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AIDS and Behavior: An Integrated Approach (1994)

Chapter: 3 UNDERSTANDING THE DETERMINANTS OF HIV RISK BEHAVIOR

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Suggested Citation:"3 UNDERSTANDING THE DETERMINANTS OF HIV RISK BEHAVIOR." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
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3
Understanding the Determinants of HIV Risk Behavior

Human behavior is determined by multiple factors in individuals and the environment. These factors occur at the micro-level (molecular and biological) and the macro-level (social and environmental) and often interact in mutually reciprocal relationships. The behaviors most closely linked with the epidemiology of AIDS—sexual contact and the injection of addictive drugs—are intense, intimate, and strongly driven. Approaching them requires a cross-disciplinary effort that should include refined knowledge of their neurobiological, psychological, and social bases, and the manners in which they interact.

This chapter presents an overview of findings and gaps in research on the determinants of HIV risk behavior and the application of that research to AIDS preventive interventions. This research constitutes a significant portion of the AIDS programs at NIAAA, NIDA, and NIMH.

NEUROBIOLOGICAL DETERMINANTS OF RISK BEHAVIOR

As reviewed later in this chapter, much has been learned from research on the psychosocial determinants of AIDS-related sexual and drug-using behaviors. However, research on the brain biology of sexuality and drug addiction has rarely been integrated into these studies, even though it may be critical for understanding and preventing highrisk behavior. Even to begin approaching the

Suggested Citation:"3 UNDERSTANDING THE DETERMINANTS OF HIV RISK BEHAVIOR." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
×

putative biology of highrisk behavior, including certain sexual behaviors and drug use, requires an expanded basic knowledge base. With respect to sexuality, characterization of sexual dimorphism at the genomic, molecular, cellular, and behavioral levels is still in its early stages. Whether and how it may relate to the drive to engage in specific, highrisk sexual behavior is not known, but it should at least be explored. Similarly, although much has been learned about the biology of substance abuse, further elucidation of molecular and cellular mechanisms underlying addictive behavior may assist in the development of new therapeutic approaches to addiction, which in turn may profoundly alter the AIDS epidemic.

Recent neuroscience investigations have contributed to knowledge about the biology of sexuality. However, to date most research has focused on the sexually dimorphic nature of the brain (e.g., how aspects of synaptic architecture differ in males and females) (Raisman and Field, 1971) and on potential neuroanatomical correlates of homosexuality in men (Gorski et al., 1978; LeVay, 1991). Extensive studies using experimental animals have identified specific pathways and centers in the brain and spinal cord involved in sexual responses among both males and females (Gorski, 1988; Gorski et al., 1978; Johnson, Coirini, Ball, et al., 1989; Johnson, Coirini, McEwen, et al., 1989; McEwen, Luine, and Fischette, 1988; Meisel and Pfaff, 1985; Parsons et al., 1982; Pfaff and Reiner, 1973; Pfaff and Sakuma, 1979; Pfaff and Schwartz-Giblin, 1988; Sar and Stumpf, 1975). Experimental animal studies have provided a rather detailed account of the neural and hormonal bases of a spectrum of sexual behaviors. However, it remains unknown if and how neuroanatomical and genetic factors in sexuality translate into sexual risk behavior.

Indeed, the biology of sexual risk taking is a missing element in basic biomedical and neurobiological AIDS research. Some outstanding issues include: identifying the neurochemical molecular substrates, if any, associated with sexual risk taking; determining how insights from the studies of the neurobiology of sexuality would relate to highrisk sexual behavior and to sexually transmitted diseases, including AIDS; and determining how society might best integrate the study of the biology of sexuality and sexual risk taking into the broader context of sexuality, sexual behavior, and sexually transmitted diseases.

Suggested Citation:"3 UNDERSTANDING THE DETERMINANTS OF HIV RISK BEHAVIOR." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
×
NEUROBIOLOGICAL BASIS OF DRUG-USING BEHAVIOR

Understanding the biological basis of drug addiction is an important link to understanding drug abuse behaviors, and unlike the biology of sexuality has been the object of a great deal of research. (However, it may be less useful in understanding highrisk drug use such as sharing injection equipment.) The possible link between alcohol and highrisk sexual behaviors has also become a subject of more intense research in recent years. The addiction syndrome consists of physical dependence, psychic dependence, and tolerance (Koob and Bloom, 1988). Physical dependence is considered to be an adaptive state resulting in profound physiological disturbances upon withdrawal of drug administration. Psychic dependence has been associated with the behaviorally reinforcing properties of the drug, resulting in a sense of satisfaction and a drive requiring continued administration to produce pleasure and avoid discomfort (Koob and Bloom, 1988). Tolerance is the requirement for progressively higher drug doses for a given effect with chronic use and appears to have a major learned component (Chen, 1979; LeBlanc, Gibbins, and Kalant, 1973; Schuster, Dockens, and Woods, 1966; Siegel, 1976, 1978; Siegel and Sdao-Jarvie, 1986; Wenger et al., 1981). Recent studies on the cellular and molecular basis of dependence and tolerance suggest that the processes are separate and distinct and are mediated by different brain systems (Koob and Bloom, 1988).

Traditional models of addiction suggest that one set of unspecified brain mechanisms mediate the primary, reinforcing, hedonic (pleasure-seeking) aspects of drug abuse and that, with time, a second ''adaptive" set of brain mechanisms antagonizes the first, necessitating higher doses to get the same subjective effect. The brain's adaptive response, however, also leads to a physiological reaction if the drug is withdrawn (Collier, 1980; Himmelsbach, 1943; Jaffe and Sharpless, 1968; Martin and Sloan, 1977; Solomon, 1977; Tabakoff and Hoffman, 1988). Contemporary studies are beginning to define the molecular and cellular bases of some of these well-known clinical phenomena.

Identification of opioid peptides (short proteins produced by nerve cells that bind to the same receptors as heroin and other opiate drugs) and mapping of their pathways in the brain have contributed an enormous amount of new data about the biology of opiates, including heroin (Bjorklund and Lindvall, 1984; Bloom, 1983; Khachaturian et al., 1985; Merchenthaler and Maderdrut, 1985). Some of the structures associated with addiction are now

Suggested Citation:"3 UNDERSTANDING THE DETERMINANTS OF HIV RISK BEHAVIOR." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
×

being defined at the molecular level. Decades of clinical research on opiate addiction have recently been augmented by the molecular cloning of opioid receptor molecules. There are three major categories of receptors (mu, kappa, and delta), each of which has at least two subtypes. Molecular genetics has begun to separate the various classes and subclasses of opioid receptors, and their structures can be used to identify and perhaps even to deliberately design drugs to further improve the treatment of opiate addiction (IOM, 1994). Cocaine addiction is less well understood than opiate addiction, but here too progress has been dramatic in recent years. It has been apparent for some time, for example, that dopamine-containing neurons are required for the primary reinforcing effects of psychostimulants such as cocaine and amphetamines (Goeders and Smith, 1983; Lyness, Friedle, and Moore, 1979; Roberts, Corcoran, and Fibiger, 1977; Roberts and Koob, 1982; Roberts et al., 1980; Routtenberg, 1972). Details of biologic mechanisms may be illustrated by focusing on cocaine, which, along with heroin, plays a pivotal role in the AIDS epidemic.

Dopaminergic neurons of the ventral tegmentum and their pathways that innervate limbic and frontal cortex are essential for the acute reinforcing actions of cocaine (Goeders and Smith, 1983; Lyness, Friedle, and Moore, 1979; Pickens, Meisch, and Dougherty, 1968; Roberts, Corcoran, and Fibiger, 1977; Roberts and Koob, 1982; Roberts et al., 1980; Routtenberg, 1972; Yokel and Wise, 1975, 1976). Considerable evidence suggests that cocaine acts by inhibiting the reuptake of dopamine by nerve cells (Ritz et al., 1987). That is, dopamine is normally released by one nerve cell and binds to its nearby neighbor. The nerve cell that releases the dopamine also has a molecular pumping system that recovers a fraction of the dopamine released. Cocaine inhibits this molecular pump, thereby increasing the amount of dopamine available to bind to the second nerve cell and also keeping levels high for longer periods. Inhibition of reuptake thus prolongs and intensifies dopamine actions. Inhibition of reuptake has been documented in the limbic nucleus accumbens and produces reinforcing actions. The increased available dopamine appears to elicit reinforcement by specifically stimulating D1 and D2 dopamine receptor subtypes (Koob, Le, and Creese, 1987; Woolverton, 1986). In sum, the specific transmitter (dopamine), the molecular reuptake transporter (the molecular "pump"), and the specific receptors involved (subtyped D1 and D2) have been associated with cocaine addiction. Each of these molecules constitutes a potential target for new therapeutic agents.

Suggested Citation:"3 UNDERSTANDING THE DETERMINANTS OF HIV RISK BEHAVIOR." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
×

The actual anatomical circuits in the brain that participate in the addictive process have been identified in some detail, although the story is not yet complete. Ventral tegmental dopaminergic nerve cells lead to the nucleus accumbens, which in turn projects to the ventral pallidum. Pallidal fibers innervate the pedunculopontine nucleus and dorsal medial thalamus, which are thought to mediate motor activation in experimental animals (Koob and Bloom, 1988). These pathways appear to play critical roles in cocaine-induced arousal-reinforcement.

The neuroanatomic and molecular bases of the withdrawal syndrome are less clearly understood (see Koob and Bloom, 1988, for review). Chronic drug use is presumed to result in compensatory, adaptive responses that antagonize the positive, reinforcing drug actions, but details of this adaptive response are not yet clear. Drug withdrawal presumably leads to the unopposed actions of the antagonistic mechanisms resulting in adverse effects, including malaise, dysphoria, and anhedonia. Additional studies are required to define the biology of the withdrawal syndrome and associated behaviors.

Neuroscience has now presented an opportunity to begin approaching the treatment of addictive drugs, including those used by injection and thus associated with HIV transmission such as heroin and injectable cocaine. Methadone has long been a successful treatment that can prevent injection of opiate drugs. Indeed, one of the principal rationales for developing new antiaddictive medications is the high mortality associated with both opiate and cocaine addiction, to which the risk of AIDS is an important contributor. In 1993, the Food and Drug Administration also approved levo-alpha-acetylmethadol (LAAM) to treat opiate addiction, and several other compounds are in clinical testing (IOM, 1994). The isolation of dopamine transporter and receptor molecules also will provide specific targets for drug development, although it is not yet clear whether or not affecting these molecular pathways will address the craving associated with cocaine addiction, and so an effective medication to combat cocaine may require substantial further advances in basic neuroscience (IOM, 1994). It may be some time before an antiaddictive medication to treat cocaine addiction, similar to methadone and LAAM in effectiveness against opiate addiction, can be found. In the long run, however, the combined efforts of neuroscientists studying the molecular, anatomic, and behavioral aspects of cocaine will very likely produce promising leads with direct treatment implications.

These new molecular insights now allow entirely new approaches

Suggested Citation:"3 UNDERSTANDING THE DETERMINANTS OF HIV RISK BEHAVIOR." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
×

to the biology of addiction. The scientific community faces a remarkable opportunity to combine biological and psychosocial approaches to treat addiction, reduce the factors that initially encourage abuse, and help to address a critical mode of HIV transmission. Prevention of transmission through a reduction in drug abuse is a potentially realistic goal best achieved through cross-disciplinary research.

