BEHAVIORAL CHANGE THROUGH EMPOWERMENT: PREVENTION OF AIDS David Ting, BS, and James H. Carter, MD, FAPA Durham, North Carolina
The acquired immunodeficiency syndrome (AIDS) will undoubtedly present health professionals, researchers, and policymakers with the greatest definitive challenge of the 1990s. Indeed, over the past 5 years, AIDS has replaced cancer as the preeminent health concern of the American public.1
PATHOLOGY AND EPIDEMIOLOGY OF AIDS To evaluate preventive interventions, one must first understand the targeted disease and the nature of its victims. Briefly stated, AIDS is a lethal immune deficiency disorder caused by the human immunodeficiency virus (HIV), resulting in the destruction of human CD4+ T-lymphocytes.2 Clinical symptoms of frank AIDS include lymphadenopathy, weight loss, fever, sweats, diarrhea, and alopecia; concomitant symptoms often include Pneumocystis carinii pneumonia and Kaposi's sarcoma.3 It is now believed that seroconversion from an occult infection to overt disease may not occur until 7 to 15 years after HIV infection.4 In the United States, HIV continues to be transmitted mainly by direct and intimate contact with infected body fluids, primarily blood, semen, and vaginal secretions. It may also be transmitted vertically, iatrogenically by blood transfer, and through contaminated needles.5 Nevertheless, nearly one third of the AIDS cases reported in 1988 occurred among intraveFrom the Department of Psychiatry, Duke University Medical Center, Durham, North Carolina. Presented on May 28, 1990 to the Human Behavior Seminar, Duke University School of Medicine, Durham, NC. Requests for reprints should be addressed to Dr James H. Carter, Dept of Psychiatry, Duke University Medical Center, Durham, NC 27710. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 3
nous (IV) drug. users and their sex partners, the majority of these being black or Hispanic. In addition, an alarming number of teenagers and even neonates born to HIV-positive mothers have developed HIV infections.6'7 Thus far, no vaccine or effective cure exists for AIDS, although the public outcry has certainly mandated continued research toward a clinical cure.8 Consequently, the only viable option today for the prevention of AIDS rests in radical behavioral changes, leading to the elimination of high-risk activity. Changes recommended by the US Centers for Disease Control to reduce the risk of AIDS include: * Reduction of the number of sex partners, resulting in a stable, mutually monogamous relationship with an uninfected person. * Protection of self during sexual activity with any possibly infected person by taking appropriate precautions to prevent contact with the person's blood, semen, or vaginal secretions. * For IV drug abusers, enrollment or continuance in programs to eliminate abuse of IV substances. Needles, other paraphernalia, and drugs must never be shared.9 In short, the recommendations for AIDS prevention call for dramatic changes in two areas of human behavior that seem at best taboo and at worst intractable (ie, sexual practices and IV drug abuse). Effecting societal change in these behaviors poses a formidable challenge to health planners and providers. Yet, these changes represent the only entirely effective measures for preventing AIDS and must be pursued seriously and deliberately. Almost unanimously, AIDS experts and public 225
GUEST EDITORIAL
policymakers agree that education represents the key to achieving societal behavioral modifications. Baldwin et al conclude that education and counseling aimed at high-risk groups must be the first priority; they allude to two essential elements of education: a target audience and the subject matter.10 The target populations for intervention include the general public, school- and college-aged populations, persons infected or at increased risk of infection, racial minorities, and health workers.11" 2 As to subject matter, health providers are currently encouraged to advocate the use of condoms as a means of facilitating "safe sex," to discourage promiscuous sex and abstinence from IV drug use.13415 In short, the thrust of prevention currently rests with presenting objective facts concerning transmission and prevention of AIDS in the hope that the target audience will apply that information toward eliminating risktaking behavior.
inconvenience. We contend that by emphasizing condom use in lieu of monogamy, health providers and counselors merely reinforce patients' unhealthy behaviors, while creating a false sense of security. Similarly, an emphasis on safe needle use may detract from the more important issues of treatment and rehabilitation from drug use. In fact, such information may contribute to the genocide of African Americans and Hispanics who are devastated by drugs and AIDS.
