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AIDS
The Second Decade
Heather G. Miller, Charles F. Turner,
and Lincoln E. Moses, Editors
COMMITTEE ON AIDS RESEARCH AND THE
BEHAVIORAL, SOCIAL, AND STATISTICAL SCIENCES
COMMISSION ON THE BEHAVIORAL AND
SOCIAL SCIENCES AND EDUCATION
NATIONAL RESEARCH COUNCIL
NATIONAL ACADEMY PRESS
WASHINGTON, D.C. 1990
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National Academy Press · 2101 Constitution Avenue, N.W. · Washington, D. C. · 20418
NOTICE: The project that is the subject of this report was approved by the Governing Board
of the National Research Council, whose members are drawn from the councils of the National
Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The
members of the committee responsible for the report were chosen for their special competences
and with regard for appropriate balance.
This report has been reviewed by a group other than the authors according to procedures
approved by a Report Review Committee consisting of members of the National Academy of
Sciences, the National Academy of Engineering, and the Institute of Medicine.
The National Academy of Sciences is a private, nonprofit, self-perpetuating society of
distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance
of science and technology and to their use for the general welfare. Upon the authority of the
charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to
advise the federal government on scientific and technical matters. Dr. Frank Press is president
of the National Academy of Sciences.
The National Academy of Engineering was established in 1964, under the charter of
the National Academy of Sciences, as a parallel organization of outstanding engineers. It is
autonomous in its administration and in the selection of its members, sharing with the National
Academy of Sciences the responsibility for advising the federal government. The National
Academy of Engineering also sponsors engineering programs aimed at meeting national needs,
encourages education and research, and recognizes the superior achievements of engineers. Dr.
Robert M. White is president of the National Academy of Engineering.
The Institute of Medicine was established in 1970 by the National Academy of Sciences
to secure the services of eminent members of appropriate professions in the examination of
policy matters pertaining to the health of the public. The Institute acts under the responsibility
given to the National Academy of Sciences by its congressional charter to be an adviser to the
federal government and upon its own initiative, to identify issues of medical care, research, and
education. Dr. Samuel O. Thier is president of the Institute of Medicine.
The National Research Council was established by the National Academy of Sciences in
1916 to associate the broad community of science and technology with the Academy's purposes
of furthering knowledge and of advising the federal government. Functioning in accordance with
general policies detained by the Academy, the Council has become the principal operating
agency of both the National Academy of Sciences and the National Academy of Engineering in
providing services to the government, the public, and the scientific and engineering communities.
The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Frank
Press and Dr. Robert M. White are chaurnan and vice-chair~nan, respectively, of the National
Research Council.
The work that provided the basis for this volume was supported by a contract from the
U.S. Public Health Service.
Library of Congress Catalog Card Number 90-50389
International Standard Book Number 0-309-04278-X, cloth
International Standard Book Number 0-309-04287-9, paper
Copyright @)1990 by the National Academy of Sciences
Printed in the United States of America
Ant Pang, Joy 199O
Second Pnning, December 1992
Third Printing, May 1993
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Committee on AIDS Research and the
Behavioral, Social, and Statistical Sciences
MARSHALL H. BECKER, School of Public Health, University of Michigan
ROBERT F. BORUCH, Graduate School of Education and Department of
Statistics, University of Pennsylvania
THOMAS J. COATES, Division of General Internal Medicine, and Center for
AIDS Prevention Studies, University of California at San Francisco
RAMON C. CORTINES,* Superintendent of Schools, Sari Francisco Unified
School District
ROBYN M. DAWES, Department of Social and Decision Sciences, Camegie
Mellon University
DON C. DES JARLAIS, Chemical Dependency Institute, Beth Israel Medical
Center, New York, and Mount Sinai School of Medicine
JOHN H. GAGNON, Department of Sociology, State University of New York
at Stony Brook
ALBERT R. JONSEN, Department of Medical History and Ethics, University
of Washington at Seattle
SHIRLEY LINDENBAUM, Department of Anthropology, Graduate Center, City
University of New York
JANE MENKEN (Vice Chair), Department of Sociology, and Population
Studies Center, University of Pennsylvania
LINCOLN E. MOSES (ChairJ, Department of Statistics, Stanford University
CLADD E. STEVENS, The New York Blood Center
BAILUS WALKER, School of Public Health, State University of New York at
Albany
National Research Council Staff
TRACY L. BRANDT, Research Assistant, Committee on AIDS Research and
the Behavioral, Social, and Statistical Sciences
SUSAN L. COYLE, Study Director, Panel on the Evaluation of AIDS
Interventions
KIRSTEN J. JOHNSON, Sr. Project Assistant, Panel on the Evaluation of
AIDS Interventions
HEATHER G. MILLER, Study Director, Panel on AIDS Interventions and
Research
KAREN E. ORLANDO, Sr. Project Assistant, Committee on AIDS Research
and the Behavioral, Social, and Statistical Sciences
JEFFREY S. STROKER, Study Director, Panel on Monitoring the Social
Impact of the AIDS Epidemic
CHARLES F. TURNER, Director, Committee on AIDS Research and the
Behavioral, Social, and Statistical Sciences
* Served through September 1, 1989.
