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Some weeks ago, PGN ran an article by syndicated columnist, Paul Varnell, entitled “Forget safe-sex programs”. Varnell expressed the frustration shared by many of us who have been working in HIV prevention and public health over the past two decades of the epidemic. Despite a wealth of knowledge about how HIV is transmitted, despite peoples’ intentions to keep from being HIV infected, and despite years of community HIV prevention efforts infection rates have continued to remain consistent (1,2). In fact, infection rates have increased in some groups of men that have sex with men (3). While this frustration is felt by most people concerned with HIV prevention, those frustrations do not lead public health professionals to conclude that HIV prevention efforts should cease and that HIV prevention funding should be diverted into vaccine research.
While vaccine development has proven critical to the advancement of our communities’ health, a solitary focus on vaccine research ignores the numerous and essential factors of the HIV epidemic, as well as other current social health issues. HIV has taught us a more general lesson: A new organism can make its way into the gay community at any time and can spread far and wide before we have a name for it and long before we have a vaccine for it. Indeed, HIV is only the most dramatic example of a range of diseases that were on the rise even before the AIDS epidemic; diseases such as hepatitis B, herpes, intestinal parasites, gonorrhea, and syphilis. What makes us think HIV is the last microbial challenge we will face? It is in the long-range interest of our community to have “safer sex” as a disease prevention technique, even if HIV is ultimately conquered.
Varnell’s point that “simply going through the motions of HIV prevention education, by providing education that may not be effective, makes no sense”, is well taken. There now exists ample evidence that simple factual presentations about how HIV is transmitted, basic condom distribution, and HIV prevention media campaigns in the absence of well crafted, culturally appropriate, and scientifically tested health-change methods, are not effective in helping people protect themselves from HIV infection (4). There is a difference between what we can’t do with prevention and what we just haven’t done yet. Scuttling HIV prevention at this point, because we haven’t yet found the answers would be something like giving up on air travel because the Wright Brothers only got 23 seconds out of the first flight. As community health workers and public health professionals we must push beyond these ineffective programs and do the hard work needed to find new ways of promoting our communities’ health.
Do the changes in the HIV epidemic over the last 20 years mean that prevention work is now pointless? Or do they simply mean that prevention work must recognize the complexity of our lives and the factors that affect our health? Most people know that tobacco kills, that exercise promotes health, and that obesity is a serious epidemic, yet smoking, physical inactivity, and obesity remain significant health concerns. The Centers for Disease Control and Prevention and other federal agencies, however, have not used that fact to argue that we should give up on health promotion efforts in those areas. Rather, they have argued that we need to fund new and aggressive health promotion efforts that are supported by sound evidence of effectiveness.
Human beings as a species are not particularly good at altering their behavior, particularly behavior that is as emotionally charged as sex, eating, or addiction. Behavior change is interwoven with a complex set of intrapsychic issues such as self-esteem, belief in one’s own ability to control one’s life, mood state, and motivations. Most importantly, behaviors such as sex do not happen in a vacuum. HIV infection always occurs in the context of a relationship; a partnership, a sexual act between two or more people, as well as a set of cultural, sexual and social norms. We need to know more about what leads us to take sexual risks and what leads us to practice protective behaviors. We need to have a deeper understanding of the complex intrapersonal, interpersonal and social factors that lead to our sexual behaviors. And, we need to use that knowledge to develop prevention programs that work.
Research has already given us some clues that are worth future investigation and may lead to new ways to promote the health of our communities. Some research has suggested that for some gay men HIV infection is viewed as “no big deal.”(5). Others research suggests, that some men driven by the “youth, body, or party culture” in the gay community, can’t imagine themselves living a fulfilling old age, so why should they try? Research has also suggested that when people feel that they have little control over their lives in general, they are less likely to take on self-protective behaviors and more likely to engage in risk (6,7,8). The use of alcohol and other drugs has also shown to be connected to sexual health risk (9, 10). This is only a partial list of the factors at play, but would anyone imagine that a single afternoon’s workshop would completely tackle even this abbreviated list?