Fostering Helplessness The current strategy in prevention involves presenting objective facts related to AIDS. In these instances, people are given a mandate-but not the means-to modify their behavior, which can increase a sense of helplessness and apathy. Consequently, they simply abandon the advice and continue their habitual practices.
Sociocultural Barriers to Prevention CURRENT STATE OF PREVENTION Education programs have accomplished mixed success in modifying behavior among high-risk groups. There are reports that some populations of drug users have indeed begun to practice safer needle use, but have not significantly altered their sexual behavior.16 Observations suggest that adolescents and college students, despite increased knowledge of health risks associated with high-risk sexual practices, have not dramatically changed their sexual practices and neither have they abandoned their use of illicit IV drugs.17 Thus, education or the dissemination of information alone have not proven to be completely effective as a means of modifying destructive behavior. Therefore, the salient question is, why has AIDS education failed?
SPECIFIC DEFICITS Faults in the current educational methods include: * an emphasis on compromise, * fostering helplessness, and * disregarding sociocultural barriers to prevention.
A third significant barrier to education-centered prevention involves sociocultural barriers to target audiences. In short, the intervention sites and the information presented, as well as racial, sociocultural, and gender insensitivities, can prevent successful intervention. For example, in its attempt to develop a comprehensive health education program, the Detroit Health Department noted that traditional biases between the health department and the high-risk groups (ie, homosexual and bisexual males, and IV drug abusers) hampered the ability of the intervention team to design a clinic-centered program.19 Schuster reports that one of the greatest physical barriers to AIDS prevention among IV drug users lies in physically locating the drug users.20 Once located, language and value differences can prevent effective communication, thereby diminishing effective intervention. It should be noted, however, that pairing an indigenous community paraprofessional with a professional has been shown to help bridge sociocultural gaps among all concerned.2'
Emphasis on Compromise
A CONCEPT FROM COMMUNITY PSYCHOLOGY
Goldsmith advocates the use of "condom sense" as an adjunct to "common sense" in thinking about sex and AIDS.18 He heralds the condom as the key to "safe sex," while admitting that condom use is not uncommonly associated with both condom and user failure. This message, typical of the "safe sex" shibboleths presented on television, in advertisements, and in schools, communicates that people can continue to engage in high-risk sexual behavior with a minimum of
Conventional methods of prevention, eg, educational, professional-centered programs, must be improved. The ultimate goals are to: 1) positively impact behavior modification without reinforcing negative behavior, 2) offer the target population a means of achieving lasting behavior modification, and 3) design programs of prevention with special relevance to the target population that eliminates racial and sociocultural barriers. Over the past 20 years, psychologists working within
226
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 3
GUEST EDITORIAL
the discipline of community psychology have developed the concept of empowerment, a concept applicable to AIDS prevention among minorities. Rappaport defines empowerment as a process by which people, organizations, and communities gain mastery over their lives.22 More specifically, empowerment is a concept that stresses both individual determination over one's own life and democratic participation in the life of one's community. The notion of empowerment presupposes that community members have the competency to intervene on their own behalf but lack the necessary resources. Thus, we believe that AIDS prevention is most effective when planned, executed, and propagated by members of the target minority community. As a hallmark of empowerment, professional involvement is neither required nor solicited beyond the initial recruitment stage. Empowerment, as an adjunct to AIDS education, rectifies the overriding aforementioned problems of current methods for AIDS prevention. To wit, it provides minorities with a tool by which they can apply AIDS information toward making substantial changes in their individual lives.
THE APPLICATION OF EMPOWERMENT Principles of prevention that incorporate an empowerment concept are: locating strategic intervention sites, emphasizing empowerment, providing alternatives to high-risk behavior, imposing more strict media controls, and encouraging community-based programs.
routinely visit health-care facilities (eg, African Americans and Hispanics).
