Canadian experience. In M. M. Kaback, ea., Tay-Sachs Disease: Screening and Prevention. New York: Alan Liss. Magura, S., Shapiro, J. L., Siddiqi, Q., and Lipton, D. S. (1989) Variables influencing condom use among intravenous drug users. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Marin, B. V. (1990) AIDS prevention for non-Puerto Rican Hispanics. In C. G. Leukefeld, R. J. Battjes, and Z. Amsel, eds., AIDS and Intravenous Drug Use: Future Directions for Community-Based Prevention Research. NIDA Research Monograph 93. Rockville, Md.: National Institute on Drug Abuse. Marin, B., and Marin, G. (1990) Effects of acculturation on knowledge of AIDS and HIV among Hispanics. Hispanic Journal of Behavioral Sciences 12:11~121. Marin, G. (1989) AIDS prevention among Hispanics: Needs, risk behaviors, and cultural values. Public Health Reports 104:411~1S.

138 ~ AIDS: THE SECOND DECADE Marin, G., and Mann, B. V. (In press) Perceived credibility of channels and sources of AIDS information among Hispanics. AIDS Education and Prevention. Marrnor, M., Fnedman-Kien, A. E., Laubenstein, L., Byrum, R. D., William, D. C., et al. (1982) Risk factors for Kaposi's sarcoma in homosexual men. Lancet 1: 1083-1087. Marsh, J. C, and Miller, N. A. (1985) Female clients in substance abuse treatment. International Journal of the Addictions 20:995-1019. Martin, J. L (1987) The impact of AIDS on gay male sexual behavior patterns in New York City. American Journal of Public [Iealth 77:578-581. Martin, J. L. (1990) Drug use and unprotected anal intercourse among gay men. Health Psychology 9:45~65. Martin, J. L. (In press) Drug use and unprotected anal intercourse among gay men. Health Psychology. Martin, J. L., and Hasin, D. (In press) Alcohol use and sexual behavior in a cohort of New York City gay men. IDrugs and Society. Mastroianni, L., Donaldson, P., and Kane, T., eds. (1990) Developing New Contra- ceptives: Obstacles and Opportunities. Washington, D.C.: National Academy Press. May, R. M., and Anderson, R. M. (1987) Transmission dynamics of HIV infection. Nature 326:137-142. Mays, V. M., and Cochran, S. D. (1988) Issues in the perception of AIDS risk and risk reduction activities by black and Hispanic/Latina women. American Psychologist 43:949-957. McCrae, W. M., Cult, A. M., Burton, L., and Dodge, J. (1973) Cystic Fibrosis: Parents' response to the genetic basis of the disease. Lancet 2:141-143. McCusker, J., Stoddard, A. M., Mayer, K. H., Zapka, J., Momson, C., and Saltzman, S. P. (1988) Effects of antibody test knowledge on subsequent sexual behaviors in a cohort of homosexually active men. American Journal of Public Health 78:462~67. McFarland, L., Dean, H., Trahan, B., and Muirhead, L. (1989) HIV infection in pregnant women at a public hospital in New Orleans, Louisiana. Presented at the Fifth International Conference on AIDS, Montreal, June ~9. McKusick, L., Conant, M., and Coates, T. J. (1985) The AIDS epidemic: A model for developing intervention strategies for reducing, high-risk behavior in gay men. Sexually Transmitted Diseases 12:229-234. McKusick, L., Coates, T. J., Monn, S., Pollack, L., and Hoff, C. (In press) Longitudinal predictors of unprotected anal intercourse in San Francisco gay men 198~1988: The AIDS Behavioral Research Project. American Journal of Public Health. Mechanic, D., and Aiken, L. (1989) Lessons from the past: Responding to the AIDS crisis. Health Affairs Fall: 17-32. Michigan Department of Public Health. (1988) Perinatal AIDS in Michigan. A report of the Maternal and Infant Task Force, June. Miller, T., Booraem, C., Flowers, J., and Iversen, I. (1989) Short- and long-term results of an AIDS prevention program. Presented at the Fifth International Conference on AIDS, Montreal, June =9.

