AIDS Care
ISSN: 0954-0121 (Print) 1360-0451 (Online) Journal homepage: http://www.tandfonline.com/loi/caic20
Some lessons learned about risk reduction after ten years of the HIV/AIDS epidemic J. A. Kelly & D. A. Murphy To cite this article: J. A. Kelly & D. A. Murphy (1991) Some lessons learned about risk reduction after ten years of the HIV/AIDS epidemic, AIDS Care, 3:3, 251-257, DOI: 10.1080/09540129108253070 To link to this article: http://dx.doi.org/10.1080/09540129108253070
Published online: 25 Sep 2007.
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Date: 06 November 2015, At: 17:25
AIDS CARE, VOL. 3, NO. 3, 1991
251
Some lessons learned about risk reduction after ten years of the HIWAIDS epidemic J. A. KELLY& D. A. MURPHY Downloaded by [University of Cambridge] at 17:25 06 November 2015
Community Health Behavior Program, Medical College of Wisconsin, Milwaukee, USA
Introduction While much has changed in our understanding of HIV in the decade since the first AIDS cases were diagnosed, one observation first made early in the epidemic still holds true. Behaviour change and prevention are the best and only available means of curtailing the continued spread of HIV infection. In spite of continued scientific work towards a vaccine, none is presently in sight. There is every reason to believe that a 20-year anniversary review on HIV risk reduction would also begin by noting that behaviour change is the best and perhaps only means of preventing HIV infection. Our success in preventing new HIV infections throughout the 1990s will depend upon how well we learn from, adapt and expand upon the prevention lessons of the first decade of AIDS. It is now possible to draw several conclusions about HIV/AIDS prevention, that can help guide behaviour change initiatives in the future. In this brief review we summarize the key elements of what is known about HIV risk behaviour change.
HIV/AIDS risk reduction Community education programmes about HIV and AIDS have increased public knowledge about risk Perhaps the most fundamental change over the past ten years in the area of prevention is that people in most communities have become much more knowledgeable about HIV and AIDS, about behaviours that confer risk and about risk reduction steps. Mass public education media campaigns, grassroots outreach programmes in the gay and intravenous drug user (IVDU) communities, and education programmes in schools and health service settings in most Western countries have greatly increased basic knowledge about steps for protecting against HIV, such as using condoms, avoiding unprotected intercourse or not sharing needles (DiClemente et al., 1990; Hardy, 1990). Although some groups have not yet been reached with adequate HIV risk education-chiefly, adolescents and those in inner-city areas as well as the populations of many developing countries-'front line' educational campaigns have proved successful within both the general population and in communities at elevated risk.
Address for correspondence: Jeffrey A. Kelly, Ph.D., Department of Psychiatry and Mental Health Sciences, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA.
252 J. A. KELLY L D. A. MURPHY
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Risk reduction is determined by many factors other than knowledge about risk It is axiomatic in most health behaviour areas that knowledge of risk alone is not sufficient to produce behaviour change for most people. The same holds true for HIV and AIDS. Research conducted over the past ten years has established that many factors predict the adoption of risk reduction behaviour change. These include personalization of risk or believing oneself vulnerable to AIDS (Emmons et al., 1986; Kelly et al., 1990a); having the cognitive and behavioural skills needed to implement risk reduction steps and believing oneself capable of personally effecting behaviour change (Kelly et al., 1989; McKusick et al., 1985); making changes in one’s environment to facilitate risk reduction efforts-including social networks and substance use patterns (Kelly et al., 1989; Stall et al., 1986); the type of relationship between the two sexual partners, with less safer sex compliance among affectionate couples than among casual contacts (Kelly et al., in press; McKusick et al., 1985); and perceiving precautionary changes to be consistent with the norms, values, and expectations of one’s own peer group (Kelly et al., 1990b; McKusick et al., 1985). If we assume that people who continue to engage in risk behaviour are cognitively knowledgeable about AIDS, it becomes clear that future prevention efforts must better address factors such as those above.