Emphasizing Empowerment Factors Interventionists must go beyond expounding AIDS information and begin to support and offer guidance for minorities in the quest for empowerment. For some, the source of empowerment might be found through family, religion, or self-esteem; for others, empowerment may result from applying principles from health behavior models, such as the Health Belief Model.23
Providing Alternatives to High-Risk Behavior Typically, when the interventionist asks an individual to modify his or her sexual or drug behavior, the interventionist in effect asks the individual to abstain from a practice that is most likely habitual and pleasurable. Therefore, effective intervention must offer pleasurable and less dangerous alternatives to the original high-risk behavior. Such alternatives may include youth clubs, interest groups, community organizations, religious groups, sports organizations, employment opportunities, and support groups. In fact, an alternative site may be the "rap shops," where Hispanic and African-American youngsters from highrisk groups can gather to discuss health issues in a nonthreatening environment.
Imposing Strict Media Controls
Locating Strategic Intervention Sites It is our belief that the best sites for distributing AIDS information and training may not be the clinic or the drug rehabilitation center. Instead, the most appropriate intervention sites may be schools, churches, community recreation centers, young men/women Christian associations, and workplaces. Strategically, schools are the most effective sites for intervention for youthful populations. However, in schools, AIDS education should emphasize abstinence from drugs and multiple sex partners. Students should not simply be equipped to make their own decisions on behavior, but must learn to accept responsibility for their choices. Most importantly, parents should be intimately involved with the teaching and counseling process, thus increasing their sense of responsibility and potency. Eventually, school education programs can expand to include community self-help, discussion, or action groups. Moreover, the traditional health settings seem inappropriate to attempt to educate an indigent segment of the population about AIDS who do not JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 3
The ability of the broadcast media to affect change in societal behavior has been amply demonstrated. By age 18, the average American child has spent more time watching television than in a classroom, and throughout adulthood, television plays a dominant role in the lives of most Americans.24 Broadcast and, to a lesser extent, print media hold potential use in empowerment and prevention. Because television and other media significantly impact the behavior of adults and children alike, society must impose stricter controls over the content of materials disseminated through these channels. For instance, portrayals of high-risk sexual activity, drug abuse, and the glorification of those practices must be curtailed. Rather, portrayals of positive behaviors and successful avoidance of negative behaviors should increase, providing both a model of empowerment and a clear message regarding prudent versus imprudent practices.
CONCLUSION During the last decade, AIDS has become an increasingly tragic and notorious disease. Currently, 227
GUEST EDITORIAL
prevention continues to challenge health providers and planners. The methods for AIDS prevention today rely heavily on education, which has generally failed to elicit substantial changes in risk behavior. We theorize that failure may have resulted from an emphasis on compromise, the fostering of helplessness, and the inability to reach target populations geographically and psychologically. Hence, the concept of empowerment is offered as an enhancing concept to current AIDS prevention, particularly among racial minorities. Acquired immunodeficiency syndrome presents a health dilemma, and a clinical solution may not arrive for many years. Acknowledgments The authors thank Gail R. Marsh, PhD, and Francis J. Keefe, PhD, for their assistance and encouragement in preparing this manuscript.