Twenty years into the HIV epidemic we do have evidence that certain HIV prevention and health promotion techniques work, despite the great difficulties and expense in conducting the research to prove this point. Recently, comprehensive reviews of HIV prevention research studies have been conducted to address these very questions. The good news is that HIV prevention can work for many men who have sex with men. Programs featuring interpersonal skills development and programs that address the range of intrapersonal to social factors seem to be the most effective. Community level and small group interventions are two ways to effectively engage men in this work. The bad news is that we need much more research, designed to answer what intervention components are most effective, and what works better with specific subpopulations (11, 12).
While we remain hopeful for the development of an effective vaccine for HIV, now is the time for more, rather than fewer resources to invest in HIV prevention and health promotion efforts directed to the gay community. Additionally, such efforts need to be based on evidence of effectiveness. Because research has shown some HIV prevention efforts to be effective, and others not as effective it is all the more important to build upon what is known and what has been done to date. Vaccine research is important, but a focus on vaccine development will not prevent new HIV infections until a vaccine is developed and widely utilized.
The SafeGuards Project has chosen to invest in evidence-based strategies tied to community needs evaluation and research, for effective health promotion techniques. SafeGuards staff has developed new outreach techniques and added skills building to discussion groups because of such research. The Board, staff and volunteers of The SafeGuards Project are committed to the ongoing process of asking hard questions, learning about the needs of our communities, and evolving to meet those needs. We will continue to craft and evaluate culturally appropriate and scientifically tested health-change programs, so that we can ensure that our health promotion efforts are actually making a difference. At the same time, it is important to be realistic about the magnitude of the impact that we can hope to have. The need for better prevention programs doesn’t mean we should close up shop. In fact, that’s the worst thing we could do. It’s our responsibility to our communities not just to keep the lights on, but also to keep trying - until we know what works.
by Drew Bills, Brian M. Green, Richard P. Keeling, and John Whyte. This was originally published as Guest Commentary response in the Philadelphia Gay News, August 2002.
Footnotes:(1) Centers for Disease Control and Prevention (2001). “HIV Incidence among Young Men Who Have Sex with Men-Seven U.S. Cities.” MMWR 50(21): 440-444.
(2) Centers for Disease Control and Prevention (2002). Divisions of HIV/AIDS Prevention Surveillance Report, Centers for Disease Control and Prevention.
(3) Wolitski, R. J., Waldiserri, R. O., Denning, P. H., et al. (2001). “Are We Headed for a Resurgence of the HIV Epidemic among Men Who Have Sex with Men.” American Journal of Public Health 91(6): 883-888.
(4) Holtgrave, D. R., Qualls, N. L., Curran, J. W., et al. (1995). “An Overview of the Effectiveness and Efficiency of HIV Prevention Programs.” Public Health Reports 110: 34-46.
(5) Remein, R. H. and Smith, R. A. (2000). “HIV Prevention in the Era of HAART: Implications for Providers.” AIDS Reader 10: 247-251.
(6) Wulfert, E. and Wan, C. K. (1993). “Condom Use: A Self-Efficacy Model.” Health Psychology 12: 346-353.
(7) Bandura, A. (1994). Social Cognitive Theory and Exercise of Control over HIV. Preventing AIDS: Theories and Methods of Behavioral Interventions. R. J. DiClemente, & Peterson,J.L. New York, Plenum Press: 25-59.
(8) Lauby, J. L., Semaan, S., Cohen, A., et al. (1998). “Self-Efficacy Decisional Balance and Stages of Change for Condom Use Among Women at Risk for HIV Infection.” Health Education Research 13(3): 343-356.
(9) Chesney, M. A., Barrett, D. C. and Stall, R. (1998). “Histories of Substance Use and Risk Behavior: Precursors to HIV Seroconversion in Homosexual Men.” American Journal of Public Health 88(1): 113-116.
(10) Purcell, D. W., Parsons, J. T., Halkitis, P. N., et al. (2001). “Substance Use and Sexual Transmission Risk Behavior of HIV-Positive Men Who Have Sex with Men.” Journal of Substance Abuse 13: 185-200.
(11) Johnson, W.D., et al. (2002). “HIV prevention research for men who have sex with men: A systematic review and meta-analysis.” Journal of Acquired ImmuneDeficiency Syndromes, 30:S118-S129
(12) Centers for Disease Control and Prevention (1999). Compendium of HIV Prevention Interventions with Evidence of Effectiveness. Atlanta, GA: CDC.
August 15th, 2003 | HIV/STD, Communities, Gay Men, Advocacy .