Gay men, especially in large cities hard hit by AIDS, have made signifcant behaviour changes to reduce risk Longitudinal cohort studies of gay men in San Francisco, New York, and other AIDS epicentres have convincingly demonstrated substantial reductions in high-risk behaviour since the early 1980s (Coates et al., 1988; Martin, 1987; McCusker et al., 1987). This finding, as well as decreased needle-sharing by IVDU’s in cities hard-hit by AIDS (Des Jarlais et al., 1985; Friedman et al., 1987) constitutes what is perhaps the best news to date in HIV prevention. However, even this good news must be viewed cautiously, since a large proportion of these populations were already infected before behaviour changes were made. Furthermore, recent data indicate that a substantial proportion of gay men are ‘relapsing’ back to unsafe sex either on an occasional or frequent basis (Ekstrand & Coates, 1990; Kelly et al., 1991a; Kelly et al., in press). HIV seroprevalence among gay men varies by city, region, country and the behavioural characteristics of the population. This ranges from about 50% among gay men in San Francisco and 38% in New York to much lower levels in other areas (Curran et al., 1988). Nonetheless, because HIV prevalence has increased so much over the past decade, fewer episodes of high-risk behaviour are now required to confer considerable risk of acquiring HIV infection. From this perspective, it has become important to shift the prevention focus for highly vulnerable populations such as gay men and IVDUs from risk reduction to very consistent, well maintained cessation of the highest risk activities. We still know very little about how to promote potentially lifelong and permanent changes in risky sexual behaviour practices.
Among gay men, the front line for prevention e f l m is shifting to cities not previously considered as traditional AIDS epicentres and to ‘hard to reach’ homosexually active populations A number of studies have demonstrated that HIV risk behaviour rates remain high among the homosexually active who live outside the traditional AIDS epicentres (Kelly et al.,
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1990b; St. Lawrence et al., 1989). Presumably, this is due to less effective prevention efforts and resources; lower perceived fear of AIDS because few cases are personally known; and peer norms that do not yet adequately reinforce safer sex behaviour changes in many communities. While there seems to be a growing popular sterotype that HIV risk behaviour is no longer a major problem for gay men, this impression may be truer for San Francisco, New York, or Los Angeles than for cities and communities with less mobilized prevention resources and where the threat of HIV/AIDS is still viewed by many as distant. Much of what we know about risk reduction among gay men is based on intensively studied and extensively retested longitudinal cohorts in several major AIDS epicentres. These cohorts tend to oversample white gay men who are older, better educated, of higher socioeconomic status and more motivated concerning HIV/AIDS than the community as a whole. These studies are thus likely to overestimate the magnitude of behaviour change in other groups such as young, socioeconomically disadvantaged gay men, those in racial minorities as well as men who have sex with men but who are not gay self-identified or acculturated. ‘Second generation’ prevention models are needed both for gay men who live in smaller cities as well as those who are less well-resourced and harder to reach using traditional channels. Intravenous drug users are concerned about HIVIAIDS and can be engaged to reduce needlesharing risks although sexual risk behaviour is more recalcitrant to change Early in the epidemic, many people believed that IVDUs would be almost unreachable in health promotion efforts. This view has proven incorrect. Numerous studies have documented reductions in needle sharing and reuse, as well as increased evidence of needle cleaning and requests for drug treatment in community IVDU populations (Des Jarlais el al., 1985; Friedman et al., 1987; Jackson 8t Rotkiewicz, 1987). Unfortunately, very little controlled research has been conducted to examine why these changes have occurred. In general they are attributed to community outreach AIDS education; fear among addicts in areas where IVDU deaths due to AIDS are common; implementation of needle exchange programmes for addicts conducted by government, health, and AIDS prevention organizations; and improved access for the urban poor to drug treatment programmes. While it has proved difficult to pinpoint reasons for change in IVDU populations, it is now clear that community-based, practical outreach programmes can effect change in risky drug injection practices. Just as for gay men, most research on HIV risk behaviour among drug addicts has been conducted in major urban epicentres; much less is known about risk and risk reduction changes in IVDU populations outside the several large American and European cities where most studies have been undertaken. Evidence of sexual risk reduction among IVDUs and their partners is much less clearcut than evidence of injection practice risk change. While a number of surveys indicate an awareness of HIVIAIDS risks related to sexual activities and the intention to use condoms (Abdul-Quader et al., 1987; Des Jarlais, 1988), we are aware of no studies that convincingly demonstrate high rates of condom use either by IVDUs or their sexual partners. Thus, there has been little evidence of change in practices that result in HIV transmission from IVDUs to their sexual partners. This carries serious implications for future rates of heterosexuallyor perinatally-transmitted HIV infection especially in areas where drug abuse is prevalent.