PREVENTION | 139 Minkoff, H. L., and Landesman, S. H. (1988) The case for routinely offering prenatal testing for human immunodeficiency virus. American Journal of Obstetrics and Gynecology 159:793-796. Moatti, J. P., Tavares, J., Durbec, J. P., Bajos, N., Menard, C., and Serrand, L. (1989) Modifications of sexual behavior due to AIDS in French heterosexual "at risk" population. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Mondanaro, J. (1989) Chemically Dependent Women: Assessment and Treatment. Lexington, Mass.: Lexington Press. Moody, R., Foss, L. A., Parker, J., Callan, W., and Williamson, D. (1989) Seroprevalence of antibodies to the human immunodeficiency virus (HIV) in applicants for marriage licenses in Alabama. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Murray, R. F., Chamberlain, N., Fletcher, J., Hopkins, E., Jackson, R., King, P. A., and Powledge, T. M. (1980) Special considerations for minority participation in prenatal diagnosis. Journal of the American Medical Association 243:125~1256. Neal-Cooper, F., and Scott, R.B. (1988) Genetic counseling in sickle cell anemia: Experiences with couples at risk. Public Health Reports 103:17~178. New York City Department of Health. (1989) The Pilot Needle Exchange Study in New York City: A Bridge to Treatment. Department of Health, New York City. New York State Department of Health. (1989) AIDS in New York State Through 1988. Public Affairs Group, New York State Department of Health, Albany, N.Y. Nichols, E. K. (1989) Mobilizing Against AIDS. Cambridge, Mass.: Harvard University Press. NOVA Research Company. (1989) Conference Proceedings: NIDA Conference on AIDS Intervention Strategies for Female Sexual Partners. Vol. 1. Berkeley, Calif., March 19-22. Novick, D. M., Joseph, H., Croxson, T. S., Salsitz, E. A., Wang, G., et al. (1989) Absence of antibody to HIV in long-term, socially rehabilitated methadone mainte- nance patients. Presented at the Fifth International Conference on AIDS, Montreal, June ~9. Nzila, N., Laga, M., Kivuvu, M., Mokwa' K., Manoka, A. T., et al. (1989) Evaluation of condom utilization and acceptability of spennicides among prostitutes in Kinshasa, Zaire. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Getting, L. A., and Steele, M. W. (1982) A controlled retrospective follow-up study of the impact of genetic counseling on parental reproduction following the birth of a Down syndrome child. Clinical Genetics 21:7-13. Office of Technology Assessment (OTA). (1988) How Effective is AIDS Education? Washington, D.C.: Office of Technology Assessment. O'Reilly, K., Higgins, D. L., Galavotti, C., Sheridan, J., Wood, R., and Cohn, D. (1989) Perceived community noIms and risk reduction: Behavior change in a cohort of gay men. Photocopied materials distributed at the Fifth International Conference on AIDS, Montreal, June =9. Padian, N., Marquis, L., Francis, 13. P., Anderson, R. E., Rutherford, G. W., et al. (1987) Male-to-female transmission of human immunodeficiency virus. Journal of the American Medical Association 258:788-790.