Literature Cited 1. Centers for Disease Control. Update acquired immunodeficiency syndrome (AIDS) worldwide. MMWR. 1 988;37:286-295. 2. Fauci AS. The human immunodeficiency virus: infectivity and mechanisms of pathogenesis. Science. 1 988;239:617-622. 3. Zakowski PC, Gottlieb MS, Groopman J. Acquired immunodeficiency syndrome (AIDS), Kaposi's sarcoma and Pneumocystis carinii pneumonia. Lung Biology in Health and Disease. 1984;22:195-225. 4. Jaffe HW. Acquisition and transmission of HIV. Infect Dis Clin North Am. 1988;2:299-306. 5. Tindall B, Cooper DA, Donovan B, Penny R. Primary HIV infection: clinical and serological aspects. Infect Dis Clin North Am. 1988;2:343-352. 6. Centers for Disease Control. Revision of the CDC surveillance case definition of acquired immunodeficiency syndrome. MMWR. 1987;35:3-15. 7. Yankauer A. AIDS and public health. Am J Public Health. 1988;78:364-366. 8. Daniell FD, Skelly RR, Friedman S. HIV preventive
228
medicine services and public health interventions: the Bethesda experience. MilitMed. 1990;155:27-33. 9. Centers for Disease Control. First 100 000 cases of acquired immunodeficiency syndrome: United States. MMWR. 1989;38:2-8. 10. Baldwin TE, Bertozzi S, Bristow LR. Prevention and control of acquired immunodeficiency syndrome: an interim report. JAMA. 1989;258:2097-2103. 11. Blendon RJ, Donelan K. Discrimination against people with AIDS. N Engl J Med. 1988;319:1022-1026. 12. Wallack JJ. AIDS anxiety among health professionals. Hosp Community Psychiatry. 1989;40:507-51 0. 13. Tucker VL, Cho CT. AIDS and adolescents, how can you help them reduce their risk? Postgrad Med. 1991 ;89:49-53. 14. Centers for Disease Control. HIV-related knowledge and behavior among high school students: selected US sites 1989. MMWR. 1990;39:385-390, 395-397. 15. Solomon CM. Reducing the risk. American Medical Association News. 1990(Oct 5):7. 16. Schilling RF, Schinke SP, Nichols SE, Zayas LH. Developing strategies for AIDS prevention research with black and Hispanic drug users. Public Health Rep. 1989;1 04:2-11. 17. Roscoe B, Kruger TL. AIDS: late adolescents' knowledge and its influence on sexual behavior. Adolescence. 1990;25:39-48. 18. Goldsmith MF. Sex in the age of AIDS calls for common sense and 'condom sense.' JAMA. 1987;257:2261 -2263, 2266. 19. Durlak JA. Comparative effectiveness of paraprofessionals and professional helpers. Psychol Bull. 1979;86:80-92. 20. Schuster CR. Intravenous drug use and AIDS prevention. Public Health Rep. 1988; 103:261 -266. 21. Carter JH, Thornton Cl. Integrating an alcoholism program for low-income blacks in a neighborhood health center. Alcoholism Digest. 1976;5:6-1 0. 22. Shinn M. Expanding community psychology's domain. Am J Community Psychol. 1987; 1 5:557-574. 23. Solomon MZ, Dejong M. Recent sexually transmitted disease prevention efforts and their implications for AIDS health education. Health Educ Q. 1986;13:301 -316. 24. Rubenstein EA. Television and the young viewer. American Scientist. 1978;66:685-693.
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 3
The acquired immunodeficiency syndrome (AIDS) will undoubtedly present health professionals, researchers, and policymakers with the greatest definitive challenge of the 1990s. Indeed, over the past 5 years, AIDS has replaced cancer as the preeminent health concern of the American public.1
PATHOLOGY AND EPIDEMIOLOGY OF AIDS To evaluate preventive interventions, one must first understand the targeted disease and the nature of its victims. Briefly stated, AIDS is a lethal immune deficiency disorder caused by the human immunodeficiency virus (HIV), resulting in the destruction of human CD4+ T-lymphocytes.2 Clinical symptoms of frank AIDS include lymphadenopathy, weight loss, fever, sweats, diarrhea, and alopecia; concomitant symptoms often include Pneumocystis carinii pneumonia and Kaposi's sarcoma.3 It is now believed that seroconversion from an occult infection to overt disease may not occur until 7 to 15 years after HIV infection.4 In the United States, HIV continues to be transmitted mainly by direct and intimate contact with infected body fluids, primarily blood, semen, and vaginal secretions. It may also be transmitted vertically, iatrogenically by blood transfer, and through contaminated needles.5 Nevertheless, nearly one third of the AIDS cases reported in 1988 occurred among intraveFrom the Department of Psychiatry, Duke University Medical Center, Durham, North Carolina. Presented on May 28, 1990 to the Human Behavior Seminar, Duke University School of Medicine, Durham, NC. Requests for reprints should be addressed to Dr James H. Carter, Dept of Psychiatry, Duke University Medical Center, Durham, NC 27710. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 3