Women are at an increasing risk for HIV/AIDS but little is known about efective prevention approaches for females AIDS is now among the 10 leading causes of death in women of reproductive age in the
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254 J. A. KELLY & D. A. MURPHY
United States (Chu et al., 1990). While preliminary prevention studies have been reported (e.g. McDonald et al., 1990), specific approaches most efficacious for women are not known. For example, one programme targeting reduction of high-risk sexual behaviours of female partners of IVDUs (Trapido et al., 1990) found that while half of the subjects made positive changes, 10% made changes that increased their HIV risk and the remainder made no change at all. A major difficulty in developing and conducting outreach programmes with women is that for some cultures AIDS is not just a health issue but also relates to the family power structure. In some ethnic groups females report experiencing verbal or physical abuse when they advocate condom use (Cochran & Mays, 1989), and in some Latin communities it is not considered appropriate for women to discuss sex at all (Worth & Rodriguez, 1987). Such sociocultural factors appear to influence attitudes regarding the basic resources for facilitating HIV prevention. In a survey of over 700 women at contraceptive care clinics, 37% were uncertain of their ability to initiate condom use and 22% felt ‘too embarrassed’ to purchase condoms in a drug store (Valdiserri et al., 1989a). Prevention programmes incorporating behaviour-change skills that have been used in other health risk areas need to be initiated witb women to prevent an epidemic in the USA and elsewhere similar to that seen over the past 10 years in gay men.
HZV has already afected many segments of the adolescent population: developmental factors may make this population the most resistant to change Although adolescents constitute only a small proportion of AIDS cases, the latency period between infection and symptoms indicates that many young adults acquired HIV as teenagers. Risk behaviour is prevalent among adolescents (Broering et al., 1989), many adolescents are still misinformed or confused about HIV transmission (e.g. DiClemente et al., 1988; Strunin & Higson, 1987), and condom use is not popular among adolescents (Kegeles et al., 1988). As of yet, there has been very little study of risk reduction interventions among adolescents. One promising study-the first to demonstrate behaviour change among adolescents-was conducted with runaway adolescents by Rotheram-Borus et a1. (1 990). Intensive intervention resulted in a significant increase in consistent condom use and reductions in the percentage of youths reporting a high-risk pattern of sexual behaviour. Risk-reduction programmes for adolescents are at an early stage of development. The high and growing STD rates among adolescents portend the increasing prevalence of HIV in this population as well.
Cognitive-behavioural skills training interventions can assist individuals and groups in changing risk-producing aspects of their behaviour Even ten years after AIDS was first identified, there have been only a handful of experimentally-controlled risk reduction behaviour change interventions reported in the literature. All the interventions reported to date demonstrating risk behaviour change have involved similar elements. These included a group format, detailed HIV/AIDS risk education, training in cognitive and behavioural skill areas needed to implement change (including sexual assertiveness, condom use, risk reduction problem solving, and risk behaviour selfmanagement skills), reinforcement of change efforts, and practical problem solving of difficult risk situations that are encountered. This form of cognitive-behavioural model has been shown to be effective for gay men (Kelly et al., 1989; Kelly & St. Lawrence, 1990;
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Valdiserri et al., 1989b) and runaway adolescents (Rotheram-Borus et al., 1990) who engage in high-risk behaviour. Public health and AIDS organizations, health and sexuallytransmitted disease clinics, schools, and other programmes regularly provide counselling for persons at risk for HIV and are often called upon to offer or develop risk reduction programmes. Cognitive-behavioural and skills training models have proved useful for such face-to-face intervention provided they are accompanied by appropriate risk behaviour education, are developed to properly sensitize individuals to risk so as to motivate skill learning and use, and are culturally relevant to participants in the intervention.