. . .
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Panel on AIDS Interventions and Research
MARSHALL H. BECKER (Chair,, School of Public Health, University of
Michigan
PHILIP W. BLUMSTEIN, Department of Sociology, University of Washington
at Seattle
MARGARET A. CHESNEY, Department of Epidemiology and Biostatistics,
and Center for AIDS Prevention Studies, University of California at San
.
. ~ranclsco
ANKE A. EHRHARDT, HIV Center for Clinical and Behavioral Studies, New
York State Psychiatric Institute, Columbia University
MINDY T. FULLILOVE, HIV Center for Clinical and Behavioral Studies, New
York State Psychiatric Institute, Columbia University
KAREN HEIN, Division of Adolescent Medicine, Albert Einstein College of
Medicine, and Montefiore Medical Center, Bronx, New York
JANE ALLYN PILIAVIN, Department of Sociology, University of Wisconsin at
Madison
JAMES L. SORENSEN, Substance Abuse Services, San Francisco General
Hospital, and University of California at San Francisco
REED V. TUCKSON, March of Dimes Birth Defects Foundation, White
Plains, New York
JAMES A. WILEY, Survey Research Center, University of California at
Berkeley
Consultants
JANE C. BALIN, Department of Sociology, University of Pennsylvania
MIMI CANTWELL, National Academy Press
WENDY CHAVKIN, School of Public Health, Columbia University, and
Chemical Dependency Institute, Beth Israel Medical Center, New York
JUDITH B. COHEN, San Francisco General Hospital, and University of
California at San Francisco
SUSHAMA GUNJAL, National Research Council staff
SAHR J. KPUNDEH, Department of Political Science, Howard University
ANDREW S. LONDON, Department of Sociology, and Population Studies
Center, University of Pennsylvania
LEAH MAZADE, National Academy Press
BARBARA S. MENSCH, School of Public Health, Columbia University
LISA A. RATMANSKY, Department of Sociology, University of Pennsylvania
LAURA RUDKIN-MINIOT, Department of Sociology, Princeton University
PEARL T.C.Y. TOY, San Francisco General Hospital, and University of
California at San Francisco
DOOLEY WORTH, Department of Epidemiology and Social Medicine,
Montefiore Medical Center, Bronx, New York
1V
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Liaison Representatives, U.S. Public Health Service
LINDA ALEXANDER, Walter Reed Army Institute for Research
ZILI AMSEL, National Institute on Drug Abuse
WENDY BALDWIN, National Institute of Child Health and Human
Development
G. STEPHEN BOWEN, Centers for Disease Control
DAVID F. BROWNELL, Centers for Disease Control
VIRGINIA CAIN, National Institute of Child Health and Human Development
ALLAN W. CZARRA, National Heart, Lung, and Blood Institute
WILLIAM W. DARROW, Centers for Disease Control
TIMOTHY J. DONDERO, JR., Centers for Disease Control
ANITA EICHLER, National Institute of Mental Health
JACOB A. GAYLE, Centers for Disease Control
MICHELE KIELY, National Institute of Allergy and Infectious Diseases
LLOYD J. KOLBE, Centers for Disease Control
LYNN LEVIN, Walter Reed Anny Institute for Research
SAMUEL C. MATHENY, Health Resources and Services Administration
KEVIN O 'REILLY, Centers for Disease Control
MARCIA ORY, National Institute on Aging
CHRISTINE PARKER, National Heart, Lung, and Blood Institute
AMY R. SHEON, National Institute of Allergy and Infectious Diseases
ELLEN STOVER, National Institute of Mental Health
MATILDA WHITE RILEY, National Institute on Aging
RONALD W. Watson, National Center for Health Statistics, Centers for
Disease Control
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Preface
It is sometimes difficult today to remember that only 10 years ago the
acquired immune deficiency syndrome (AIDS) was unknown. Dunng
the first decade of this epidemic, more than 65,000 people died from this
disease in the United States, and many more were infected with the human
immunodeficiency virus (HIV), which causes AIDS. We do not know
what effects this epidemic will ultimately have. The available evidence
indicates, however, that the swathe cut by this disease is widening and,
despite considerable efforts to retard the spread of HIV infection, it is
likely that morbidity and mortality from HIV infection will continue
throughout the 1990s.