140 ~ AIDS: THE SECOND DECADE Parish, K. L., Mandel, J., Thomas, J., and Gomperts, E. (1989) Prediction of safer sex practice and psychosocial distress in adults with hemophilia at risk for AIDS. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Parmet, W. E. (1987) AIDS and the limits of discrimination law. Law, Medicine & Health Care 15:61-72. Paul, J., Stall, R., and Davis, F. (1989) Sexual risk for HIV transmission in a gay male substance-abusing population. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Peterson, J. L., and Marin, G. (1988) Issues in the prevention of AIDS among Black and Hispanic men. American Psychologist 43:871-877. Peterson, J. L., Fullilove, R. E., Catania, J. A., and Coates, T. J. (1989) Close encounters of an unsafe kind: Risky sexual behaviors and predictors among black gay and bisexual men. Presented at the Fifth International Conference on AIDS, Montreal, June ~9. Pindyck, J. (1988) Transfusion-associated HIV infection: Epidemiology, prevention, and public policy (editorial review). AIDS 2:239-248. Potterat, J. J., Spencer, N. E., Woodhouse, D. E. and Muth, J. B. (1989) Partner notification in the control of human immunodeficiency virus infection. American Journal of Public Health 79:87~876. Powledge, T. M., and Fletcher, J. (1979) Guidelines for the ethical, social, and legal issues in prenatal diagnosis: A report from the Genetics Research Group of the Hastings Center, Institute of Society, Ethics, and the Life Sciences. New England Journal of Medicine 300:168-172. Presidential Commission on the Human Immunodeficiency Virus Epidemic. (1988) Final Report of the Presidential Commission on the Human Immunodeficiency Virus Epidemic. Washington, D.C.: Government Printing Office. Price, W., Merigan, T., and Peterman, T. (1989) Condom usage reported by female sexual partners of asymptomatic HIV seropositive hemophiliac men. Presented at the Fifth International Conference on AIDS, Montreal, June 4-9. Puckett, S. B., and Bye, L. L. (1987) The stop AIDS project: An interpersonal AIDS-prevention program. The Stop AIDS Project, Inc., San Francisco, Calif. Reed, B. G. (1987) Intervention strategies for drug dependent women: An introduction. In G. M. Beschner, B. G. Reed, and J. Mondanaro, eds., Treatment Services for Drug Dependent Women. Vol. 1. Rockville, Md.: National Institute on Drug Abuse. Reed, B. G., Lovach, J., Bellows, N., and Mosie, R. (1981) The many faces of addicted women: Implications for treatment and future research. In A. J. Schecter, ea., Drug Dependence and Alcoholism, Vol. 1. New York: Plenum Press. Remafedi, G. (1987~. Homosexual youth: A challenge to contemporaIy society. Journal of the American Medical Association 258:222-225. Remien, R., Rabkin, J., Williams, J., Gorman, J., and Ehrhardt, A. A. (1989~. Cessation of alcohol and drug use disorders ~n an HIV~ sample Presented at the Fifth International Conference on AIDS, Montreal, June =9. Rhame, F. S., and Maki' D. G. (1989) The case for wider 1lse of testing for HIV infection. New England Journal of Medicine 320:1248-1254. Robertson, J. A., and Plant, M. A. (1988) Alcohol, sex and risks of HIV infection. Drug and Alcohol Dependence 22:75-78.