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Interventions using peer mediators and changing risk reduction social norms hold promise for the promotion of population-wide behaviour change While it is of great importance to develop effective ways to counsel individuals and groups in risk reduction using face-to-face intervention, it is also critical to explore larger-scale population- or community-level behaviour change approaches. An analogy might be drawn with cigarette smoking, where individual smokers may require and benefit from direct assistance in personal behaviour change but where a broader objective is to discourage smoking and encourage smoking cessation among the entire population. From the perspective of HIV prevention, it is increasingly important to examine better ways of promoting norm changes that can facilitate risk reduction at a community level. Relevant norm changes are those that associate social and peer disapproval with high-risk behaviour, associate social reinforcement with the adoption of precautionary changes, and establish peer expectations that favour risk reduction. For several years, it has been apparent that ‘grassroots’ prevention campaigns using credible trained peers as intervention agents are useful in community interventions for IVDUs. In the gay community, ‘STOP AIDS’ (a model based upon peer-led small group education and risk reduction sessions in informal social settings such as people’s homes) has been widely credited with creating norm changes favouring risk reduction. In a recent study, we conducted an experimental community-level test of an intervention intended to promote change in the risk behaviour levels of gay men who live in small cities (Kelly et al., 1991b). In this field study, large numbers of men patronizing gay bars were surveyed to establish risk characteristics of a community population and, in an intervention city, persons most popular and socially influential with their gay male peers were identified and taught how to endorse and recommend risk reduction changes to their friends and acquaintances. At postintervention and through long-term follow-up, significant risk behaviour reductions were found in the experimental city’s population of gay men relative to those in matched control cities, confirming that population-wide behaviour change can be effected through intervention with key opinion leaders of that population (Kelly et al., 1991b). The same approach may well prove useful for promotion of behaviour change in other populations including adolescents, IVDUs and heterosexual adults at risk for HIV. Conclusion
While there have clearly been many advances in our understanding of HIV risk reduction and some evaluation of preventive interventions, much hard work lies ahead. Community AIDS organizations have long been conducting grassroots prevention programmes of an innovative nature, but these have rarely been carefully evaluated. It is now essential to integrate more closely community interventions with research evaluation methodologies so
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that ineffective approaches can be discarded and effective approaches widely disseminated. The paucity of published intervention studies of risk reduction behaviour change remains striking. Among gay men, there is a need to quickly refocus attention on maintaining longterm change and to reach the many populations and individuals that have not yet effected consistent, meaningful risk behaviour change. HIV/AIDS prevention in minority communities and with the socioeconomically disadvantaged requires the development of new, culturally-relevant approaches that address HIV risk in the context of many competing life concerns, demands, and stressors associated with disadvantage. Even 10 years after AIDS was first reported, women and adolescents vulnerable to HIV have still received scant attention with respect to prevention and behaviour change. In the Third World, we have barely identified the magnitude of the HIV epidemic and done little yet to change it. Now, just as a decade ago, prevention remains one of our greatest and most urgent challenges.
Acknowledgements Preparation of this article was supported by National Institute of Mental Health grants R01MH41800, R01-MH44149, and R01-MH42908.
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KEGELES,S.M., ADLER,N.E. & IRWIN, C.E., JR (1988) Sexually active adolescents and condoms: changes over one year in knowledge, attitudes and use, American Journal of Public Health, 78(4), pp. 460-461. KELLY,J.A., ST. LAWRENCE, J.S., HOOD,H.V. & BRASFIELD, T.L. (1989) Behavioral intervention to reduce AIDS risk activities, Journal of Consulting and Clinical Psychology, 57, pp. 60-67. KELLY,J.A. & ST. LAWRENCE, J.S. (1990) The impact of community-based groups to help persons reduce HIV infection risk behaviors, AIDS Care, 2, pp. 25-36. KELLY,J.A., ST. LAWRENCE, J.S., BRASFIELD et al. (1990a) Psychological factors which predict AIDS high-risk and AIDS precautionary behavior, Journal of Consulting and Clinical Psychology, 58, pp. 117-120. J.S., BRASFIELD, T.L., STEVENSON, L.Y., DIM, Y.E. & HAUTH,A.C. (1990b) AIDS