PSYCHOSOCIAL DETERMINANTS OF RISK BEHAVIOR

More than a decade into the AIDS epidemic, efforts to change sex and drug using behaviors to reduce transmission of HIV have met with limited success. Sexual risk taking in the general population assessed in a limited number of studies appears to be substantial, and there is evidence that preventive behaviors have not generally been adopted. For example, a national probability study of the general heterosexual population of the United States found that condom use was low. Only 17 percent of those with multiple sex partners, 12.6 percent of those with risky sex partners, and 10.8 percent of untested transfusion recipients used condoms all the time (Catania et al., 1992). These data also suggest that the U.S. population as a whole has failed to incorporate prevention messages into sexual behavior. In fact, a consistent observation from many studies is that many of those at risk for HIV infection—whether through sex or drug use—do not recognize the danger they face (Brunswick et al., 1993; Klepinger et al., 1993; Kline and Strickler, 1993) and that, even when they do, knowledge alone is not enough to effect behavior change to reduce their risks. Understanding the resistance to as well as the motivation for behavior change is essential for designing effective AIDS prevention interventions. Basic and applied psychological and social research have contributed much to an understanding of the psychosocial and cultural determinants of HIV risk behavior.

PSYCHOSOCIAL PERSPECTIVES ON RISK BEHAVIOR

Theoretical models (primarily psychological) that dominate studies of HIV risk behavior fall into two major groups: those that predict risk behavior and those that predict behavior change. Models that predict risk behavior attempt to identify variables that explain, for example, why some members of a given population perform a given behavior at a given time while others do not (Fishbein et al., 1991). Models that predict behavior change focus on stages

Suggested Citation:"3 UNDERSTANDING THE DETERMINANTS OF HIV RISK BEHAVIOR." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
×

through which the individual may proceed while attempting to change behavior (Fishbein et al., 1991). A third set of theoretical issues is raised by the maintenance of safe behavior once such behavior has been initiated.

Early in the HIV/AIDS epidemic the Health Belief Model (Becker, 1974; Maiman and Becker, 1974; Rosenstock, 1974) and the Theory of Reasoned Action (Ajzen and Fishbein, 1977), which had been developed to explain health behaviors, were widely used to identify determinants of HIV risk behavior. The application of these models focuses on perceived susceptibility, perceived benefits, constraints to behavior, and intentions to behave in particular ways, such as using condoms, in the context of HIV risk.

Social Cognitive Learning Theory (Bandura, 1977), which in its early years was used to help people overcome phobias, also has been applied to HIV risk behavior. Its central concepts are those of "modeling" and "efficacy beliefs." Modeling is the process by which people are influenced by observing others. Efficacy beliefs include outcome (or response) efficacy, which is the belief that a given behavior will result in a given outcome (e.g., a belief that wearing a condom will prevent HIV transmission), and self-efficacy, which is the individual's belief that he or she can effectively carry out a desired behavior in a particular setting (e.g., successfully negotiate the use of a condom during a sexual encounter). In recent years self-efficacy has been viewed as the key social cognitive learning variable in predicting risk behavior.

By the mid-1980s most models of behavioral performance included an amalgam of variables from health belief models and social cognitive learning theory. This amalgamated theory tends to assume that individuals who formulate an intention to behave in a particular way and have the skills and self-efficacy beliefs to do so are likely to carry out the intended behavior. Many of the intervention studies reviewed below are influenced by these models and use variables from this amalgamation, especially variables assessing susceptibility, skills, and efficacy.

PSYCHOLOGICAL THEORIES OF BEHAVIOR CHANGE

Behavior change is a process, and as such we need models that can describe the process and identify benchmarks along its way. Stage theories of behavioral change provide researchers with tools for identifying these benchmarks so that interventions can be tailored to the place in the process that a group or community has attained with the goal of advancing them from that place. A

Suggested Citation:"3 UNDERSTANDING THE DETERMINANTS OF HIV RISK BEHAVIOR." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
×

successful intervention, therefore, might not result in the elimination of a risk behavior. Instead, a successful intervention is one that advances an individual or group from one stage to another. Two stage models of change have been adapted for use with HIV risk behavior: the AIDS Risk Reduction Model and the Stages of Change Model.

The AIDS Risk Reduction Model (ARRM) (Catania, Kegeles, and Coates, 1990) incorporates elements of the health belief and social cognitive learning models to describe the process through which individuals change their behavior. A goal of this model is to understand why people fail to progress over the change process. ARRM highlights three stages in the change process: Stage One is labeling highrisk behavior as problematic, which incorporates the notion of susceptibility from the health belief models. This involves knowing which sexual activities are associated with HIV transmission, believing that one is personally susceptible to contracting HIV, and believing that having AIDS is undesirable. Stage Two is making a commitment to changing highrisk behaviors, which includes weighing costs and benefits, and evaluating response efficacy, incorporating the efficacy concept from social cognitive learning theory. Stage Three is seeking and enacting solutions, that is, taking steps to actually perform the new behavior and then performing it. This enactment is influenced by social norms and problem-solving options, and it may include seeking help.

The Stages of Change Model (Prochaska, in press; Prochaska and DiClemente, 1983; Prochaska, DiClemente, and Norcross, 1992), formally called the Transtheoretical Model, was developed in the context of psychotherapy and has only recently been applied to HIV risk behavior. The Centers for Disease Control and Prevention, for example, is using the model in its AIDS Community Demonstration Projects, which target hard-to-reach groups at risk for HIV infection (O'Reilly and Higgins, 1991). This model posits four stages of change: Precontemplation, in which the individual does not intend to change behavior within the next six months; Contemplation, in which the individual intends to change behavior within the next six months; Preparation, in which the individual is seriously planning behavior change within the next 30 days, has made some attempt to modify behavior, but has not yet met a specific criterion (such as always using condoms); and Action, in which the individual has modified a behavior and met a specific criterion for less than six months. Maintenance is used to describe the period in which the individual continues the behavior change beyond six months. Movement through these stages

Suggested Citation:"3 UNDERSTANDING THE DETERMINANTS OF HIV RISK BEHAVIOR." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
×

does not always occur in a linear manner. Individuals often must make several attempts at behavior change before they achieve their goals. The efficacy of an intervention program to change behavior requires a good fit between the stage the individual is in and the stage that the intervention targets.

The model specifies ten cognitive, affective, and behavioral strategies and techniques people use as they progress through the stages of change over time. These strategies and techniques include consciousness raising, in which the individual's level of awareness is heightened; self-reevaluation, which is the individual's reappraisal of his or her problem; social reevaluation, which focuses on the impact of a problem on others; self-liberation, which acknowledges the role of choice in behavioral change; social liberation, which involves changes in the environment that lead to more options for the individual; counter-conditioning, which changes the conditional stimuli that control responses; stimulus control, which restructures the environment to reduce the probability of a particular conditional stimulus; contingency management; dramatic relief, as through catharsis; and support relationships (Prochaska and DiClemente, 1983).

An alternative to stage models is Diffusion Theory (Rogers, 1983) which describes the process by which an innovation is communicated through certain channels over time among members of a social system. Diffusion Theory informs interventions that involve entire communities rather than individuals. As such, it takes into account sociocultural influences that might inhibit or encourage particular behaviors, and it has been applied successfully in community-level interventions that will be described later (e.g., Kelly, Winett, Roffman, et al., 1993). One of the key channels for communicating new ideas is through opinion leaders. In any system, there may be innovative opinion leaders whose influence can accelerate the rate at which innovations are adopted through the social system. The interpersonal networks of opinion leaders allow them to disseminate information and to serve as social models whose behavior may be imitated by other members of the system.

Interventions based on Diffusion Theory have focused on the training or persuasion of peer opinion leaders who may or may not be the same as community leaders. Diffusion Theory indirectly addresses sustainability of the intervention; a successful diffusion intervention changes the community such that the new (safer) behavior becomes normative. Additional intervention is

Suggested Citation:"3 UNDERSTANDING THE DETERMINANTS OF HIV RISK BEHAVIOR." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
×

not needed once a critical portion of the targeted community has adopted the new behavior.

Stage models of behavior change are helpful in that they provide diagnostic tools for determining where in the behavior change process a given group or community finds itself. For example, given the history of the AIDS epidemic in the United States, gay men as a group may recognize that unprotected sexual intercourse is a behavior that places them or their partners at risk of HIV infection. In contrast, Hispanic/Latina women as a group may not yet recognize this behavior as potentially harmful (Gomez and Marin, 1993). These two groups being at different stages of behavior change would thus require different kinds of interventions.

Despite their conceptual contributions, current theoretical models are limited in their ability to predict risk behavior for two main reasons. First, with respect to sexual behavior, the models are based on the assumption that sexual encounters are regulated by self-formulated plans of action, and that individuals are acting in an intentional and volitional manner when engaging in sexual activity. However, sexual behavior is often impulsive and, at least in part, physiologically motivated. A well-formulated plan of action that is the product of a careful weighing of potential harms and benefits can be dismissed in the context of a passionate sexual encounter when competing proximal goals (i.e., sexual gratification) offset well-informed intentions (i.e., to use a condom).

Second, the dominant theoretical models of behavior do not easily accommodate contextual personal and sociocultural variables such as gender and racial/ethnic culture. Gender roles and cultural values and norms influence the behavior of women and men and the nature of the relationships in which sexual activity occurs. Unsafe sexual practices often are not the result of a deficit of knowledge, motivation, or skill, but instead have meaning within a given personal and sociocultural context. With the exception of Diffusion Theory, which takes gender and culture into account, current theoretical models of HIV risk behavior do not easily accommodate contextual personal and sociocultural variables. A great deal of work remains to be done in this area.

One theory that some think has potential application to understanding the context of HIV risk for women is the Self in Relation Theory of women's development. This theory suggests that the "relational self" is the core of self-structure in women and the basis for growth and development (Miller, 1986). Furthermore, this theory argues, women are basically oriented to others, and as

Suggested Citation:"3 UNDERSTANDING THE DETERMINANTS OF HIV RISK BEHAVIOR." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
×

a consequence their relationships and the maintenance of these relationships are highly charged with meaning. When applied to HIV, the Self in Relation Theory would suggest that the risk involved in initiating changes in intimate relationships (i.e., changes related to risk reduction) is greater for women than for men and may undermine women's intentions and their attempts to adopt safer sex behaviors. According to this theory, within women's ascribed roles as unequals, giving to others is a central aspect of women's identity, and sex becomes something that women "give" to men. There is little room for women's realization of their own sexuality (Miller, 1986). Stepping out of the traditional role, as required by safer sex negotiation, therefore potentially places women in direct conflict with men (Miller, 1986).

To date, models designed to explain or predict risk behavior tend to treat the social and environmental variables as independent variables, without considering that they may be interactive or mutually reciprocal. The models also tend to focus only on one level of analysis—the individual—without regard for other levels, such as the culture and community to which an individual belongs.

SOCIAL SCIENCE PERSPECTIVES ON BEHAVIOR AND BEHAVIOR CHANGE

Social science perspectives have only recently been applied broadly to AIDS research (Adam, 1992), but their potential for productively refocusing the investigation of AIDS is evidenced in some of the more recently completed ethnographies, social network analyses, and community outreach interventions and evaluations. Social science research has the capability to reveal the complex and important linkages between social structure and individual behavior and to suggest how specific social changes can inspire individual changes (Friedman, Des Jarlais, and Ward, 1994).