PREVENTION ~ 141 Rowe, M., and 13ridgham, B. (1989) Executive Summary and Analysis: AIDS and Discrimination Review of State Laws That Affect HIV Infection (1983 to 1988). Washington, D.C.: Health Policy Project. George Washington University Intergovernmental Rubinstein, A., Sicklick, M., Gupta, A., Bernstein, L., Klein, N., et al. (1983) Acquired immunodeficiency with reversed T4/T8 ratios in infants born to promiscuous and drug-addicted mothers. Journal of the American Medical Association 249:235 2356. Rucknagel, D. L. (1983) A decade of screening in the hemoglobinopathies: Is a national program to prevent sickle cell anemia possible? The American Journal of Pediatric Hematology and Oncology 5:373-377. Russell, L. B. (1986) Is Prevention Better Than Cure? Washington, D.C.: The Brookings Institute. Rutherford, G. W., Oliva, G. E., Grossman, M., Green, J. R., Wara, D. W., et al. (1987) Guidelines for the control of perinatally transmitted HIV infection and care of infected mothers, infants, and children. Western Journal of Medicine 147:10~108. Sachs, B. P., Tuomala, R., and Frigoletto, F. (1987) AIDS: Suggested protocol for counseling and screening in pregnancy. Obstetrics and Gynecology 70:408~11. Saint Cyr-Delpe, M. (1989) Update to the community response on women and AIDS. Presented at the Fifth International Conference on AIDS, Montreal, June ~9. Sakondhavat, C. (1990) The female condom (letter). American Journal of Public Health 80:498~99. Saltzman, S., Stoddard, A., McCusker, J., and Mayer, K. (1989) Factors associated with recurrence of unsafe sexual practices in a cohort of gay men previously engaging In "safer" sexual practices. Presented at the Fifth International Conference on AIDS, Montreal, June =9. San Francisco AIDS Foundation. (1987) Designing an Effective AIDS Risk Prevention Campaign Strategy for San Francisco: Resultsirom the Fourth Probability Sample of an Urban Gay Male Community. San Francisco, Cal~f.: Research and Decision Corporation, Communication Technologies. Schechter, M. T., Craib, K. J. P., Willoughby, B., Douglas, B., McLeod, W. A., et al. (1988) Patterns of sexual behavior and condom use in a cohort of homosexual men. American Journal of Public Health 78:1535-1538. Schild, S. (1964) Parents of children with phenylketonuria. Children 11:92-96. Schilling, R. F., Schinke, S. P. Nichols, S. E., Zayas, L. H., Muller, S. O., et al. (1989) Developing strategies for AIDS prevention research with black and Hispanic drug users. Public Health Reports 104:2-11. Schmidt, K. W., Krasnik, A., Bendstrup, E., Zoffman, H., and Larson, S. O. (1989) Occurrence of sexual behavior related to the risk of HIV-infection. Danish Medical Bulletin 36:8~88. Schneck, M., Goode, L., Connor, E., Holland, B., Oxtoby, M., and Oleske, J. (1989) Reproductive history (HX) of HIV antibody positive (HIV+) women followed in a prospective study in Newark, N.J. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Schneider, B. E. (1988) Gender and AIDS. In R. Kulstad, ea., AIDS 1988: AAAS Symposia Papers. Washington, D.C.: American Association for the Advancement of Science.

142 ~ AIDS: THE SECOND DECADE Schoenbaum, E. E., Hartel, D., Selwyn, P. A., Klein, R. S., Davenny, K., et al. (1989) Risk factors for human immunodeficiency virus infection in intravenous drug users. New England Journal of Medicine 321:87~879. Seidlin, M., Dugan, T., Vogler, M., Bebenroth, D., Krasinski, K., and Holzman, R. (1989) Risk factors for HIV transmission in steady heterosexual couples. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Selwyn, P. A., Feiner, C., Cox, C. P., Lipshutz, C., and Cohen, R. L. (1987) Knowledge about AIDS and high-risk behavior among intravenous drug users in New York City. AIDS 1:247-254. Selwyn, P. A., Schoenbaum, E. E., Davenny, K., Robertson, V. J., Feingold, A. R., et al. (1989) Prospective study of human immunodeficiency virus infection and pregnancy outcomes in intravenous drug users. Journal of the American Medical Association 261: 1289-1294. Serrano, Y., and Goldsmith, D. (1989) Street outreach strategies for intravenous drug and crack users, their sexual partners, and addicted prostitutes at risk for AIDS. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Serrano, Y., and Johnson, P. (1989) Women injection drug users: Issues and strategies, experiences in New York City and ADAPT. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Shaw, M. W. (1987) Invited editorial comment: Testing for the Huntington gene: A right to know, a right not to know, or a duty to know. American Journal of Medical Genetics 26:243-246. Shaw, N., and Paleo, L. (1986) Women and AIDS. In L. McKusick, ea., What To Do About AIDS. Berkeley, Calif.: University of California Press. Skidmore, C., and Robertson, J. R. (1989) Long term follow-up and assessment of HIV serostatus and risk taking in a cohort of 203 intravenous drug users. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Smiley, M. L.' White, G. C. II, Becherer, P., Macik, G., Matthews? T. J.' et al. (1988) Transmission of human immunodeficiency virus to sexual partners of hemophiliacs. American Journal of Hematology 28:27-32. Soloick, R. (1978) Sexual responsiveness, age and change: Facts and potentials. In R. Solnick, ea., Sexuality and Aging. Los Angeles, Calif.: University of Southern Califomia Press. Soluick, R., and Birren, J. (1977) Age and male erectile response and sexual behavior. Archives of Sexual Behavior 6:1-9. Solomon, M. Z., and DeJong, W. (1986) Recent sexually transmitted disease prevention efforts and their implications for AIDS health education. Health Education Quarterly 13:31~3 16. Solomon, M. Z., and DeJong, W. (1989) Preventing AIDS and other STDs through condom promotion: A patient education intervention. American Journal of Public Health 179:453~58. Sorenson, J., Gibson, D., Heitzmann, C., Calvillo, A., Dumontet, R., et al. (1988) Pilot trial of small group AIDS education with intravenous drug abusers (abstract). In L. S. Harris, ea., Problems of Drug Dependence, 1988: Proceedings of the Committee on the Problems of Drug Dependence. National Institute on Drug Abuse Research Monograph 90. Washington, D.C.: U.S. Government Printing Office.