nous (IV) drug. users and their sex partners, the majority of these being black or Hispanic. In addition, an alarming number of teenagers and even neonates born to HIV-positive mothers have developed HIV infections.6'7 Thus far, no vaccine or effective cure exists for AIDS, although the public outcry has certainly mandated continued research toward a clinical cure.8 Consequently, the only viable option today for the prevention of AIDS rests in radical behavioral changes, leading to the elimination of high-risk activity. Changes recommended by the US Centers for Disease Control to reduce the risk of AIDS include: * Reduction of the number of sex partners, resulting in a stable, mutually monogamous relationship with an uninfected person. * Protection of self during sexual activity with any possibly infected person by taking appropriate precautions to prevent contact with the person's blood, semen, or vaginal secretions. * For IV drug abusers, enrollment or continuance in programs to eliminate abuse of IV substances. Needles, other paraphernalia, and drugs must never be shared.9 In short, the recommendations for AIDS prevention call for dramatic changes in two areas of human behavior that seem at best taboo and at worst intractable (ie, sexual practices and IV drug abuse). Effecting societal change in these behaviors poses a formidable challenge to health planners and providers. Yet, these changes represent the only entirely effective measures for preventing AIDS and must be pursued seriously and deliberately. Almost unanimously, AIDS experts and public 225
GUEST EDITORIAL
policymakers agree that education represents the key to achieving societal behavioral modifications. Baldwin et al conclude that education and counseling aimed at high-risk groups must be the first priority; they allude to two essential elements of education: a target audience and the subject matter.10 The target populations for intervention include the general public, school- and college-aged populations, persons infected or at increased risk of infection, racial minorities, and health workers.11" 2 As to subject matter, health providers are currently encouraged to advocate the use of condoms as a means of facilitating "safe sex," to discourage promiscuous sex and abstinence from IV drug use.13415 In short, the thrust of prevention currently rests with presenting objective facts concerning transmission and prevention of AIDS in the hope that the target audience will apply that information toward eliminating risktaking behavior.
inconvenience. We contend that by emphasizing condom use in lieu of monogamy, health providers and counselors merely reinforce patients' unhealthy behaviors, while creating a false sense of security. Similarly, an emphasis on safe needle use may detract from the more important issues of treatment and rehabilitation from drug use. In fact, such information may contribute to the genocide of African Americans and Hispanics who are devastated by drugs and AIDS.
Fostering Helplessness The current strategy in prevention involves presenting objective facts related to AIDS. In these instances, people are given a mandate-but not the means-to modify their behavior, which can increase a sense of helplessness and apathy. Consequently, they simply abandon the advice and continue their habitual practices.
Sociocultural Barriers to Prevention CURRENT STATE OF PREVENTION Education programs have accomplished mixed success in modifying behavior among high-risk groups. There are reports that some populations of drug users have indeed begun to practice safer needle use, but have not significantly altered their sexual behavior.16 Observations suggest that adolescents and college students, despite increased knowledge of health risks associated with high-risk sexual practices, have not dramatically changed their sexual practices and neither have they abandoned their use of illicit IV drugs.17 Thus, education or the dissemination of information alone have not proven to be completely effective as a means of modifying destructive behavior. Therefore, the salient question is, why has AIDS education failed?
SPECIFIC DEFICITS Faults in the current educational methods include: * an emphasis on compromise, * fostering helplessness, and * disregarding sociocultural barriers to prevention.