KELLY,J.A., ST. LAWRENCE, risk behavior patterns among gay men in small cities, American Journal of Public Health, 80, pp. 416-418. KELLY,J.A., ST. LAWRENCE, J.S. & BRASFIELD, T.L. (1991a) Predictors of vulnerability to AIDS risk behavior relapse, Journal of Consulting and Clinical Psychology, 59, pp. 163-166. J.S., DIM, Y.E. et al. (1991b) HIV risk behavior reduction following intervention with KELLY,J.A., ST. LAWRENCE, key opinion leaders of a population: an experimental community-level analysis, Ametican Journal of Public Health, 81, pp. 168-171. KELLY,J.A., KALICHMAN,S.C.,KAUTH, M.R. et al. (1991~)Situational factors associated with AIDS risk behavior lapses and coping strategies used by gay men who successfully avoid lapses, American Journal of Public Health, in press. ~ ~ R T I NJ.L. , (1987) The impact of AIDS on gay male sexual behavior patterns in New York City, American Journal of Public Health, 77, pp. 578-581. S.P. (1988) Effects of HIV MCCUSKER, J., STODDARD, A.M., MAYER,K.M., ZAPKA, J., MORRISON,C. & SALTZMAN, antibody test knowledge on subsequent sexual behaviors in a cohort of homosexually active men, Amm’can Journal of Public Healzh, 70, pp. 462-467. D. (1990) Developing AIDS education for women in county WIC clinics, MCDONALD, M., KLEPPEL,L. & JENSSEN, American Journal of Public Health, 80, pp. 1391-1392. T.J. et al. (1985) Reported changes in the sexual behavior of men at risk for MCKUSICK, L., WILEY,J.A., COATES, AIDS San Francisco 1982-1984, The AIDS Behavioral Research Project, Public Health Reports, 100, pp. 622-629. ROTHERAM-BORUS, M.J., KOOPMAN, C. & HAIGNERE,C. (1990) Reducing HIV sexual risk behaviors among runaway adolescents. Paper presented at the VI International Conference on AIDS, San Francisco. J.S.,HOOD,H.V., BRASFIELD, T.L. & KELLY,J.A. (1989) AIDS risk knowledge and risk behavior ST. LAWRENCE, among homosexual men in high- and low-AIDS prevalence cities, Public Health Reports, 104, pp. 391-395. L., WILEY,J., COATES,T.J. & OSTROW,D.G. (1986) Alcohol and drug use during sexual STALL,R., MCKUSICK, activity and compliance with safe sex guidelines for AIDS, Health Educational Quarterly, 13, pp. 359-371. STRUNIN,L. & HINGSON,R. (1 987) Acquired immunodeficiency syndrome and adolescents: knowledge, beliefs, attitudes, and behaviors, Pediatrics, 79(5), pp. 825-828. TWIM), E., CHITWOOD, D., McKAY, C. & VOGEL,J. (1990) AIDS risk behavior change in female sexual partners of IVD’DLls. Paper presented at the Sixth International Conference on AIDS, San Francisco, California. R.O.,ARENA,V.C., PROCTOR,D. & BONATI,F.A. (1989a) The relationship between women’s attitudes VALDISERRI, about condoms and their use: implications for condom promotion programs, American Journal of Public Health, 79, pp. 499-501. C.R. (1989b) VALDISERRI, R.O., LYTER, D.W., LEVITON,L.C., CALLAHAN, C.M., KINGSLEY, L.A.. & RINALDO, AIDS prevention in homosexual and bisexual men: results of a randomized trial evaluating two risk reduction interventions, AIDS, 3(1), pp. 21-26. WORTH, D. & RODRIGUEZ,R. (1987) Latina women and AIDS, SIECUS Report, January-February, pp. 5-7.
ISSN: 0954-0121 (Print) 1360-0451 (Online) Journal homepage: http://www.tandfonline.com/loi/caic20
Some lessons learned about risk reduction after ten years of the HIV/AIDS epidemic J. A. Kelly & D. A. Murphy To cite this article: J. A. Kelly & D. A. Murphy (1991) Some lessons learned about risk reduction after ten years of the HIV/AIDS epidemic, AIDS Care, 3:3, 251-257, DOI: 10.1080/09540129108253070 To link to this article: http://dx.doi.org/10.1080/09540129108253070
Published online: 25 Sep 2007.
Submit your article to this journal
Article views: 7
View related articles
Citing articles: 6 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=caic20 Download by: [University of Cambridge]
Date: 06 November 2015, At: 17:25
AIDS CARE, VOL. 3, NO. 3, 1991
251
Some lessons learned about risk reduction after ten years of the HIWAIDS epidemic J. A. KELLY& D. A. MURPHY Downloaded by [University of Cambridge] at 17:25 06 November 2015
Community Health Behavior Program, Medical College of Wisconsin, Milwaukee, USA
Introduction While much has changed in our understanding of HIV in the decade since the first AIDS cases were diagnosed, one observation first made early in the epidemic still holds true. Behaviour change and prevention are the best and only available means of curtailing the continued spread of HIV infection. In spite of continued scientific work towards a vaccine, none is presently in sight. There is every reason to believe that a 20-year anniversary review on HIV risk reduction would also begin by noting that behaviour change is the best and perhaps only means of preventing HIV infection. Our success in preventing new HIV infections throughout the 1990s will depend upon how well we learn from, adapt and expand upon the prevention lessons of the first decade of AIDS. It is now possible to draw several conclusions about HIV/AIDS prevention, that can help guide behaviour change initiatives in the future. In this brief review we summarize the key elements of what is known about HIV risk behaviour change.