Several social science researchers contend that an overemphasis on behavioral change at the individual level has weakened attempts to reduce the spread of HIV and is in part to blame for the limited success of behavioral interventions to date (Friedman, 1993; Kayal, 1993). Individual behavior occurs in a complex social and cultural context, and analysis that removes that behavior from its broader setting ignores essential determinants. Current theory and research, dominated by psychological models that examine rational factors and cognitive processes that shape the isolated individual's decision-making patterns, have obscured the social and relational factors involved in behavior, such as the role of

Suggested Citation:"3 UNDERSTANDING THE DETERMINANTS OF HIV RISK BEHAVIOR." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
×

peer pressure, emotions, cultural beliefs, and organizational structures of communities at risk (Friedman, 1993; Wermuth, Ham, and Robbins, 1992).

A number of factors have contributed to the focus on the individual as the unit of analysis in AIDS research. First, some have argued, prevailing public perceptions of the AIDS epidemic as just punishment for the immoral and dangerous behaviors practiced among devalued and stigmatized groups (gays, injection drug users, people with low-income, and racial/ethnic minorities) result in a "blame the victim" mentality. From this viewpoint AIDS patients are held personally responsible for contracting the disease (Albert, 1986; Crystal and Schiller, 1993). A distinction is made in the public eye between "innocent" AIDS victims (infants, hemophiliacs) and "guilty" AIDS victims (gays, injection drug users). AIDS is thus a disease inextricably bound up with moral judgments. Unfortunately, such judgments and lack of interest in trying to fully understand the disease and its victims are not confined to the lay public. Patient reports of hostile and dismissive treatment by medical personnel are further corroborated by studies that show physicians' lack of sympathy for AIDS patients (Sosnowitz and Kovacs, 1992). Second, an individualistic emphasis is further fueled when the groups hardest hit by the AIDS epidemic are frequently represented as problem populations and socially distanced as "not like the rest of us" (NRC, 1993). Third, because of the representation of AIDS as punishment for sins and the portrayal of those most affected as outside of normal society, different standards of success and failure are used to judge their attempts at behavior change. Individuals are held responsible for the exertion of self-control during sex and drug activities, situations notorious for their uncontrollable and spontaneous nature (Schensul and Schensul, 1990). Finally, government policies predominant during the 1980s were structured to place responsibility for prevention of the disease at the local level; funds cut from urban programs, including health programs, did little to shift primary responsibility for AIDS prevention from the individual to the community or to government. Taken together, it is not difficult to see why an individualistic focus has prevailed and why the incorporation of a broader social science perspective on the spread of HIV has been slow in coming (Adam, 1992).

Several levels of social arrangements can affect behaviors related to the transmission of HIV—ranging from couples to social networks to the community to society as a whole. Each level of analysis reveals different factors that shape behavior, and demonstrates

Suggested Citation:"3 UNDERSTANDING THE DETERMINANTS OF HIV RISK BEHAVIOR." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
×

that individual behavior cannot be accurately analyzed apart from the social and cultural structures in which it is embedded.

At the broadest level, social conditions, such as the lack of universal access to health care, racial and ethnic discrimination, unemployment, and lack of public monies to promote AIDS prevention, contribute to a social context in which HIV transmission is prone to occur. For example, the continuing high unemployment rate among African American men (45 percent) fuels the appeal of the illegal drug trade as an alternate means of support, which in turn creates an environment that fosters drug use. Yet unemployment is not often represented as integral to the high rate of injection drug use among African American men and the subsequent transmission of HIV (Schneider, 1992). Similarly, the lack of access to health care among many low-income and racial and ethnic groups means that many cases of HIV infection never reach the attention of the medical community for diagnosis and treatment, thereby ensuring both an underestimation of the AIDS epidemic in certain populations, and its spread to other group members. Unfortunately, then, current health care arrangements make it likely that those populations most affected by HIV are those least likely to receive the preventive care needed to stem its spread. To effect change in the social arrangements at this level requires federal policy initiatives of broad scope as well as changes in the public's prevailing attitudes and mores. Both of these can be influenced by better knowledge about the structures of social life that affect the transmission and prevention of HIV. One important structure in this regard is the social network.

Social Networks

A social network is composed of an individual's relationships in the immediate social world; the number and type of relationships and the degree of closeness among those relationships are part of the structure of that network. Thus, networks are an indicator of social integration—how extensively and how tightly one is woven into the fabric of social life. Social networks are a source of emotional and instrumental support, providing companionship, information, and reference groups. Both the content (e.g., friendship, professional) of the interactions in the network and the form or structure of the network itself (e.g., close knit or loose; extensive or limited) can affect behavior profoundly. Recent research using network analysis suggests that the social network may be highly amenable to specific intervention efforts.

Suggested Citation:"3 UNDERSTANDING THE DETERMINANTS OF HIV RISK BEHAVIOR." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
×

Contained within one's network is the smallest unit of social interaction, the dyad—or couple—which has been studied in research on relations between sex partners and drug-using partners. However, social influence does not begin and end with a partner; intimate partner relationships, though important, are just one small unit of an individual's larger social network. The scope and character of one's broader social network—the array of contacts upon whom one relies for support, who serve as reference groups, and who establish group standards of conduct (social norms) and sanction behavior—is central to understanding the behavior that puts one at risk for HIV infection (Klovdahl, 1985; Klovdahl et el., 1994; Neaigus et al., 1994). It is at this level that the operation of social norms can best be observed and understood, and where intervention may be feasible. For example, in a study subsequently replicated, peer opinion leaders (''trendsetters") in gay communities in three different cities were identified, recruited, and trained in the active encouragement of safe sex practices among their peers. Pre- and post-intervention measures, while imperfect, showed significant self-reported changes in safer sex practices among the target population (Kelly, St. Lawrence, Stevenson, et al., 1992). This manipulation of the network to reinforce safe sex behaviors was a direct attempt to change the norms of the group to support the practice of safe sex.

Research on the social networks of injection drug users has also yielded some provocative results. These studies directly contradict prevailing views of the injection drug user as socially isolated from all influences other than those of other injection drug users. Negative stereotypes of injection drug users foster the notion that, motivated solely by the overwhelming need to obtain a fix, injection drug users inevitably sever all social ties. However, recent research reveals that injection drug users with AIDS receive instrumental and (less often) emotional support from family members, particularly mothers or other female relatives (Crystal and Schiller, 1993). In addition, a number of male injection drug users engage in sustained relationships with women who do not inject drugs, tying the men (if loosely) to a broader social network not composed exclusively of other drug addicts (Wermuth, Ham, and Robbins, 1992). The extent of such ties with non-injectors is related to the extent of highrisk behavior (Neaigus et al., 1994).

Social network analysis has also been used to examine whether alcohol use among injection drug users increases the likelihood of unsafe sex practices. In one study for example, researchers found that injection drug users who had loose ties to extensive networks

Suggested Citation:"3 UNDERSTANDING THE DETERMINANTS OF HIV RISK BEHAVIOR." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
×

were more likely to engage in unsafe sex while using alcohol (Latkin et al., 1993).

Finally, network analysis has also been employed as a technique to better estimate the actual number of AIDS cases in a population. The current reporting system contains weaknesses that result in the underreporting of AIDS cases, including: loss of information forwarded by individual doctors to local health authorities who then pass information on to CDC; delays of two or more months from the time an AIDS death is recorded to the time it is reported to local authorities; and the apparent reluctance of some physicians to report AIDS as the cause of death for married men. By asking a nationally representative sample for the characteristics of people they knew who died of AIDS, researchers in one large-scale study were able to obtain an ostensibly more reliable count of AIDS deaths than would have come from the CDC (Laumann et al., 1993).

Social Norms

Social norms are rules or standards of conduct that are generated and enforced by the members of a group. It is within the context of social networks that norms of behavior can be clearly identified and observed and that peer influences and social pressures upon individuals to engage in seemingly irrational behaviors can be seen in context and become more comprehensible. If the norms specific to HIV-related behaviors are reinforced and sanctioned within social networks, then the hope of behavioral change may reside at this same level.

Drug use, for example, is presented to initiates as a social and romantic act among friends. Introduction to injection drugs is accomplished by an experienced user injecting the novice with the user's needle. Needle sharing is thus represented as an act of trust and friendship in a subculture otherwise characterized by mistrust. Sharing needles is seen as integral to the maintenance of the subculture. Refusal to share needles is seen as implying distance, hostility, and mistrust, something that injection drug users can ill afford to engender in their partners, who are needed for material support (Des Jarlais, Friedman, and Strug, 1986). Promotion of the use of clean needles and the avoidance of sharing needles must be understood in this context.

Similarly, using a condom can be seen as an act of distrust and suspicion, rather than an act of caring, respect, and mutuality. Traditional norms of sexual behavior, supported by gender differentials

Suggested Citation:"3 UNDERSTANDING THE DETERMINANTS OF HIV RISK BEHAVIOR." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
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in power, dictate that women should not initiate discussion of sexual practices or try to change their male partner's sexual behavior. Thus, under these conditions, programs that highlight the importance of open communication between women and their partners in order to promote condom use may be of limited value (Wermuth, Ham, and Robbins, 1992).

Community

Through social networks, individuals are linked to neighborhoods and communities both geographic and cultural. The overlap of disparate sociocultural communities in a single geographic space is a feature of most areas in the United States. Geographic co-location creates important linkages between distinct subgroups, but it does not overcome all factors that create social distance. This fact has implications for the spread of AIDS in local sexual networks. Such networks may be based in a particular social group, but they likely include individuals from other groups as well. For example, strong sexual connections exist between members of drug-using networks and others in the non-drug-using community. As described in Chapter 2, this is a major source of HIV infection; and reaching the non-drug-using partners of injection drug users has constituted one of the most difficult challenges for HIV prevention.

Communities defined culturally often traverse geographic boundaries. In the context of AIDS, the most obvious example is the gay community, whose national political organization was instrumental in the dissemination of critical information and provision of social support and health care to gay men at a time when lethargy characterized the response of the medical community to the spread of HIV among them. The organized gay community succeeded in getting members of the larger gay community to practice safer sex. For example, the Gay Men's Health Crisis (GMHC) created support groups and dispensed needed information about HIV transmission. Thus, social organization and social context were shown to be critical factors in the reduction of risky behaviors (Schneider, 1992). Effective lobbying and media campaigns by groups such as ACT-UP convinced the government and research community to accelerate the distribution of experimental AIDS drugs, prompted the establishment of needle exchanges in many cities, and served to change the nature of public discourse about AIDS, by bringing an informed discussion of the AIDS epidemic "out of the closet."

Suggested Citation:"3 UNDERSTANDING THE DETERMINANTS OF HIV RISK BEHAVIOR." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
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In addition to the dissemination of essential information about the HIV virus, provision of health care and support services, and changes in government practices regarding access to experimental drugs, other equally important but relatively uninvestigated effects that result from such successful community organization include greater recognition of responsibility for one's behavior and identification with and pride in one's community (Kayal, 1993). Thus, community organization may not only be an efficient conduit for the provision of information to a broader group, but may also serve as an agent of change and a source of inspiration, pride, and identification for individual members.

Cultural Sensitivity

The greatest rate of increase of AIDS cases is among racial and ethnic groups and women—HIV is spreading fastest among African American and Hispanic/Latina heterosexual women and African American and Hispanic/Latino injection drug users (Singer, 1991). It is a commonly held belief that HIV informational campaigns and prevention and treatment services will not be effective unless they are carefully tailored to take into account the beliefs and practices of diverse cultural groups. This is especially so because the behaviors involved in HIV transmission are of such a highly sensitive, private, and potentially controversial nature. Communities differ in such things as their ability to organize, the extent of financial and other resources available to them to support HIV prevention efforts, and other dimensions such as religiosity, literacy, and privacy needs. This means that the skills, resources, personnel, and procedures needed to organize African American and Hispanic/Latino injection drug users may differ markedly from those employed successfully among the predominantly white gay community (Friedman et al., 1992). This leads many to believe that community leaders must be carefully identified and intimately involved, and that members of the target population must be consulted in the formulation and organization of any informational campaign or intervention strategy.