Dunng the first decade of this epidemic our nation has faced enormous
challenges. Some of those challenges have been met. The development
of tests to detect antibodies to HIV, for example, led to a substantial
reduction in risk associated with transfusions and blood products. Many
challenges, however, remain unmet. One of the most serious and en-
dunng obstacles arises from the thin substrate of facts pertaining to the
prevalence of HIV infection in the United States and to the effectiveness
of alternative strategies to prevent further spread of HIV in our popula-
tion. The nation's future success in curbing the spread of the virus and
reducing the toll exacted by this disease will depend to a great extent
on the nation's commitment to empirical efforts that will improve this
knowledge base.
With this second report, our committee continues the work it began in
1987 to monitor the AIDS epidemic and to investigate issues related to
preventing the transmission of HIV. The committee's deliberations on the
issues discussed in this report began in the spring of 1989 at the behest of
a consortium of Public Health Service agencies that have supported the
work of the committee since its inception. A specially appointed Panel on
AIDS Interventions and Research assisted in this latest effort, as did many
other individuals too numerous to mention here. All gave generously of
. .
V11
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Viii ~ PREFACE
their time and knowledge, for which the committee expresses its sincere
gratitude.
Establishing the scope of a report such as this is always difficult.
There is often tension between keeping the text concise and straightfor-
ward and providing sufficient background material to make the issues
comprehensible to a broad range of readers. This report attempts to tread
a fine tine between satisfying the needs of readers who are expert in at
least one area and those who are being introduced to new topics. The
committee recognizes that it cannot meet the needs of all readers. For
some, the material presented here will be too basic. For those who are
less familiar with these issues, however, it is our hope that this report
will provide a useful introduction.
The topics addressed in the report span a range of substantive ar-
eas, from improving the quality of survey data on behaviors associated
with HIV transmission to modifying the behavior of blood donors. The
report also considers two specific populations in whom much interest
has been centered: adolescents and female prostitutes. The inclusion of
these populations in separate chapters of this report does not signify that
either group is thought to be a major source of infection. Rather, in
the case of adolescents, the committee sought to highlight the opportu-
nity to limit the spread of infection in this population and to encourage
health-promoting behaviors by young people who have, in many cases,
only begun to experiment with risk-associated behaviors. In the case of
female prostitutes, the commiaee's work serves another purpose: to lay
to rest concerns that have lingered since the beginning of the epidemic
that prostitutes were a major bridge for HIV transmission to the larger
heterosexual population. Epidemiologic evidence indicates that HIV in-
fection is not an occupational disease for this group and that it is unlikely
that prostitutes will serve as a major conduit of infection. As is the case
with all women, however, their risk of becoming infected has increased
over the past few years. As the patterns of MV infection have undergone
subtle shifts, there arises a need to focus more attention on the risks that
women in general face.
After a decade of struggle against AIDS, the logical question is:
Where do we go from here? Some individuals claim that the epidemic
has peaked and no longer needs the attention and resources that have
been directed toward it in the past. Others say that there are more press-
ing problems facing our nation. The committee, although recognizing
the frustration that often underlies such viewpoints, finds little credible
evidence that the end of this epidemic is in sight. The picture for the
near future is one of a continuing toll of sickness and death. Behavioral
OCR for page R9
PREFACE ~ iX
change continues to be our primary weapon in retarding the spread of
HIV. Amassing the knowledge needed to better understand and facilitate
behavioral change will require a long-term commitment to rigorous scien-
tific investigation. That commitment must be made and maintained—to
forestall the bleak prospect of a third decade of this epidemic that is little
different from the last.