HIV/AIDS risk reduction Community education programmes about HIV and AIDS have increased public knowledge about risk Perhaps the most fundamental change over the past ten years in the area of prevention is that people in most communities have become much more knowledgeable about HIV and AIDS, about behaviours that confer risk and about risk reduction steps. Mass public education media campaigns, grassroots outreach programmes in the gay and intravenous drug user (IVDU) communities, and education programmes in schools and health service settings in most Western countries have greatly increased basic knowledge about steps for protecting against HIV, such as using condoms, avoiding unprotected intercourse or not sharing needles (DiClemente et al., 1990; Hardy, 1990). Although some groups have not yet been reached with adequate HIV risk education-chiefly, adolescents and those in inner-city areas as well as the populations of many developing countries-'front line' educational campaigns have proved successful within both the general population and in communities at elevated risk.
Address for correspondence: Jeffrey A. Kelly, Ph.D., Department of Psychiatry and Mental Health Sciences, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA.
252 J. A. KELLY L D. A. MURPHY
Downloaded by [University of Cambridge] at 17:25 06 November 2015
Risk reduction is determined by many factors other than knowledge about risk It is axiomatic in most health behaviour areas that knowledge of risk alone is not sufficient to produce behaviour change for most people. The same holds true for HIV and AIDS. Research conducted over the past ten years has established that many factors predict the adoption of risk reduction behaviour change. These include personalization of risk or believing oneself vulnerable to AIDS (Emmons et al., 1986; Kelly et al., 1990a); having the cognitive and behavioural skills needed to implement risk reduction steps and believing oneself capable of personally effecting behaviour change (Kelly et al., 1989; McKusick et al., 1985); making changes in one’s environment to facilitate risk reduction efforts-including social networks and substance use patterns (Kelly et al., 1989; Stall et al., 1986); the type of relationship between the two sexual partners, with less safer sex compliance among affectionate couples than among casual contacts (Kelly et al., in press; McKusick et al., 1985); and perceiving precautionary changes to be consistent with the norms, values, and expectations of one’s own peer group (Kelly et al., 1990b; McKusick et al., 1985). If we assume that people who continue to engage in risk behaviour are cognitively knowledgeable about AIDS, it becomes clear that future prevention efforts must better address factors such as those above.
Gay men, especially in large cities hard hit by AIDS, have made signifcant behaviour changes to reduce risk Longitudinal cohort studies of gay men in San Francisco, New York, and other AIDS epicentres have convincingly demonstrated substantial reductions in high-risk behaviour since the early 1980s (Coates et al., 1988; Martin, 1987; McCusker et al., 1987). This finding, as well as decreased needle-sharing by IVDU’s in cities hard-hit by AIDS (Des Jarlais et al., 1985; Friedman et al., 1987) constitutes what is perhaps the best news to date in HIV prevention. However, even this good news must be viewed cautiously, since a large proportion of these populations were already infected before behaviour changes were made. Furthermore, recent data indicate that a substantial proportion of gay men are ‘relapsing’ back to unsafe sex either on an occasional or frequent basis (Ekstrand & Coates, 1990; Kelly et al., 1991a; Kelly et al., in press). HIV seroprevalence among gay men varies by city, region, country and the behavioural characteristics of the population. This ranges from about 50% among gay men in San Francisco and 38% in New York to much lower levels in other areas (Curran et al., 1988). Nonetheless, because HIV prevalence has increased so much over the past decade, fewer episodes of high-risk behaviour are now required to confer considerable risk of acquiring HIV infection. From this perspective, it has become important to shift the prevention focus for highly vulnerable populations such as gay men and IVDUs from risk reduction to very consistent, well maintained cessation of the highest risk activities. We still know very little about how to promote potentially lifelong and permanent changes in risky sexual behaviour practices.