However, others argue that, as important as it is in crafting meaningful community messages and programs, cultural sensitivity itself may be inherently problematic for HIV prevention. As Bayer (1994) points out, modification of those behaviors responsible for HIV transmission often entails endorsement of a political and moral agenda unacceptable to the communities involved. For example, racial/ethnic community leaders in New

Suggested Citation:"3 UNDERSTANDING THE DETERMINANTS OF HIV RISK BEHAVIOR." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
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York and other cities where needle exchange programs have been proposed protest vehemently against their implementation, contending that the supply of clean needles actively encourages and perpetuates the very drug trade and drug addiction that community leaders are trying to eradicate among the local population. In this instance, observance of cultural sensitivity to one group may prevent implementation of proven HIV reduction measures for another. Balancing concern for cultural sensitivity with concern for HIV prevention is a delicate act.

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

Women and Gender Dynamics

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

Suggested Citation:"3 UNDERSTANDING THE DETERMINANTS OF HIV RISK BEHAVIOR." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
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It would be useful to explore how theoretical work might help to conceptualize the meaning of gender in HIV risk reduction and potentially improve understanding of the psychosocial context of HIV risk in a gender-specific manner. A gender-specific approach to prevention would take into account the broader social context of women's "permanent inequality" (Miller, 1986) in status and power relative to men, gender differences in psychosocial development, and gender role socialization. Investigating women's risk of HIV within this gender-specific framework is especially relevant because sexual and drug-using behaviors often occur within the context of relationships with men (Amaro, 1993).

Male partners play a critical role in women's initiation and progression of drug use, and in involvement in drug-related criminal activities such as prostitution (Anglin, Hser, and McGlothlin, 1987; Hser, Anglin, and McGlothlin, 1987; Rosenbaum, 1981; Worth and Rodriguez, 1987). For men, introduction and progression in drug use and related criminal activity occurs primarily through a same-sex friend. For women this occurs most often in the context of love or a sexual relationship or friendship with someone of the opposite sex. Thus, for women, addiction is often closely tied to love and sexual relationships with men, which brings a different dynamic into disengaging from drug use.

The impact of the male partner in women's drug use begins at an early age. Research indicates that adolescent girls with a male partner who uses marijuana and/or cocaine are three times more likely to use drugs during pregnancy and six time more likely to use drugs a year after delivery than girls whose partners did not use drugs (Amaro, Zuckerman, and Cabral, 1989). Having a male partner who uses drugs—especially heavier drug use—places girls at risk of drug use themselves (Amaro, Zuckerman, and Cabral, 1989), a finding that is consistent with reports among women addicts (Anglin, Hser, and McGlothlin, 1987) and women alcoholics (Lisansky Gomberg and Lisansky, 1984).

Some suggest that research that places women at the center of analysis should investigate women's efforts to transform sexual relationships, among other topics (Schneider, 1992). Research is needed to understand power relations between women and men and how these play out in the negotiation of safer sex, as well as the role of physical and sexual abuse and its impact on HIV risk reduction. Violence and abuse are a daily reality in the lives of many addicted women and among women with male partners who are addicted (Amaro et al., 1990; Fullilove, Fullilove, Kennedy, et al., 1992); but research is needed to document the extent to which

Suggested Citation:"3 UNDERSTANDING THE DETERMINANTS OF HIV RISK BEHAVIOR." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
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fear of abuse or experience of abuse deter women from discussing condom use with male partners, as well as how women cope with such fear. The work of Gomez and Marin (1993) for example, suggests that fear of the partner's anger in response to requests to use condoms is an important predictor of condom use among Hispanic/Latina women.

Motherhood is another gender-specific issue to consider. Many women in the United States who are HIV positive are both African American or Hispanic/Latina and mothers. It is thus essential to recognize the centrality that motherhood plays in the lives of these women. For many African American and Hispanic/Latina women, the role of mother is the primary pathway to greater social status and respect in their communities. Particularly for those women devalued because of their drug-using status, the role of mother takes on added importance (Wermuth, Ham, and Robbins, 1992). Inconsistent use of birth control and condoms and ambivalence about abortion may contribute to difficult and problematic decision making about pregnancy. Many women are torn between the value placed on children and motherhood and the possibility that the child may be born HIV positive. In addition, many who are taught to place the care of others before their own needs do not take the steps necessary to foster their own well-being, a problem exacerbated by the fact that they are also less likely to have the support of a mate once they become infected with HIV. As a consequence, the support network of HIV-positive women may be more constricted than that of other AIDS patients. Their unfavorable financial position bars them from obtaining the expensive drugs needed to treat AIDS and prevents them from traveling long distances for the limited amount of care that may be available to them. They are also consumed by worry over the care of their children after they die, given that foster care systems are already overwhelmed and given the likelihood that children who are HIV positive may suffer even greater discrimination in placement.

In sum, in the collective effort to prevent HIV infection, strategies employed without an understanding of the social conditions that facilitate HIV infection—such as poverty, discrimination, and inequality between women and men—may ultimately be ineffective. Increasingly, it will be important to investigate the interactions of such social conditions with psychological and neurobiological factors that possibly together influence the behavior of individuals.

Suggested Citation:"3 UNDERSTANDING THE DETERMINANTS OF HIV RISK BEHAVIOR." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
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INTERVENTIONS TO CHANGE BEHAVIOR

The theoretical models and constructs described above (notwithstanding their limitations) have been applied to the design of preventive interventions and behavior change strategies in an attempt to prevent further transmission of HIV. AIDS preventive intervention research typically focuses on identifying and modifying behaviors—usually those related to drug use and sex—known to be associated with HIV infection and targets both infected and uninfected persons in a range of populations and settings. Although, as noted above, most studies targeted individuals, some recently have begun to focus on the community as the target for intervention, recognizing the importance of socially created norms as determinants of behavior.

AIDS intervention studies employ a range of methodologies. Although experimental studies that randomize subjects into control and experimental groups have been considered to be the "gold standard," most studies do not adhere to this rigid design because of the difficulties associated with maintaining experimental conditions in the settings involved. (For a critique of the randomized controlled trial, see Oakley, 1989.) Rather, simple pre-post comparison studies are the most common means of assessing the effects of prevention programs, and specific changes (such as increased condom use) and mediating variables (such as demonstrated self-efficacy) have been the standard outcome measures for determining whether or not a particular intervention has been successful.

This theoretically based intervention research has identified some significant predictors of changes in sexual and drug-using behaviors among gay men, adolescents, and heterosexual adults, including: perceived social norms or social supports that favor behavior change, self-efficacy, accurate estimation of personal risk, alcohol and other drug-use patterns, HIV serostatus knowledge, and removal of structural barriers (for example, the provision of clean needles through needle exchange programs).

Table 3.1 displays a sample of AIDS preventive intervention studies funded by the institutes discussed in this report. The sample is limited to those studies that are reported in published articles or abstracts from international AIDS meetings. The following discussion, however, also refers to findings from studies funded by other sources as well as intervention studies that may not have been published. Most HIV interventions utilize strategies to reduce either highrisk sexual or drug-using behaviors, although some target both. Additionally, while most interventions

Suggested Citation:"3 UNDERSTANDING THE DETERMINANTS OF HIV RISK BEHAVIOR." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
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focus on the individual, a few have targeted the community as the context in which individual behavioral choices are made.

INDIVIDUAL-FOCUSED INTERVENTIONS
Sexual Behavior

HIV intervention studies targeting sexual behavior have been conducted in a variety of settings for a variety of groups, including men who have sex with men, adolescents, young adults, and heterosexual adult men and women (including drug users). Some researchers have conducted controlled studies on modifying the risk behaviors of men who have sex with men and have shown that interventions focused on individuals and small groups can produce behavior changes, at least in the short term. Some techniques found to be effective in modifying risk behavior include: audiovisual presentation that eroticized safer sex materials (D'Emaro et al., 1988), brief training on how to negotiate safer sex (Valdiserri, Lyter, Leviton, et al., 1989), training on how to reduce stress (Coates et al., 1989), and intensive group counseling (Kelly et al., 1989; Kelly et al., 1990). Group counseling of a brief nature also has resulted in sustained behavior change. In one study, for example, researchers found that one year after the counseling intervention, condom use during insertive anal intercourse had increased at a higher rate among subjects in the experimental group (36 percent at baseline to 80 percent) than among those in the control group (44 percent at baseline to 55 percent) (Valdiserri, Lyter, Leviton, et al., 1989).

Short-term behavior change has been achieved among adolescents as a result of AIDS education, but this varies by sexual experience. For example, studies that have assessed the long-term effects on risk behavior reduction of interventions focusing on high school students have demonstrated that intensive sex education delays the onset of intercourse among high school students who have never had sex. However, among sexually experienced teenagers, even this intense sex education seems to produce no effect in reducing sexual risk taking (Eisen, Zellman, and McAlister, 1990; Howard and McCabe, 1990; Kirby, et al., 1991).

Some adolescents, such as runaway youth, are particularly hard to reach with AIDS behavioral interventions. As part of an effort to reduce HIV risky sexual behaviors among such adolescents, one group of researchers engaged runaway youths in residential shelters in intensive small-group AIDS education and coping skills training combined with individual risk reduction counseling. Following

Suggested Citation:"3 UNDERSTANDING THE DETERMINANTS OF HIV RISK BEHAVIOR." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
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TABLE 3.1 A Sample of AIDS Preventive Intervention Research

Investigator

Title

Institute

Participants

Allen, Serufilira, Bogaerts, Van de Perre, Nsengumuremyi, Lindan, Carael, Wolf, Coates, Hulley (1992)

Confidential HIV testing and condom promotion in Africa: Impact on HIV and gonorrhea rates

NIMH

Women of childbearing age [N = 1,458), outpatient research clinic, Rwanda

Calsyn, Meinecke, Saxon, Stanton (1992)

Risk reduction in sexual behavior: A condom giveaway program in a drug abuse treatment clinic

NIDA

Men attending outpatient drug abuse treatment clinic (N = 103), Seattle, WA

Calsyn, Saxon, Freeman, Whittaker (1992)

Ineffectiveness of AIDS education and HIV antibody testing in reducing highrisk behaviors among injection drug users

NIDA

Female and male IDUs receiving or seeking treatment (N = 313), Seattle, WA

Calsyn, Saxon, Wells, Greenberg (1992)

Longitudinal sexual behavior changes in injecting drug users

NIDA

Female and male IDUs receiving or seeking treatment (N = 313), Seattle, WA

Colon, Robles, Freeman, Matos (1993)

Effects of a HIV risk reduction education program among injection drug users in Puerto Rico

NIDA

Female and male IDUs not in treatment [N = 2,144), San Juan, Puerto Rico

Suggested Citation:"3 UNDERSTANDING THE DETERMINANTS OF HIV RISK BEHAVIOR." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
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Projects Funded by NIAAA, NIDA, and NIMH

Objective of Intervention

Study Design

Key Findings

To evaluate the impact of HIV testing and counseling on self-reported condom and spermicide use, gonorrhea rates, and HIV seroconversion.