HEATHER G. MILLER, STUDY Director
CHARLES F. TURNER, Director
LINCOLN E. MOSES, Chair
Committee on AIDS Research and the Behavioral,
Social, and Statistical Sciences
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Acknowledgments
During the course of this study, the committee was assisted by a number
of scientists who took time to share their insights and expertise. To those
who assisted us in our work, the committee extends its sincere thanks
and appreciation. The committee's work has been supported by the U.S.
Public Health Service, and by the Rockefeller, Russell Sage, and Sierra
Foundations.
Note on Contributions
This report is the collective product of the committee, and it was prepared
with the assistance of the committee's Pane] on AIDS Interventions and
Research. The content of this report reflects the deliberations of the
committee, and the report presents the committee's recommendations.
The list below identifies the persons who shared major responsibility for
preparing initial drafts of materials for each chapter in this report. The
committee reviewed all contributions, and they have been revised and
edited in light of the committee's discussions and the comments of outside
reviewers. The purpose of the following alphabetical list, therefore, is
to give credit to individuals but not to assign final responsibility for
the published text. It should also be noted that, although the list covers
major sections of this volume, these sections frequently contain additional
paragraphs or pages from other hands.
SUMMARY: Coyle, Miller, Tumer
CHAPTER 1: Coates, Des Jariais, Miller, Moses, Turner, Worth
CHAPTER 2: Chavkin, Coates, Des lariats, Ehrhardt, Miller, Stryker,
Worth
CHAPTER 3: Des lariats, Ehrhardt, Fullilove, Hein, Menken,
Mensch, Miller, Tumer
CHAPTER 4: Cohen, Coyle
CHAPTER 5: Chesney, Miller, Piliavin, Stevens, Toy
CHAPTER 6: Blumstein, Dawes, Lindenbaum, Rudkin-Miniot,
Sorensen, Turner, Wiley
x
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Contents
SUMMARY ......
1 THE AIDS EPIDEMIC IN THE SECOND DECADE
Introduction, 39
Changing Epidemiology of AIDS in the United States, 43
A Picture of Emerging Risk: AIDS Among Women, 48
Tracking the Epidemic: Data Needs, 67
References, 72
2 PREVENTION: THE CONTINUING CHALLENGE
Impact of Interventions Among Gay Men, 82
Interventions for Intravenous Drug Users, 89
AIDS Prevention Strategies for Women, 92
Maintaining Risk Reduction Behavior, 108
Impediments to Improved Intervention, 114
References, 127
3 AIDS AND ADOLESCENTS.....
Epidemiology of AIDS and HIV Among Adolescents, 148
Behaviors That Put Adolescents at Risk, 167
Intervening to Prevent Further Spread of Infection, 201
What Do Teens Know About AIDS? 208
Reaching Adolescents, 213
Doing Better in the Second Decade, 232
References, 234
X1
38
..81
.147
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Xii ~ CONTENTS
4 INTERVENTIONS FOR FEMALE PROSTITUTES 253
Epidemiology of AIDS and HIV Among Prostitutes, 254
Patterns of Prostitution, 263
Intervention Programs, 270
Impediments to More Effective Interventions, 276
Future Needs and Options for HIV Prevention, 281
References, 283
5 AIDS AND THE BLOOD SUPPLY 289
Brief History and Overview of the Problem, 291
The Blood Collection System in the United States, 292
Maintaining an Adequate Supply of Safe Blood, 297
Protecting the Blood Supply From HIV Infection, 317
Research to Improve the Existing System, 327
Reducing the Risk of HIV Infection Through Appropriate
Use of Transfused Blood and Blood Components, 331
References, 344
6 METHODOLOGICAL ISSUES IN AIDS SURVEYS 359
Fallibility of Measurement in Other Sciences, 362
Recruitment of Respondents in Sex and
Seroprevalence Surveys, 365
Nonsampling Issues in AIDS Surveys, 391
Emp~ncal Studies of Sexual Behaviors, 401
Empirical Studies of Drug-Using Behaviors, 420
Summary of Findings, 428
Improving Validity and Reliability, 430
Ethnographic Studies, 440
Recommendations, 449
References, 450
APPENDIX ...........
INDEX ......
....473
......... 477
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AIDS
The Second Decade
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