A third significant barrier to education-centered prevention involves sociocultural barriers to target audiences. In short, the intervention sites and the information presented, as well as racial, sociocultural, and gender insensitivities, can prevent successful intervention. For example, in its attempt to develop a comprehensive health education program, the Detroit Health Department noted that traditional biases between the health department and the high-risk groups (ie, homosexual and bisexual males, and IV drug abusers) hampered the ability of the intervention team to design a clinic-centered program.19 Schuster reports that one of the greatest physical barriers to AIDS prevention among IV drug users lies in physically locating the drug users.20 Once located, language and value differences can prevent effective communication, thereby diminishing effective intervention. It should be noted, however, that pairing an indigenous community paraprofessional with a professional has been shown to help bridge sociocultural gaps among all concerned.2'
Emphasis on Compromise
A CONCEPT FROM COMMUNITY PSYCHOLOGY
Goldsmith advocates the use of "condom sense" as an adjunct to "common sense" in thinking about sex and AIDS.18 He heralds the condom as the key to "safe sex," while admitting that condom use is not uncommonly associated with both condom and user failure. This message, typical of the "safe sex" shibboleths presented on television, in advertisements, and in schools, communicates that people can continue to engage in high-risk sexual behavior with a minimum of
Conventional methods of prevention, eg, educational, professional-centered programs, must be improved. The ultimate goals are to: 1) positively impact behavior modification without reinforcing negative behavior, 2) offer the target population a means of achieving lasting behavior modification, and 3) design programs of prevention with special relevance to the target population that eliminates racial and sociocultural barriers. Over the past 20 years, psychologists working within
226
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 3
GUEST EDITORIAL
the discipline of community psychology have developed the concept of empowerment, a concept applicable to AIDS prevention among minorities. Rappaport defines empowerment as a process by which people, organizations, and communities gain mastery over their lives.22 More specifically, empowerment is a concept that stresses both individual determination over one's own life and democratic participation in the life of one's community. The notion of empowerment presupposes that community members have the competency to intervene on their own behalf but lack the necessary resources. Thus, we believe that AIDS prevention is most effective when planned, executed, and propagated by members of the target minority community. As a hallmark of empowerment, professional involvement is neither required nor solicited beyond the initial recruitment stage. Empowerment, as an adjunct to AIDS education, rectifies the overriding aforementioned problems of current methods for AIDS prevention. To wit, it provides minorities with a tool by which they can apply AIDS information toward making substantial changes in their individual lives.
THE APPLICATION OF EMPOWERMENT Principles of prevention that incorporate an empowerment concept are: locating strategic intervention sites, emphasizing empowerment, providing alternatives to high-risk behavior, imposing more strict media controls, and encouraging community-based programs.
routinely visit health-care facilities (eg, African Americans and Hispanics).
Emphasizing Empowerment Factors Interventionists must go beyond expounding AIDS information and begin to support and offer guidance for minorities in the quest for empowerment. For some, the source of empowerment might be found through family, religion, or self-esteem; for others, empowerment may result from applying principles from health behavior models, such as the Health Belief Model.23
Providing Alternatives to High-Risk Behavior Typically, when the interventionist asks an individual to modify his or her sexual or drug behavior, the interventionist in effect asks the individual to abstain from a practice that is most likely habitual and pleasurable. Therefore, effective intervention must offer pleasurable and less dangerous alternatives to the original high-risk behavior. Such alternatives may include youth clubs, interest groups, community organizations, religious groups, sports organizations, employment opportunities, and support groups. In fact, an alternative site may be the "rap shops," where Hispanic and African-American youngsters from highrisk groups can gather to discuss health issues in a nonthreatening environment.
Imposing Strict Media Controls
Locating Strategic Intervention Sites It is our belief that the best sites for distributing AIDS information and training may not be the clinic or the drug rehabilitation center. Instead, the most appropriate intervention sites may be schools, churches, community recreation centers, young men/women Christian associations, and workplaces. Strategically, schools are the most effective sites for intervention for youthful populations. However, in schools, AIDS education should emphasize abstinence from drugs and multiple sex partners. Students should not simply be equipped to make their own decisions on behavior, but must learn to accept responsibility for their choices. Most importantly, parents should be intimately involved with the teaching and counseling process, thus increasing their sense of responsibility and potency. Eventually, school education programs can expand to include community self-help, discussion, or action groups. Moreover, the traditional health settings seem inappropriate to attempt to educate an indigent segment of the population about AIDS who do not JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 3
The ability of the broadcast media to affect change in societal behavior has been amply demonstrated. By age 18, the average American child has spent more time watching television than in a classroom, and throughout adulthood, television plays a dominant role in the lives of most Americans.24 Broadcast and, to a lesser extent, print media hold potential use in empowerment and prevention. Because television and other media significantly impact the behavior of adults and children alike, society must impose stricter controls over the content of materials disseminated through these channels. For instance, portrayals of high-risk sexual activity, drug abuse, and the glorification of those practices must be curtailed. Rather, portrayals of positive behaviors and successful avoidance of negative behaviors should increase, providing both a model of empowerment and a clear message regarding prudent versus imprudent practices.