Prospective design (questionnaire; observed STD incidence)

At 1-year follow-up, condom use increased, HIV seroconversion and prevalence of gonorrhea decreased.

To determine whether condom availability would increase condom use. Condom-filled jars were placed throughout the clinic (in offices, rest rooms, waiting room, and therapy room).

Pretest-posttest design (questionnaire)

At 4-month follow-up, condom possession increased and use of condoms for vaginal intercourse increased.

To determine effectiveness of AIDS education in reducing highrisk sexual and drug-using behaviors. Random assignment was made to one of three conditions: (1) AIDS education, (2) AIDS education with optional HIV testing, and (3) wait list.

Multiple group, randomized, controlled design (structured interview)

At 4-month follow-up, drug use, needle sharing, and risky sexual behavior decreased among all three groups. Educational effects were absent.

To determine whether injection drug users maintained positive changes in sexual behavior over an 18-month period.

Repeated measures design (structured interview)

At 18-month follow-up, fewer men and women had multiple sex partners. Condom use increased for the men. Women did not report significant increases in condom use.

To measure the effect of adding an educational component to a community outreach program for reducing highrisk drug-using and sexual behaviors among IDUs.

Randomized, controlled design (structured interview)

Although substantial reduction in risk behaviors was measured, there were no significant group differences at 7-month follow-up. Educational enhancement effects were absent.

Suggested Citation:"3 UNDERSTANDING THE DETERMINANTS OF HIV RISK BEHAVIOR." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
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Investigator

Title

Institute

Participants

El-Bassel, Schilling (1992)

Fifteen-month follow-up of women methadone patients taught skills to reduce heterosexual HIV transmission

NIDA

Female methadone patients (N = 62), New York City

Feucht, Stephens, Gibbs (1991)

Knowledge about AIDS among intravenous drug users: An evaluation of an education program

NIDA

Female and male IDUs [N = 657), Cleveland, OH

Friedman, Jose, Neaigus, Sufian et al. (1991)

Peer mobilization and widespread condom use by drug injectors

NIDA

Female and male sexually active IDUs (N = 243), New York

Hays, Kegeles, Coates (1993)

Community mobilization promotes safer sex among young gay and bisexual men

NIMH

Young gay and bisexual men (N = 303), Santa Barbara, CA and Eugene, OR

Jemmott, Jemmott (1992)

Increasing condom-use intentions among sexually active black adolescent women

NIMH

Inner-city black female adolescents (N = 109)

Kaplan, O'Keefe (1993)

Let the needles do the talking! Evaluating the New Haven needle exchange

NIDA

Needles used by IDUs in New Haven, CT

Suggested Citation:"3 UNDERSTANDING THE DETERMINANTS OF HIV RISK BEHAVIOR." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
×

Objective of Intervention

Study Design

Key Findings

Follow-up of original study participants (see Schilling) to determine any differences in maintenance of changes in risk behavior.

Follow-up evaluation of randomized, controlled study

At 15-month follow-up, skills training group members were more likely to use condoms and were more comfortable talking about safe sex.

To assess the effect of a one-on-one AIDS educational session, which included a film, a discussion about AIDS risk behaviors and how to change them, and voluntary AIDS testing.

Pretest-posttest design (structured interview)

There were significant increases in AIDS knowledge following the education session.

To evaluate whether mobilizing peer pressure during group meetings, one-on-one counseling, and while distributing condoms, bleach, and other supplies increases condom use among drug injectors.

Pretest-posttest design (structured interview/ethnography)

Both consistent condom use and the proportion of sexual acts in which a condom was used increased at follow-up.

To develop and evaluate a community intervention to reduce highrisk sexual behaviors. The intervention community received peer outreach, peer-designed safer sex promotional materials, and a workshop. The other community was wait listed.

Sequential stepwise lagged controlled design (mail surveys)

Rates of unprotected anal intercourse decreased at the intervention site while remaining stable at the control site.

To evaluate whether social cognitive theory intervention (Urban League AIDS prevention program) would increase intentions to use condoms. The intervention included factual information, outcome expectancies about condom use, and self-efficacy training.

Pretest-posttest design (questionnaire)

Program participation was associated with increased AIDS knowledge and intentions and self-efficacy to use condoms.

To evaluate the effectiveness of the New Haven Needle Exchange Program for reducing needle sharing and HIV infection.

Mathematical and statistical modeling using data from a syringe tracking and testing system (STT)

Incidence of HIV infection among needle exchange participants was estimated to have decreased by 33 percent as a result of the needle exchange program.

Suggested Citation:"3 UNDERSTANDING THE DETERMINANTS OF HIV RISK BEHAVIOR." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
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Investigator

Title

Institute

Participants

Kelly, St. Lawrence, Diaz, Stevenson, Hauth, Brasfield, Kalichman, Smith, Andrew (1991)

HIV risk behavior reduction following intervention with key opinion leaders of population: An experimental analysis

NIMH

Male patrons of gay bars in small U.S. cities (N = 659 surveys), Biloxi, MS, Hattiesburg, MS Monroe, LA

Kelly, St. Lawrence, Hood, Brasfield (1989)

Behavioral intervention to reduce AIDS risk activities

NIMH

Gay men engaging in unsafe sexual practices (N = 104)

Kelly, St. Lawrence, Stevenson, Hauth, Kalichman, Diaz, Brasfield, Koob, Morgan (1992)

Community AIDS/HIV risk reduction: The effects of endorsements by popular people in three cities

NIMH

Male patrons of gay bars in small U.S. cities (N = 1,469 surveys), Biloxi, MS, Hattiesburg, MS, Monroe, LA

Magura, Siddiqi, Shapiro, Grossman, Lipton (1991)

Outcomes of an AIDS prevention program for methadone patients

NIDA

Female and male methadone patients (N = 289), New York City

McCusker, Stoddard, Zapka, Morrison, Zorn, Lewis (1992)

AIDS education for drug abusers: Evaluation of short-term effectiveness

NIDA

Clients of an inpatient drug detoxification program (N = 567), Worcester, MA

Suggested Citation:"3 UNDERSTANDING THE DETERMINANTS OF HIV RISK BEHAVIOR." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
×

Objective of Intervention

Study Design

Key Findings

To evaluate the effectiveness of a community intervention using one experimental city and two control cities. Trained opinion leaders in experimental city delivered AIDS risk reduction intervention to their peers to reduce highrisk sexual behaviors.

Quasi-experimental field study (repeated survey)

Repeated surveys of the men in each city found larger reductions in unprotected anal intercourse in the experimental city.

To evaluate a 12-session group intervention program with AIDS risk education, skills training, and reinforcement for reducing unsafe sexual behavior.

Randomized, controlled design

At 4-month follow-up, AIDS knowledge, sexual assertiveness, and condom use increased, whereas unprotected anal intercourse decreased.

To evaluate effectiveness of a mass-level community intervention in three cities. Trained opinion leaders provided AIDS risk reduction messages to reduce highrisk sexual behaviors.

Sequential stepwise lagged controlled design

Intervention consistently produced systematic reductions in unprotected anal intercourse.

To evaluate effects of a voluntary AIDS prevention program with didactic AIDS education, HIV antibody counseling/testing, and facilitated peer support groups to reduce risky IV drug use and sexual behavior.

Comparative design (self-administered questionnaires)

AIDS education was associated with increased knowledge of AIDS risks and improved attitudes toward condom use. Peer group participation was associated with increased use of condoms.

To compare effects of two AIDS interventions (basic vs. enhanced) on reducing risky drug use and sexual behavior. The basic intervention included two group educational sessions, whereas the enhanced program included one individual and six group sessions.

Multiple group, randomized design

Immediately following intervention, enhanced-group members reported greater self-efficacy; other knowledge and attitudes did not differ by intervention. At 6-month follow-up, enhanced group reduced frequency of injection.

Suggested Citation:"3 UNDERSTANDING THE DETERMINANTS OF HIV RISK BEHAVIOR." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
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Investigator

Title

Institute

Participants

Nyamathi, Leake, Flaskerud, Lewis, Bennett (1993)

Outcomes of specialized and traditional AIDS counseling programs for impoverished women of color

NIDA

Impoverished African-American and Latina women (N = 858), Los Angeles, CA

Rhodes, Wolitski, Thornton-Johnson (1992)

An experiential program to reduce AIDS risk among female sex partners of injection-drug users

NIDA

Female sex partners of male IDUs (N = 93), Long Beach, CA

Rolf, Baldwin, Trotter, Alexander et al. (1991)

AIDS prevention for youth of rural Native American tribes

NIAAA

Rural Native American youth (N = 180)

Rotheram-Borus, Koopman, Haignere. Davies (1991)

Reducing HIV sexual risk behaviors among runaway adolescents

NIMH

Runaway female and male youth; mostly African American and Hispanic (N = 145), New York City

Schilling, El-Bassel. Schinke, Gordon, Nichols (1991)

Building skills of recovering women drug users to reduce heterosexual AIDS transmission

NIDA

Female methadone patients [N = 91), New York City

Stephens, Feucht, Roman (1991)

Effects of an intervention program on AIDS-related drug and needle behavior among intravenous drug users

NIDA

Female and male IDUs (N = 322), Cleveland, OH

Suggested Citation:"3 UNDERSTANDING THE DETERMINANTS OF HIV RISK BEHAVIOR." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
×

Objective of Intervention

Study Design

Key Findings

To compare differential effects of two AIDS education programs for reducing risky drug use and sexual behavior. The standard intervention lasted one hour. A specialized two-hour intervention was individualized to the expressed concerns of the women.

Pretest-posttest comparative design

There were significant improvements for both interventions. The specialized program was not more effective than the standard one.

Education and counseling to motivate personal risk reduction, provide participants with cognitive and behavioral skills, and enhance participants' ability to make positive changes in their lives.

Pretest-posttest design

Ninety-one percent of program participants reported positive behavioral changes; 98 percent reported a greater sense of control.

Multi-component, community outreach program conducted in school, focusing on HIV/AIDS and alcohol and other drug abuse. Intention was to change highrisk sexual and drug-using behaviors and local norms of attitudes and behaviors.

Quasi-experimental design (surveys)

Data from pilot studies of two schools indicate that intervention increased knowledge about AIDS and alcohol and other drugs, and intentions to reduce highrisk behaviors.

Intensive intervention to provide risk education about HIV/AIDS, training in coping skills for highrisk situations, counseling to address individual barriers to safer sex and access to health care and other services.

Non-randomized controlled design

At 3- and 6-month follow-ups, consistent condom use increased and reports of highrisk sexual behavior decreased among youth receiving intervention.

To compare information-only control group and skills-building intervention group for reducing highrisk sexual behavior and increasing condom use.

Multiple group, randomized design (structured interview)

Skills-building intervention was associated with increased condom use and comfort with discussion of sexual issues. Intervention had no impact on drug use.

To evaluate the impact of an AIDS educational intervention for reducing HIV risk behaviors. The intervention included individual risk reduction counseling. Each participant received condoms, bleach, and brochures.

Quasi-experimental pretest-posttest design (interviews)

Intravenous drug use and syringe sharing decreased. Effects of intervention endured for up to one year.