Among gay men, the front line for prevention e f l m is shifting to cities not previously considered as traditional AIDS epicentres and to ‘hard to reach’ homosexually active populations A number of studies have demonstrated that HIV risk behaviour rates remain high among the homosexually active who live outside the traditional AIDS epicentres (Kelly et al.,
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1990b; St. Lawrence et al., 1989). Presumably, this is due to less effective prevention efforts and resources; lower perceived fear of AIDS because few cases are personally known; and peer norms that do not yet adequately reinforce safer sex behaviour changes in many communities. While there seems to be a growing popular sterotype that HIV risk behaviour is no longer a major problem for gay men, this impression may be truer for San Francisco, New York, or Los Angeles than for cities and communities with less mobilized prevention resources and where the threat of HIV/AIDS is still viewed by many as distant. Much of what we know about risk reduction among gay men is based on intensively studied and extensively retested longitudinal cohorts in several major AIDS epicentres. These cohorts tend to oversample white gay men who are older, better educated, of higher socioeconomic status and more motivated concerning HIV/AIDS than the community as a whole. These studies are thus likely to overestimate the magnitude of behaviour change in other groups such as young, socioeconomically disadvantaged gay men, those in racial minorities as well as men who have sex with men but who are not gay self-identified or acculturated. ‘Second generation’ prevention models are needed both for gay men who live in smaller cities as well as those who are less well-resourced and harder to reach using traditional channels. Intravenous drug users are concerned about HIVIAIDS and can be engaged to reduce needlesharing risks although sexual risk behaviour is more recalcitrant to change Early in the epidemic, many people believed that IVDUs would be almost unreachable in health promotion efforts. This view has proven incorrect. Numerous studies have documented reductions in needle sharing and reuse, as well as increased evidence of needle cleaning and requests for drug treatment in community IVDU populations (Des Jarlais el al., 1985; Friedman et al., 1987; Jackson 8t Rotkiewicz, 1987). Unfortunately, very little controlled research has been conducted to examine why these changes have occurred. In general they are attributed to community outreach AIDS education; fear among addicts in areas where IVDU deaths due to AIDS are common; implementation of needle exchange programmes for addicts conducted by government, health, and AIDS prevention organizations; and improved access for the urban poor to drug treatment programmes. While it has proved difficult to pinpoint reasons for change in IVDU populations, it is now clear that community-based, practical outreach programmes can effect change in risky drug injection practices. Just as for gay men, most research on HIV risk behaviour among drug addicts has been conducted in major urban epicentres; much less is known about risk and risk reduction changes in IVDU populations outside the several large American and European cities where most studies have been undertaken. Evidence of sexual risk reduction among IVDUs and their partners is much less clearcut than evidence of injection practice risk change. While a number of surveys indicate an awareness of HIVIAIDS risks related to sexual activities and the intention to use condoms (Abdul-Quader et al., 1987; Des Jarlais, 1988), we are aware of no studies that convincingly demonstrate high rates of condom use either by IVDUs or their sexual partners. Thus, there has been little evidence of change in practices that result in HIV transmission from IVDUs to their sexual partners. This carries serious implications for future rates of heterosexuallyor perinatally-transmitted HIV infection especially in areas where drug abuse is prevalent.
Women are at an increasing risk for HIV/AIDS but little is known about efective prevention approaches for females AIDS is now among the 10 leading causes of death in women of reproductive age in the
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United States (Chu et al., 1990). While preliminary prevention studies have been reported (e.g. McDonald et al., 1990), specific approaches most efficacious for women are not known. For example, one programme targeting reduction of high-risk sexual behaviours of female partners of IVDUs (Trapido et al., 1990) found that while half of the subjects made positive changes, 10% made changes that increased their HIV risk and the remainder made no change at all. A major difficulty in developing and conducting outreach programmes with women is that for some cultures AIDS is not just a health issue but also relates to the family power structure. In some ethnic groups females report experiencing verbal or physical abuse when they advocate condom use (Cochran & Mays, 1989), and in some Latin communities it is not considered appropriate for women to discuss sex at all (Worth & Rodriguez, 1987). Such sociocultural factors appear to influence attitudes regarding the basic resources for facilitating HIV prevention. In a survey of over 700 women at contraceptive care clinics, 37% were uncertain of their ability to initiate condom use and 22% felt ‘too embarrassed’ to purchase condoms in a drug store (Valdiserri et al., 1989a). Prevention programmes incorporating behaviour-change skills that have been used in other health risk areas need to be initiated witb women to prevent an epidemic in the USA and elsewhere similar to that seen over the past 10 years in gay men.
HZV has already afected many segments of the adolescent population: developmental factors may make this population the most resistant to change Although adolescents constitute only a small proportion of AIDS cases, the latency period between infection and symptoms indicates that many young adults acquired HIV as teenagers. Risk behaviour is prevalent among adolescents (Broering et al., 1989), many adolescents are still misinformed or confused about HIV transmission (e.g. DiClemente et al., 1988; Strunin & Higson, 1987), and condom use is not popular among adolescents (Kegeles et al., 1988). As of yet, there has been very little study of risk reduction interventions among adolescents. One promising study-the first to demonstrate behaviour change among adolescents-was conducted with runaway adolescents by Rotheram-Borus et a1. (1 990). Intensive intervention resulted in a significant increase in consistent condom use and reductions in the percentage of youths reporting a high-risk pattern of sexual behaviour. Risk-reduction programmes for adolescents are at an early stage of development. The high and growing STD rates among adolescents portend the increasing prevalence of HIV in this population as well.