CONCLUSION During the last decade, AIDS has become an increasingly tragic and notorious disease. Currently, 227
GUEST EDITORIAL
prevention continues to challenge health providers and planners. The methods for AIDS prevention today rely heavily on education, which has generally failed to elicit substantial changes in risk behavior. We theorize that failure may have resulted from an emphasis on compromise, the fostering of helplessness, and the inability to reach target populations geographically and psychologically. Hence, the concept of empowerment is offered as an enhancing concept to current AIDS prevention, particularly among racial minorities. Acquired immunodeficiency syndrome presents a health dilemma, and a clinical solution may not arrive for many years. Acknowledgments The authors thank Gail R. Marsh, PhD, and Francis J. Keefe, PhD, for their assistance and encouragement in preparing this manuscript.
Literature Cited 1. Centers for Disease Control. Update acquired immunodeficiency syndrome (AIDS) worldwide. MMWR. 1 988;37:286-295. 2. Fauci AS. The human immunodeficiency virus: infectivity and mechanisms of pathogenesis. Science. 1 988;239:617-622. 3. Zakowski PC, Gottlieb MS, Groopman J. Acquired immunodeficiency syndrome (AIDS), Kaposi's sarcoma and Pneumocystis carinii pneumonia. Lung Biology in Health and Disease. 1984;22:195-225. 4. Jaffe HW. Acquisition and transmission of HIV. Infect Dis Clin North Am. 1988;2:299-306. 5. Tindall B, Cooper DA, Donovan B, Penny R. Primary HIV infection: clinical and serological aspects. Infect Dis Clin North Am. 1988;2:343-352. 6. Centers for Disease Control. Revision of the CDC surveillance case definition of acquired immunodeficiency syndrome. MMWR. 1987;35:3-15. 7. Yankauer A. AIDS and public health. Am J Public Health. 1988;78:364-366. 8. Daniell FD, Skelly RR, Friedman S. HIV preventive
228
medicine services and public health interventions: the Bethesda experience. MilitMed. 1990;155:27-33. 9. Centers for Disease Control. First 100 000 cases of acquired immunodeficiency syndrome: United States. MMWR. 1989;38:2-8. 10. Baldwin TE, Bertozzi S, Bristow LR. Prevention and control of acquired immunodeficiency syndrome: an interim report. JAMA. 1989;258:2097-2103. 11. Blendon RJ, Donelan K. Discrimination against people with AIDS. N Engl J Med. 1988;319:1022-1026. 12. Wallack JJ. AIDS anxiety among health professionals. Hosp Community Psychiatry. 1989;40:507-51 0. 13. Tucker VL, Cho CT. AIDS and adolescents, how can you help them reduce their risk? Postgrad Med. 1991 ;89:49-53. 14. Centers for Disease Control. HIV-related knowledge and behavior among high school students: selected US sites 1989. MMWR. 1990;39:385-390, 395-397. 15. Solomon CM. Reducing the risk. American Medical Association News. 1990(Oct 5):7. 16. Schilling RF, Schinke SP, Nichols SE, Zayas LH. Developing strategies for AIDS prevention research with black and Hispanic drug users. Public Health Rep. 1989;1 04:2-11. 17. Roscoe B, Kruger TL. AIDS: late adolescents' knowledge and its influence on sexual behavior. Adolescence. 1990;25:39-48. 18. Goldsmith MF. Sex in the age of AIDS calls for common sense and 'condom sense.' JAMA. 1987;257:2261 -2263, 2266. 19. Durlak JA. Comparative effectiveness of paraprofessionals and professional helpers. Psychol Bull. 1979;86:80-92. 20. Schuster CR. Intravenous drug use and AIDS prevention. Public Health Rep. 1988; 103:261 -266. 21. Carter JH, Thornton Cl. Integrating an alcoholism program for low-income blacks in a neighborhood health center. Alcoholism Digest. 1976;5:6-1 0. 22. Shinn M. Expanding community psychology's domain. Am J Community Psychol. 1987; 1 5:557-574. 23. Solomon MZ, Dejong M. Recent sexually transmitted disease prevention efforts and their implications for AIDS health education. Health Educ Q. 1986;13:301 -316. 24. Rubenstein EA. Television and the young viewer. American Scientist. 1978;66:685-693.
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 3