Suggested Citation:"3 UNDERSTANDING THE DETERMINANTS OF HIV RISK BEHAVIOR." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
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Investigator

Title

Institute

Participants

Walter, Vaughan (1993)

AIDS risk reduction among a multiethnic sample of urban high school students

NIMH

Female and male high school students (N = 1,316), four New York City schools

Watters, Estilo, Clark, Lorvick (1994)

Syringe and needle exchange as HIV/AIDS prevention for injection drug users

NIDA

Female and male IDUs (N = 5,644), San Francisco, CA

Wiebel, Jimenez, Johnson, Ouellet et al. (1993)

Positive effect on HIV seroconversion of street outreach intervention with IDUs in Chicago: 1988-1992

NIDA

IDUs not in drug treatment (N = 641), Chicago, IL

up both three and six months later, researchers found a higher increase in condom use and safer sex among those who attended the intervention site than among those at the control site (Rotheram-Borus et al., 1991). The long-term efficacy of this shelter-based intervention is yet to be assessed; however, the results of this study suggest that, at least on a short-term basis, adolescents with multiple risks in their lives, including vulnerability for HIV infection, can modify their sexual risk taking.

Most HIV prevention efforts targeting sexual behavior among young adults have focused on college students. Of those efforts, none on record has demonstrated measurable behavioral change as an outcome. These prevention programs have spanned a great variety of interventions, from a single audiovisual presentation of AIDS information (Gilliam and Seltzer, 1989; Rhodes and Wolitski, 1989), to a human reproduction course covering AIDS (Gerrard and Reis, 1989), to a full semester course specifically on AIDS

Suggested Citation:"3 UNDERSTANDING THE DETERMINANTS OF HIV RISK BEHAVIOR." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
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Objective of Intervention

Study Design

Key Findings

To evaluate effectiveness of a teacher-delivered curriculum geared toward increasing knowledge about AIDS, increasing self-efficacy related to AIDS-prevention, and reducing AIDS risk behaviors. Control groups received no formal AIDS education.

Experimental field study (surveys)

At 3-month follow-up, modest favorable effects of the intervention were observed: increases in knowledge, beliefs, and self-efficacy, and reductions in risky sexual behavior.

To evaluate the effects of an all-volunteer syringe exchange program on risky injection drug use. Community outreach workers provided AIDS education, bleach, and referral to drug treatment.

Serial, cross-sectional design (surveys)

The intervention resulted in increased condom use, use of bleach to clean needles, and decreased syringe sharing.

To evaluate the effectiveness of street outreach for out-of-treatment drug users on drug-using behavior and HIV seroconversion.

Prospective design

Intervention reduced HIV seroconversion and sharing of unsterile injection equipment. Sexual risks were somewhat resistant to the intervention.

(Abramson, Sekler, and Cloud, 1989), to a week-long AIDS awareness program for the whole campus (Dommeyer et al., 1989). Of all these programs stressing education and awareness, only one examined the behavioral outcomes of its intervention (Abramson, Sekler, and Cloud, 1989). Moreover, that study, which found an increase in carrying and using condoms following a semester-long intervention, also reported a high attrition rate (37 percent of experimental subjects, 69 percent in the control group), so it is possible that the behavior change may not be attributable to the intervention.

University students in three skills training programs demonstrated improved skill in negotiating safer sex and in developing positive attitudes toward condoms, at least in the short term (Franzini et al., 1990; Kyes, 1990; Tanner and Pollack, 1988). However, it is not known how these improved skills and attitudes will affect sexual risk-taking behavior over time. Design of these programs

Suggested Citation:"3 UNDERSTANDING THE DETERMINANTS OF HIV RISK BEHAVIOR." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
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varied. One randomized study compared an experimental group that participated both in an AIDS education lecture and in a three-session sexual assertiveness training course with a control group that only received the AIDS education lecture (Franzini et al., 1990). Two other studies eroticized safer sex messages in order to change attitudes toward condom use (Kyes, 1990; Tanner and Pollack, 1988). Because they did not assess long-term behavior change, no resulting behavior change can be attributed to the interventions.

Studies designed for adult heterosexual women and men have reported short-term behavior change as a result of interventions. In one study, four 90-minute skills training sessions combined with two follow-ups were given to patients at an urban primary health care clinic (Kelly et al., in press). After three months, researchers found a higher rate of condom use among experimental subjects relative to control subjects. In another study, in this case, among blood donors, the number of men and women who practiced unsafe sex was reduced by an intervention consisting of HIV status notification and post-notification counseling (Cleary et al., 1991).

Prospective cohort studies that focus on couples with discordant HIV status (one partner seronegative and the other seropositive) have in some cases demonstrated long-term program effectiveness. A study in Zaire involving intensive couples counseling after notification of HIV test results found that condom use had increased dramatically—from less than 5 percent at baseline to 71 percent after one month. After 18 months, 77 percent of the couples reported still using condoms during all sexual encounters. The rate of HIV seroconversion during the follow-up was 3 per 100 person-years (Kamenga et al., 1991). A study in Rwanda that offered HIV antibody posttest counseling combined with AIDS education group counseling to cohabiting discordant couples produced similar results: condom use increased from 3 percent at baseline to 57 percent at follow-up one year later; the rate of HIV seroconversion was 4 per 100 person-years among men and 9 per 100 person-years among women during follow-up (Allen, Tice, and Van de Perre, et al. 1992).

The efficacy of HIV counseling and testing among commercial sex workers has been evaluated in a few studies (Corby, Barchi, and Wolitski, 1990; Ngugi et al., 1988; Papaevangelou et al., 1988). In one prospective study, condom use increased among female sex workers in Kenya who received HIV counseling, testing, and AIDS education relative to those who did not (Ngugi et al., 1988). A

Suggested Citation:"3 UNDERSTANDING THE DETERMINANTS OF HIV RISK BEHAVIOR." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
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subsequent evaluation of the program estimated that such health education interventions could prevent between 6,000 and 10,000 new HIV infections annually (Moses et al., 1991).

All of the studies targeting sexual behavior and condom use have focused on the acceptance and regular use of male condoms. However, there may be woman-controlled methods of sexual risk reduction that may be more appropriate or useful in some instances. As illustrated in Box 3.1, the new ''female condom" has potential in this regard, but data on its acceptability and efficacy are still preliminary.

Injection Drug Use

Some prospective studies report that methadone maintenance treatment may prevent the spread of HIV. The treatment itself has been found to have a significant impact both on decreasing the use of injection drugs (Ball et al., 1988) and on HIV seroconversion (Metzger et al., 1993; Moss et al., 1994). Moss et al. (1994) found that those who stayed in methadone maintenance for one or more years had lower HIV seroconversion rates (1 percent) than those who had been in the program for less than one year (3.8 percent). Yancovitz et al. (1991) found in their experimental study that among patients waiting for comprehensive methadone maintenance treatment, far fewer in the experimental group injected heroin (63 percent at intake to 29 percent at one-month follow-up) than those in the control group (62 percent to 60 percent). However, it has not been determined that limited services to injection drug users will have lasting effects on modifying such AIDS-related risk behaviors as needle sharing and unsafe sex.

Researchers have found mixed results from controlled clinical trials of individual and group counseling that provide skills training for people who inject drugs. Some studies found skills training to be effective in changing behavior in certain areas: use of condoms had increased at 2-week follow-up in one study (Schilling, El-Bassel, Schinke, et al., 1991) and drug injection had decreased at 6-month follow-up in two others (Des Jarlais, Casriel, Friedman, et al., 1992; McCusker et al., 1992). However, other studies demonstrated no measurable risk reduction as a result of skills training (Colon et al., 1992; Sorensen et al., in press), brief AIDS information counseling (Calsyn, Saxon, Freeman, et al., 1992; Dengelegi, Weber, and Torquato, 1990; Gibson et al., 1991), and HIV counseling and testing (Gibson, Young, and Lovelle-Drache, 1993). Because in these studies control group subjects modified their behavior

Suggested Citation:"3 UNDERSTANDING THE DETERMINANTS OF HIV RISK BEHAVIOR." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
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Box 3.1 The Female Condom

An estimated 3 million women worldwide have HIV infection, and AIDS has become the leading cause of death among women between the ages of 20 and 40 years in major cities throughout sub-Saharan Africa, Western Europe, and the Americas (Chin, 1990; Hankins and Handley, 1992). In the United States, women still represent a small percentage of all AIDS cases; however, their proportion is growing (CDC, 1993a). While the sharing of injection equipment had been the primary risk factor for HIV infection among women in the United States, current epidemiologic data indicate that sexual activity has now surpassed needle sharing as the leading risk factor for AIDS among women. There are indications that many of the traditional HIV prevention and intervention programs have not had a major impact in reducing highrisk sexual behavior among women (Sorensen et al., 1991; Weissman and National AIDS Research Consortium, 1991). To date, the most common and effective risk reduction method is condom use. But many woman at risk report not using them, a situation resulting from a variety of factors, including socioeconomic circumstances, sex roles in the street drug culture, and fear that mistrust, rejection, and even violence will result if they suggest that their partners use condoms (Padian, 1988; Schilling, El-Bassel, Gilbert, et al., 1991; Valdiserri, Arena, Proctor, et al., 1989).

There are few woman-controlled methods of sexual risk reduction, and what is available is not effective in preventing HIV infection. For example, both the effectiveness and the side effects of spermicides have raised questions about their feasibility as an HIV risk reduction technique (Stein, 1992). Sponges and diaphragms are promoted as HIV risk reduction mechanisms because they reduce the incidence of sexually transmitted diseases (Rosenberg and Gollub, 1992), but neither has actually been tested to determine whether it reduces risk of HIV infection.

However, a new device called the "female condom," may potentially address this need. The first female condom, made of rubber with a steel coil rim, was introduced in the 1920s (British Journal of Family Planning, 1992). It was not until the late 1980s, however, that a more acceptable device was developed—the Femidom™ female condom, which has been commercially available in the United Kingdom since September 1992 and received FDA approval in the United States in 1993. In the United States, the female condom has been marketed since January 2, 1994 by Wisconsin Pharmacal Company under the name of Reality™. The design combines features of the male condom and the diaphragm (Bounds, 1989). The Reality™ female condom is a polyurethane sheath with a flexible inner ring that secures the condom against the cervix and an outer ring that prevents the condom from entering the vaginal canal. Various tests

Suggested Citation:"3 UNDERSTANDING THE DETERMINANTS OF HIV RISK BEHAVIOR." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
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have shown that there is no viral leakage from the female condom (Leeper, 1990; Voeller, 1991).

The female condom has several advantages over the male condom, both as a contraceptive and as an STD prevention method. First, since it is woman-controlled, women are not as dependent on the cooperation of sex partners to protect themselves from HIV and other sexually transmitted diseases. Second, the female condom is inserted before intercourse, providing additional protection against infections from pre-ejaculated fluids. Third, the female condom protects a greater proportion of the vagina, providing additional protection against STDs. Fourth, the Reality™ condom is less likely to rupture than the male condom (Bounds et al., 1988; Gollub and Stein, 1993; Leeper and Conrardy, 1989). Also, because of its loose fit, it causes less loss of sensitivity, permits penetration before complete erection of the penis, and permits continued intimacy in the resolution phase of intercourse, since it need not be removed immediately.

Several small-scale studies have tested the acceptability of Reality™ among both women and men, but only two studies to date have been conducted among women at highrisk of HIV infection—commercial sex workers. In one such study, participants claimed that female condoms were more protective against HIV and STD infection and were more feasible to use than male condoms. Many used them with their regular sex partners, who also found them acceptable (Hernandez-Avila, 1992). In the other study, 90 percent of the women said they would recommend the female condom to friends (Sakondhavat, 1990). In all acceptability studies, although the samples have been small, a majority of women and men have felt that the female condom was easy to use and was an acceptable method of both contraception and HIV/STD prevention (Schilling, El-Bassel, Leeper, et al., 1991).