Cognitive-behavioural skills training interventions can assist individuals and groups in changing risk-producing aspects of their behaviour Even ten years after AIDS was first identified, there have been only a handful of experimentally-controlled risk reduction behaviour change interventions reported in the literature. All the interventions reported to date demonstrating risk behaviour change have involved similar elements. These included a group format, detailed HIV/AIDS risk education, training in cognitive and behavioural skill areas needed to implement change (including sexual assertiveness, condom use, risk reduction problem solving, and risk behaviour selfmanagement skills), reinforcement of change efforts, and practical problem solving of difficult risk situations that are encountered. This form of cognitive-behavioural model has been shown to be effective for gay men (Kelly et al., 1989; Kelly & St. Lawrence, 1990;
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Valdiserri et al., 1989b) and runaway adolescents (Rotheram-Borus et al., 1990) who engage in high-risk behaviour. Public health and AIDS organizations, health and sexuallytransmitted disease clinics, schools, and other programmes regularly provide counselling for persons at risk for HIV and are often called upon to offer or develop risk reduction programmes. Cognitive-behavioural and skills training models have proved useful for such face-to-face intervention provided they are accompanied by appropriate risk behaviour education, are developed to properly sensitize individuals to risk so as to motivate skill learning and use, and are culturally relevant to participants in the intervention.
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Interventions using peer mediators and changing risk reduction social norms hold promise for the promotion of population-wide behaviour change While it is of great importance to develop effective ways to counsel individuals and groups in risk reduction using face-to-face intervention, it is also critical to explore larger-scale population- or community-level behaviour change approaches. An analogy might be drawn with cigarette smoking, where individual smokers may require and benefit from direct assistance in personal behaviour change but where a broader objective is to discourage smoking and encourage smoking cessation among the entire population. From the perspective of HIV prevention, it is increasingly important to examine better ways of promoting norm changes that can facilitate risk reduction at a community level. Relevant norm changes are those that associate social and peer disapproval with high-risk behaviour, associate social reinforcement with the adoption of precautionary changes, and establish peer expectations that favour risk reduction. For several years, it has been apparent that ‘grassroots’ prevention campaigns using credible trained peers as intervention agents are useful in community interventions for IVDUs. In the gay community, ‘STOP AIDS’ (a model based upon peer-led small group education and risk reduction sessions in informal social settings such as people’s homes) has been widely credited with creating norm changes favouring risk reduction. In a recent study, we conducted an experimental community-level test of an intervention intended to promote change in the risk behaviour levels of gay men who live in small cities (Kelly et al., 1991b). In this field study, large numbers of men patronizing gay bars were surveyed to establish risk characteristics of a community population and, in an intervention city, persons most popular and socially influential with their gay male peers were identified and taught how to endorse and recommend risk reduction changes to their friends and acquaintances. At postintervention and through long-term follow-up, significant risk behaviour reductions were found in the experimental city’s population of gay men relative to those in matched control cities, confirming that population-wide behaviour change can be effected through intervention with key opinion leaders of that population (Kelly et al., 1991b). The same approach may well prove useful for promotion of behaviour change in other populations including adolescents, IVDUs and heterosexual adults at risk for HIV. Conclusion
While there have clearly been many advances in our understanding of HIV risk reduction and some evaluation of preventive interventions, much hard work lies ahead. Community AIDS organizations have long been conducting grassroots prevention programmes of an innovative nature, but these have rarely been carefully evaluated. It is now essential to integrate more closely community interventions with research evaluation methodologies so
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that ineffective approaches can be discarded and effective approaches widely disseminated. The paucity of published intervention studies of risk reduction behaviour change remains striking. Among gay men, there is a need to quickly refocus attention on maintaining longterm change and to reach the many populations and individuals that have not yet effected consistent, meaningful risk behaviour change. HIV/AIDS prevention in minority communities and with the socioeconomically disadvantaged requires the development of new, culturally-relevant approaches that address HIV risk in the context of many competing life concerns, demands, and stressors associated with disadvantage. Even 10 years after AIDS was first reported, women and adolescents vulnerable to HIV have still received scant attention with respect to prevention and behaviour change. In the Third World, we have barely identified the magnitude of the HIV epidemic and done little yet to change it. Now, just as a decade ago, prevention remains one of our greatest and most urgent challenges.
Acknowledgements Preparation of this article was supported by National Institute of Mental Health grants R01MH41800, R01-MH44149, and R01-MH42908.
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