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.

144 ~ AIDS: THE SECOND DECADE Stimson, G. V. (1989) Syringe exchange programmes for injecting drug users. AIDS 3:253-260. Stryker, J. (1989) IV drug use and AIDS: Public policy and dirty needles. Journal of Health Politics, Policy and Law 14:719-740. Sundet, J. M., Kvalem, I. L., Magnus, P., Gronnesby, J. K., Stigum, H., and Baklceteig, L. S. (1989) The relationship between condom use and sexual behavior. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Sunita, J., Flynn, N., Bailey, V., Sweha, A., Ding, D., and Sloan, W. (1989) IVDU and AIDS: More resistance to changing their sexual than their needle-shanng practices. Presented at the Fifth International Conference on AIDS, Montreal, June ~9. Sweeney, P., Allan, D., and Onorato, I., and State and Local Health Departments. (1989) HIV infection among women attending women's health clinics in the United States, 1988-1989. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Tafoya, T. (1989) Pulling coyote's tale: Native Amencan sexuality and AIDS. In V. M. Mays, G. W. Albee, and S. F. Schneider, eds., Primary Prevention of AIDS: Psychological Approaches. Newbury Park, Calif.: Sage Publications. Tanner, W. M., and Pollack, R. H. (1988) The effect of condom use and erotic instructions on attitudes towards condoms. The Journal of Sex Research 25:537- 541. Traeen, B., Rise, J. and Kraft, P. (1989) Condom behavior in 17, 18, and 19 year-old Norwegians. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Truman B., Lehman, J. S., Brown, L., Peyser, N., Peters, D., et al. (1989) HIV infection among intravenous drug users (IVDUs) in NYC. Presented at the Fifth International Conference on AIDS, Montreal, June i9. Turner, C. (1989) Research on sexual behaviors that transmit HIV: Progress and problems. AIDS 3:S63-S70. Turner, C. F., Miller, H. G., and Moses, L. M., eds. (1989) AIDS, Sexual Behavior, and Intravenous Drug Use. Washington, D.C.: National Academy Press. Tu~nock, B. J., and Kelly, C. I. (1989) Premantal testing for human immunodeficiency virus. Journal of the American Medical Association 261:3415-3418. U.S. Conference of Mayors. (1989) AIDS/HIV anti-discrimination initiatives. AIDS Information Exchange 6:2. Valdisem, R. O. (1989) Preventing AIDS: The Design of Effective Programs. New Brunswick, N.J.: Rutgers University Press. Valdiserri, R., Lyter, D., Callahan, C., Kingsley, L., and Rinaldo, C. (1987) Condom use in a cohort of gay and bisexual men. Presented at the Third International Conference on AIDS, Washington, D.C., June 1-5. Valdisem, R., Lyter, D., Leviton, L. C., Callahan, C. M., Kingsley, L. A., et al. (1988) Variables influencing condom use in a cohort of gay and bisexual men. American Journal of Public Health 78:801-805. Valdiserri, R. O., Lyter, D. W., Leviton, L. C., Callahan, C. M., Kingsley, L A., and Rinaldo, C. R. (1989a) AIDS prevention in homosexual and bisexual men: Results of a randomized trial evaluating two risk reduction interventions. AIDS 3:21-26.