This preliminary research suggests promising results for the female condom, including acceptability among female populations with varying sexual histories and practices. However, studies so far have been based on very small samples, and additional data are needed to further test the acceptability and efficacy of female condom use. Moreover, no studies have been conducted in the United States among women at highrisk for HIV infection, such as commercial sex workers, injection drug users, or those who exchange sex for drugs. In addition, the female condom is not readily accessible in the United States. How the new female condom will fare among highrisk populations, and in the general population, remains to be seen.

Suggested Citation:"3 UNDERSTANDING THE DETERMINANTS OF HIV RISK BEHAVIOR." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
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to the same extent as did subjects participating in interventions, it is impossible to tell whether behavior actually changed in both groups or if other factors influenced reports of behavior. Such factors might include informal communication between subjects, intensive and repeated interviews, and general societal trends (Calsyn, Saxon, Freeman, et al., 1992; Gibson, Young, and Lovelle-Drache, 1993; McCusker et al., 1992).

Even though many of these individual-focused intervention studies have demonstrated sexual and drug-use behavior change, they may be limited in a few ways: (1) most rely solely on self-reported data; (2) for the most part they have not yet demonstrated long-term behavior change (beyond 6 months); (3) it is not yet known whether they work with populations outside of their target groups; (4) many interventions may not be cost-effective to implement on a larger scale, and (5) with few exceptions, they do not measure HIV transmission and do not necessarily indicate that HIV infection has been averted.

COMMUNITY-FOCUSED INTERVENTIONS
Sexual Behavior

Intervention research at the community level has employed peerled AIDS education to reach people at highrisk for HIV infection who may not be willing to participate in small-group/programs (Kegeles et al., 1993) and to change norms in the community as a whole (Kelly, St. Lawrence, Stevenson, et al., 1992; Kelly, Winett, Roffman, et al., 1993). In one intervention study mentioned previously, gay men who served as popular opinion leaders were trained to deliver AIDS risk reduction messages to other gay men who frequented gay bars. The result of this intervention was that after three months, the number of gay men in the study who practiced unprotected sex was reduced in the range of 15 to 24 percent from baseline levels (Kelly, St. Lawrence, Stevenson, et al., 1992). When this community-based intervention was replicated in other small cities in Wisconsin, Washington, West Virginia, and New York, similar results were found at 9-month follow-up (Kelly, Winett, Roffman, et al., 1993). The goal of attracting socially isolated men into participating in safer sex educational activities was accomplished by an intervention designed by and for young gay men aged 18 to 29. This intervention reduced unprotected anal intercourse among its subjects, from 33 percent at baseline to 25 percent at 9-month follow-up in one experimental city, however, little change was observed at follow-up in control cities (Kegeles

Suggested Citation:"3 UNDERSTANDING THE DETERMINANTS OF HIV RISK BEHAVIOR." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
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et al., 1993). Although these experiments effected short-term behavioral change among gay men as a result of community-level peer education, both long-term impact and generalizability to other risk groups remain to be demonstrated.

In a number of African countries, a combination of peer-led education with free condom distribution has been used to attempt to change behaviors among commercial sex workers and their clients (Lamptey, 1991; Welsh et al., 1992); however, so far, only a few programs have been evaluated for their effectiveness (Asamoah-Adu et al., 1994; Williams et al., 1992; Wilson et al., 1993). In the Nigerian state of Cross River, community-based interventions trained commercial sex workers, clients, and brothel owners and managers as peer educators, initiated community outreach by peer educators, and distributed condoms at brothels (Williams et al., 1992). A follow-up evaluation one year later found that consistent condom use had increased from 12 percent to 24 percent and, among clients, AIDS knowledge had improved and attitudes toward condom efficacy were more favorable. In Zimbabwe a similar community-level peer education and condom distribution program resulted in increased consistent condom use among sex workers (8.6 percent at baseline to 58.3 percent at 1-year follow-up) and clients (25.4 percent at baseline to 44.7 percent at follow-up) (Wilson et al., 1993). Consistent condom use by sex workers and their clients in Ghana rose from 6 percent in 1987 to 71 percent in 1988 and then fell back to 64 percent in 1991 (Asamoah-Adu et al., 1994). Condom distribution strategies have been widely used, but more careful study should be initiated to determine their efficacy in reducing HIV infections. Also, interventions should target steady partners of sex workers, since it appears that sex workers use condoms less frequently in their personal relationships than in their interactions with clients (Dorfman, Derish, and Cohen, 1992; NRC, 1990b).

The impact of AIDS education on other adult heterosexual has mostly come from mass media campaigns directed at the general public. Several studies have found evidence that these campaigns have had an impact on AIDS knowledge, attitudes, and behavior (Hausser et al., 1988; Izazola, Valdespino, and Sepulveda, 1988; Lehmann et al., 1987; Mills, Campbell, and Waters, 1986; Moatti et al., 1992; Wober, 1988). For example, media campaigns in Switzerland that included mail distribution of an AIDS informational booklet and multimedia advertisements promoting condom use, nonsharing of syringes, and monogamy resulted in a demonstrated increase in AIDS knowledge, condom sales, and condom use (Hausser et al., 1988; Lehmann et al., 1987).

Suggested Citation:"3 UNDERSTANDING THE DETERMINANTS OF HIV RISK BEHAVIOR." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
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Injection Drug Use

Research results from evaluations of needle exchange programs have been highly promising in showing reductions in risky drug using behavior, despite the fact that none of the evaluation studies was a randomized, controlled trial (due to the extreme difficulty of conducting such a trial in this context). In a 1993 report prepared for CDC, Lurie and Reingold (1993) reviewed sixteen such studies and found that among the 14 that evaluated the impact of needle exchange programs on the sharing of syringes, 10 demonstrated decreases in sharing and 4 showed no change. Of the 8 studies that evaluated the impact of needle exchange programs on frequency of drug injection, 3 showed a decrease, 4 showed no change, and one found that needle exchange clients were less likely to stop using drugs than a comparison group. Because these studies did not specifically address the interaction of needle exchange programs and risky sexual behavior, no firm conclusions were made in this regard (see Lurie and Reingold, 1993, for details).

In the NIDA-sponsored National AIDS Demonstration Research Program (NADR), (see Box 6.1 in Chapter 6), street outreach projects that recruited out-of-treatment injection drug users into HIV prevention services contributed to a substantial reduction in the percentage of injection drug users who shared needles—from 48 percent at baseline to 24 percent at follow-up 6 months later (Stephens et al., 1993). Drug users and their sex partners also increased their consistent use of condoms by 9 percent as a result of this program (see Stephens et al., 1993, for details). Social networks of injection drug users were also targeted for peer-led street outreach in the NADR program. In one study in Chicago, 86 percent of subjects stopped sharing injection equipment and HIV seroconversion rates dropped substantially as a result of the network-approach intervention, from 5 percent at baseline to less than 1 percent at the follow-up four years later (Wicbel et al., 1993).

MAINTAINING BEHAVIOR CHANGE AND PREVENTING RELAPSE

Initiating change in risky behavior is only the first step in controlling the spread of HIV/AIDS. Maintaining behavior change over time is a much more significant challenge. Because many years may elapse between a person's initial infection with HIV and the onset of serious AIDS symptoms, people infected with

Suggested Citation:"3 UNDERSTANDING THE DETERMINANTS OF HIV RISK BEHAVIOR." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
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HIV must consistently restrict their sexual expression and drug use to only those acts that are safe if they are to avoid transmission of HIV to their sex and drug-using partners. Also, because HIV infection is highly concentrated within some well-defined subpopulations, each unsafe act within those groups conveys far greater risk for HIV transmission. Broad, if not universal, efforts to initiate and maintain risk reduction are necessary for avoiding continued high HIV seroconversion levels, especially among communities at higher risk. Research on sustained behavioral risk reductions has primarily focused on gay men. Although it should broaden to other groups, findings from this research may significantly contribute to all HIV prevention efforts.

Using longitudinal data from the San Francisco Men's Health Study, Ekstrand and Coates (1990) discovered that after a period of engaging only in safer sex, 16 percent of participants reinitiated unprotected insertive anal intercourse and 12 percent reinitiated unprotected receptive anal intercourse. A replication study—also among gay men in San Francisco—similarly found that it was more common for men to return to unsafe sexual practices after a period of exclusively safer sex than to engage consistently in highrisk sex (Stall et al., 1990). Given the fact that HIV prevention efforts for gay men have traditionally focused almost exclusively on initiation of safer sex techniques, these findings as well as those of other longitudinal studies (Hart et al., in press; Kippax et al., 1991; O'Reilly et al., 1990) clearly indicate that ensuring consistent maintenance of safer sex over long periods of time is a challenge.

The variability in rates of maintenance of safer sexual practices reported in such studies might reflect differences in sampling methods, measurement of sexual risk, observation, time periods, number of observations, the effect of loss due to follow-up bias, and prevalence of risk-taking behaviors across different populations of gay men. However, one finding that is clear from all the studies, despite these important methodological differences is that some portion of gay men reinitiate riskier sexual behaviors after a period of safer sexual behaviors, and that this behavioral pattern could be the source of continuing HIV seroconversions.

The research described above relies exclusively on self-reported data, the validity of which have been discussed at length elsewhere (NRC, 1991). While self-reporting remains the best available methodology for obtaining information about AIDS risk behaviors in diverse populations, it is useful to supplement and

Suggested Citation:"3 UNDERSTANDING THE DETERMINANTS OF HIV RISK BEHAVIOR." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
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validate these data with a reliable biological outcome measure of seroconversion where possible.

One study that did so (Kingsley et al., 1991) used data from the Multicenter AIDS Cohort Study (MACS), a four-city study of gay-identified men, and found that declines in HIV seroconversion observed during the first three years of the study were reversed by the fifth year, by which time 11.3 percent of the men who were initially HIV negative were estimated to have seroconverted. Based on the health education offered to study participants (including HIV testing) and based on the fact that the cohort defined by the study is aging, the researchers believed that this estimate of new seroconversions was conservative when applied to the community at large.

Correlates of nonmaintenance of safer sex techniques have been empirically detected from several longitudinal research projects. These correlates include low self-efficacy, heavy drug or alcohol use, having sex under the influence of drugs or alcohol, having larger numbers of sex partners, having had sex before 1984 with someone diagnosed with AIDS, relative youth, and depression (Kelly, St. Lawrence, and Brasfield, 1991; O'Reilly et al., 1990; Stall et al., 1990). In addition to individual behavioral factors, certain social factors may influence nonmaintenance of safer sex behaviors, such as lack of community support for risk reduction, social support or pressure to take health risks, high reinforcement value for unprotected sex, and identification of unprotected anal intercourse as a favorite sexual act (Kelly, St. Lawrence, and Brasfield, 1991; O'Reilly et al., 1990; Stall et al., 1990). Identifying and understanding these correlates may have more significant impact on HIV prevention than does measuring the rates of long-term behavior maintenance.

Identifying the characteristics of gay men who have seroconverted may also provide useful information about nonmaintenance of behavioral risk reduction over time. Racial/ethnic minority status, youth, lower education levels, lower socioeconomic status, and higher likelihood of cocaine or amphetamine use have been identified as correlates of HIV seroconversion in several independent studies (Kingsley et al., 1991; Waight and Miller, 1991; Willoughby et al., 1990). However, because these analyses were conducted using data sets that were not specifically designed to study nonmaintenance of safer sex techniques over time, and because many of the earlier study cohorts are aging, new cohorts of men who have sex with men should be formed in order to specifically study safer sex behavioral maintenance issues. Also, most of the

Suggested Citation:"3 UNDERSTANDING THE DETERMINANTS OF HIV RISK BEHAVIOR." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
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analyses conducted so far have not had the benefit of a theoretical model of HIV risk behavior lapse. In order to develop both basic and applied research in this area, exploratory, inductive, retrospective research designs should be employed to identify conditions under which maintenance of safer sex techniques is attenuated.

That reductions in risk behavior among men who have sex with men have been maintained at all is a tribute to the successful interventions employed within these communities. However, successful HIV prevention requires long-term, community-wide maintenance of risk reduction which in turn calls for the development of new intervention models, especially those that target multiple risk behaviors.

EVALUATING THE EFFECTS OF AIDS INTERVENTIONS

Although identifying behavioral changes is an important outcome measure for AIDS preventive interventions, these changes do not automatically translate into reductions in HIV transmission in ways that are immediately obvious. Moreover, although modifying risky behavior is key to reducing HIV transmission, behavior change alone may not be sufficient for evaluating prevention efforts. However, with few exceptions, an attempt to estimate the number of infections averted has not been included in the design or evaluation of behavior change interventions. While it would not be possible to employ such an analysis to every prevention project, its utility as an approach should be further assessed.

An ideal experimental design would be to compare direct measurement of seroconversions in populations targeted by intervention programs to those of similar populations not receiving the intervention (preferably with random assignment to treatment and control groups). There are difficulties in mounting such large-scale social experiments. For example, interventions targeting entire communities (such as needle exchange programs or making condoms available in schools) do not allow for the easy formation of treatment and control groups, while randomization is virtually impossible in such environments.

Even if one could achieve such experimental setups, the incidence rate of new infections is low even in many populations at relatively highrisk for HIV. This means that unless the number of persons involved in an intervention study is extremely large, it would take many years before conventional statistical methods

Suggested Citation:"3 UNDERSTANDING THE DETERMINANTS OF HIV RISK BEHAVIOR." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
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could prove that a highly successful program is in fact highly successful.

For example, consider an intervention (with 100 in the control group and 100 in the intervention group) that cuts the infection rate in half for a population of injection drug users experiencing an incidence rate of 4 infections per 100 per year. After two years the study would detect on average 7.7 new infections in the control group (incidence of .04) and 3.9 new infections in the intervention group (reduced incidence of .02). Although reducing an infection rate in half is effective, conventional statistical methods would fail to find this difference statistically significant. (Precisely this same issue currently plagues the planning and design of HIV preventive vaccine trials.)

This very issue led a previous National Research Council panel to recommend using behavior change as the primary approach to evaluating AIDS preventive intervention research (NRC, 1991). However, focusing solely on behavior change outcome measures leaves unanswered the fundamental question of how many infections are really averted as a result of prevention programs.

An intermediate course between solely measuring changes in behavior on the one hand, and insisting on lengthy field studies with enormous numbers of subjects on the other is the use of mathematical modeling to provide evidence for how a given prevention activity may reduce infection. The mathematical theory of epidemics is well established, and numerous researchers have applied modeling techniques to gain insights into various aspects of the AIDS epidemic (Anderson and May, 1991; Brookmeyer and Gail, 1993; Castillo-Chavez, 1989; Jager and Ruitenberg, 1992; Kaplan and Brandeau, 1994). These models mathematically integrate the key features of risky behavior (i.e., numbers of unprotected sex partners per person per unit time, number of needle-sharing occasions per person per unit time), epidemiology (i.e., the probability of HIV transmission per potentially infectious exposure, progression of HIV infection through AIDS, AIDS-induced mortality), and demography (i.e., population immigration, birth, and non-AIDS mortality rates). In addition to incorporating behavioral variables, the models allow for incorporation of prevention program operations as demonstrated by studies of needle exchange (Kaplan and O'Keefe, 1993), bleach distribution to injection drug users (Siegel, Weinstein, and Fineberg, 1991), HIV counseling and testing (Brandeau et al., 1993; Gail, Preston, and Piantadosi, 1989), and self-deferral from blood donation (Kaplan and Novick, 1990). Thus, modeling provides an attractive approach to thinking about how prevention

Suggested Citation:"3 UNDERSTANDING THE DETERMINANTS OF HIV RISK BEHAVIOR." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
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programs effect change in HIV transmission, assuming the models are structured to include all relevant parameters.

For example, the evaluation of a needle exchange program in New Haven, Connecticut employs a mathematical model to estimate the impact of the program on HIV transmission among the participants of the needle exchange. The evaluation uses a syringe tracking and testing (STT) system to collect data on needles distributed and returned to the program by using anonymous code names for participants, tracking numbers for needles, and a technique that is capable of detecting HIV in the traces of blood remaining in the syringes. The data derived from the STT have revealed a significant drop in the portion of needles testing positive for HIV, and it is estimated that HIV incidence among needle exchange participants has fallen by 33 percent (Kaplan, 1994; Kaplan and O'Keefe, 1993).

The ability to estimate the impact of an intervention on HIV transmission also contributes to the possibility of conducting a cost-effectiveness assessment of that intervention. In a time of shrinking federal budgets and increasing research costs, the scientific community faces greater pressure to demonstrate the social value of taxpayer-supported research. One measure of value is the cost-to-benefit ratio. In the context of HIV intervention research, dollar costs are both the costs of conducting the intervention itself and the costs of medical care for a person with AIDS. Assuming one could use the methods described above for estimating the number of HIV infections averted by the implementation of an intervention, one could then compare dollars saved in medical costs affiliated with those infections with dollars spent on conducting the intervention. One could then make an assessment about the value of investing in that particular intervention.

CONCLUSION AND RECOMMENDATIONS

CONCLUSION

Basic science research in the neurobiological, psychological, and social sciences has uncovered a great deal of information about the range of factors underlying the behavior of individuals and groups, information that has been influential in the design of HIV preventive interventions. Theoretical models from psychology have played a particularly significant role. Yet, the mixed results of interventions informed by this basic research suggest that much remains to be learned—in particular, how the biological, psychological,

Suggested Citation:"3 UNDERSTANDING THE DETERMINANTS OF HIV RISK BEHAVIOR." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
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and social dimensions of behavior interact to encourage or prevent risky behavior and to initiate and maintain positive behavior change. Cross-disciplinary research in this regard will play an important role in improving the design and application of HIV preventive interventions.

The efficacy and value of such interventions may be measured by demonstrated, sustained, positive behavior change; but with respect to AIDS prevention, it also is important to show that new infections have been averted by such change. Epidemiological and mathematical methods now exist to assess the efficacy of interventions in this regard—and their cost-to-benefit ratio—and their employment should be considered wherever appropriate.

RECOMMENDATIONS FOR UNDERSTANDING THE DETERMINANTS OF HIV RISK BEHAVIOR

3.1 The committee recommends that NIAAA, NIDA, and NIMH expand basic research on the biology of sexuality as it potentially relates to highrisk sexual behaviors. This might include research on the central nervous system (CNS) sexual systems that mediate sexual behaviors, the CNS neural systems underlying sexual behavior, and the molecular genetics of sexual behaviors.

3.2 The committee recommends that NIAAA, NIDA, and NIMH expand research on the biology of substance abuse to provide additional knowledge for approaching highrisk behaviors. This might include research to define structure-activity relationships in the function of dopamine systems; the role of noradrenergic systems and molecular mechanisms in the components of addiction (including euphoria, tolerance, sensitization, and withdrawal); the role of opiate peptide receptor subtypes in components of the addiction-abuse syndrome; as well as research to identify mechanisms of cocaine addiction.

3.3 The committee recommends that, where appropriate, NIAAA, NIDA, and NIMH coordinate their efforts with other relevant federal agencies (e.g., other NIH institutes, the National Science Foundation) that are also attempting to integrate biological, behavioral, and social research to define highrisk behaviors.

3.4 The committee recommends that NIAAA, NIDA, and NIMH support AIDS research that integrates theories of gender

Suggested Citation:"3 UNDERSTANDING THE DETERMINANTS OF HIV RISK BEHAVIOR." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
×

(identity, development, and dynamics) and behavior change models.

3.5 The committee recommends that NIAAA, NIDA, and NIMH expand the research effort examining social and structural factors (such as class, race/ethnicity, gender relations, and community) that increase risk for AIDS, affect progression of disease, and provide points of intervention. This might require research that takes as the unit of analysis the social context and relationship (e.g., dyads, families, communities) in which HIV occurs—as opposed to the individual at risk of or who has HIV.

3.6 The committee recommends that NIAAA, NIDA, and NIMH, in conjunction with other NIH institutes, develop new and existing woman-controlled HIV/STD prevention methods (e.g., female condoms and microbicides) and examine the social and behavioral issues related to their use.

3.7 The committee recommends that NIAAA, NIDA, and NIMH support basic and applied research on the maintenance of behavior change, for example, risky sexual behavior and alcohol and other drug-using behavior, including the prevention of relapse. (The committee notes that this has been recommended in previous NRC reports—AIDS: The Second Decade, 1990; AIDS, Sexual Behavior, and Intravenous Drug Use, 1989—but has not been attended to adequately.)

3.8 The committee recommends that NIAAA, NIDA, and NIMH expand funding for HIV intervention research initiatives, particularly those that: (1) have rigorous evaluation components; (2) investigate motivations, intentions, and barriers in addition to behavior change; (3) include outcome measures in addition to behavior change, such as HIV seroprevalence, STD rates, and pregnancy rates; and (4) target a full range of racial/ethnic, gender, and cultural groups for the purpose of assessing between-group differences.

3.9 The committee recommends that NIAAA, NIDA, and NIMH support research that estimates the number of HIV infections averted by current prevention efforts and that includes cost estimates for these efforts.

Suggested Citation:"3 UNDERSTANDING THE DETERMINANTS OF HIV RISK BEHAVIOR." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
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AIDS and Behavior: An Integrated Approach Get This Book
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HIV is spreading rapidly, and effective treatments continue to elude science. Preventive interventions are now our best defense against the epidemic--but they require a clear understanding of the behavioral and mental health aspects of HIV infection and AIDS.

AIDS and Behavior provides an update of what investigators in the biobehavioral, psychological, and social sciences have discovered recently about those aspects of the disease and offers specific recommendations for research directions and priorities.

This volume candidly discusses the sexual and drug-use behaviors that promote transmission of HIV and reports on the latest efforts to monitor the epidemic in its social contexts. The committee reviews new findings on how and why risky behaviors occur and efforts to develop strategies for changing such behaviors. The volume presents findings on the disease's progression and on the psychosocial impacts of HIV and AIDS, with a view toward intervention and improved caregiving.

AIDS and Behavior also evaluates the status of behavioral and prevention aspects of AIDS research at the National Institute of Mental Health, the National Institute on Drug Abuse, and the National Institute on Alcohol Abuse and Alcoholism.

The volume presents background on the three institutes; their recent reorganization; their research budgets, programs, and priorities; and other important details. The committee offers specific recommendations for the institutes concerning the balance between biomedical and behavioral investigations, adequacy of administrative structures, and other research management issues.

Anyone interested in the continuing quest for new knowledge on preventing HIV and AIDS will want to own this book: policymakers, researchers, research administrators, public health professionals, psychologists, AIDS advocates and service providers, faculty, and students.

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