PREVENTION | 145 Valdisem, R. O., Arena, V. C., Proctor, D., and Bonati, F. A. (1989b) The relationship between women's attitudes about condoms and their use: Implications for condom promotion programs. American Journal of Public Health 79:499-501. van den Hoek, J. A. R., Coutinho, R. A., van Haastrecht, H. J. A., van Zadelhoff, A. W., and Goudsmit, J. (1988) Prevalence and risk factors of HIV infections among drug users and drug-using prostitutes in Amsterdam. AIDS 2:55~0. van den Hoek, J. A. R., van Haastrecht, H. J. A., and Coutinho, R. A. (1989) Risk reduction among intravenous drug users in Amsterdam under the influence of AIDS. American Journal of Public Health 79:1355-1357. VanRaden, M., Kaslow, R., Kingsley, L., Detels, R., Jacobson, L., et al. (1988) Incidence and nonsexual risk factors for recent HIV risk infection in homosexual men. Presented at the Fourth International Conference on AIDS, Stockholm, June 12-16. Vlahov, D., Anthony, J. C., Celentano, D. D., Solomon, L., Choudhury, N., and Mandell, W. (1989) Trends of risk reduction among initiates into intravenous drug use 1982-1987. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Watters, J. K. (1987) Preventing human immunodeficiency virus contagion among intravenous drug users: The impact of street-based education on risk-behavior. Presented at the 3rd International Conference on AIDS, Washington, D.C., June 1 - 5. Weiss, R., and Thier, S. O. (1988) HIV testing is the answer What's the question? New England Journal of Medicine 319:101~1012. Wells, J., Wilensky, G. R., Valleron, A. J., Bond, G., Sell, R. L., and DeFilippes, P. (1989) Population prevalence of AIDS high risk behaviors in France, the United Kingdom and the United States. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Williams, A. B. (1989) Educational needs assessment for women at risk for HIV through intravenous drug abuse. Presented at the Fifth International Conference on AIDS? Montreal, June i9. Williamson, M., Dobson, J.C., and Koch, R. (1977) Collaborative study of children treated for phenylketonuria: Study design. Pediatrics 60:815-821. Willoughby, B., Schechter, M. T., Douglas, B., Craib, K. J. P., Constance, P., et al. (1989) Self-reported sexual behavior in a cohort of homosexual men: Cross- sectional analysis at six years. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Wiznia, A., Bueti, C., Douglas, C., Cabat, T., and Rubinstein, A. (1989) Factors influencing maternal decision making regarding pregnancy outcome in HIV infected women. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Wolfe, H., Keffelew, A., Bacchetti, P., Meakin, R., Brodie, B., and Moss, A. R. (1989) HIV infection in female intravenous drug users in San Francisco. Presented at the Fifth International Conference on AIDS, Montreal, June =9. World Health Organization (WHO). (1988) AIDS: Avoidance of discrimination in relation to HIV-infected people and people with AIDS. Forty-first World Health Assembly, World Health Organization, Geneva, May. Worth, D., and Rodriguez, R. (1987) Latina women and AIDS. Siecus Report January- February:5-7.

146 ~ AIDS: THE SECOND DECADE Zeugin, P., Dubois-Arber, F., Hausser, D., and Lehmann, Ph. (1989) Sexual behavior of young adults and the effects of AIDS-prevention campaigns in Switzerland. Presented at the Fifth International Conference on AIDS, Montreal, June =9.

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Expanding on the 1989 National Research Council volume AIDS, Sexual Behavior, and Intravenous Drug Use, this book reports on changing patterns in the distribution of cases and the results of intervention efforts under way. It focuses on two important subpopulations that are becoming more and more at risk: adolescents and women. The committee also reviews strategies to protect blood supplies and to improve the quality of surveys used in AIDS research.

AIDS: The Second Decade updates trends in AIDS cases and HIV infection among the homosexual community, intravenous drug users, women, minorities, and other groups; presents an overview of a wide range of behavioral intervention strategies directed at specific groups; discusses discrimination against people with AIDS and HIV infection; and presents available data on the proportion of teenagers engaging in the behaviors that can transmit the virus and on female prostitutes and HIV infection.

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