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SEXUAL BEHAVIOR AND
I INTRAVENOUS DRUG USE
CHARLES F. TURNER, HEATHER G. MILLER, AND
LINCOLN E. MOSES, Editors
COMMITTEE ON AIDS RESEARCH AND THE
BEHAVIORAL, SOCIAL, AND STATISTICAL SCIENCES
COMMISSION ON BEHAVIORAL AND SOCIAL SCIENCES
AND EDUCATION
NATIONAL RESEARCH COUNCIL
NATIONAL ACADEMY PRESS
WASHINGTON, D.C. 1989
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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 determined 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 chairman and vice-chairman, respectively, of the
National Research Council.
The work that provided the basis for this volume was supported by grants from
the Rockefeller Foundation, the Russell Sage Foundation and by a contract with the
U.S. Public Health Service.
Library of Congress Catalog Card Number 88-43331
ISBN 0-309-03948-7 (paperbound); ~309-03976-2 (hardbound)
Copyright ~ 1989 by the National Academy of Sciences
Printed in the United States of America
First Printing, February 1989
Second Pnnting, August 1989
Third Printing, January 1990
Fourth Printing, February 1990
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Committee on AIDS Research and the Behavioral,
Social, ant} Statistical Sciences
LEWELLYS F. BARKER (NRC FellowJ, National Research Council and American
Red Cross, Washington, D.C.
MARSHALL H. BECKER, School of Public Health, University of Michigan
ROBERT BORUCH, Departments of Psychology and.Statistics, Northwestern
University
TRACY L. BRANDT (Administrative SecretaryJ, National Research Council
LESTER BRESLOW, Division of Cancer Control, School of Public Health,
University of California at Los Angeles
J. BROOKS-GUNN, Education Policy and Research Division, Educational Testing
Service, Princeton, New Jersey
THOMAS J. COATES, Division of General Internal Medicine, Center for AIDS
Prevention Services, University of California at San Francisco
ROBYN M. DAWES, Department of Social and Decision Sciences, Carnegie Mellon
University
DON C. DES JARLAIS, New York State Division of Substance Abuse Services,
New York City, and Rockefeller University
JOHN H. GAGNON, Department of Sociology, State University of New York at
Stonybrook
ALBERT R. JONSEN, Department of Medical History and Ethics, University of
Washington at Seattle
SHIRLEY LINDENBAUM, Department of Anthropology, Graduate Faculty, New
School for Social Research
GARDNER LINDZEY, Center for Advanced Study in the Behavioral Sciences,
Stanford, California
ROBERT M. MAY, Department of Zoology, University of Oxford
JANE MENKEN, Department of Sociology, University of Pennsylvania
HEATHER G. MILLER (Senior Research Associate), National Research Council
LINCOLN E. MOSES (Chair), Department of Statistics, Stanford University
CHARLES F. TURNER (Study Director), National Research Council
BAILUS WALKER, School of Public Health, State University of New York at
Albany
LAURIE SCHWAB ZABIN, Department of Population Dynamics, Johns Hopkins
University School of Hygiene and Public Health
Pane] on Statistical Issues in AIDS Research
JOAN L. ARON, Department of Population Dynamics, Johns Hopkins University
School of Hygiene and Public Health
LYNNE BILLARD, Department of Statistics, University of Georgia
RON S. BROOKMEYER, Department of Biostatistics, Johns Hopkins University
School of Hygiene and Public Health
JANE MENKEN (Chair), Department of Sociology, University of Pennsylvania
LINCOLN E. MOSES, Department of Statistics, Stanford University
BRUCE D. SPENCER, Department of Statistics, Northwestern University
MICHAEL A. STOTO, Division of Health Promotion and Disease Prevention,
Institute of Medicine
CHARLES F. TURNER (Study Director), National Research Council
. . .
111
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Pane} on AIDS ant} IV Drug Use
LEWELLYS F. BARKER (NRC Fellow), National Research Council and American
Red Cross, Washington, D.C.
LAWRENCE S. BROWN, JR. Addiction Research and Treatment Corporation, and
Department of Medicine, Harlem Hospital, New York City
DON C. DES JARLAIS (ChairJ, New York State Division of Substance Abuse
Services, New York City, and Rockefeller University
SAMUEL R. FRIEDMAN, Narcotics and Drug Research, Inc., New York City
ROBERT L. HUBBARD, Center for Social Research and Policy Analysis, Research
Triangle Park, North Carolina
SHIRLEY LINDENBAUM, Department of Anthropology, Graduate Faculty, New
School for Social Research
HEATHER G. MILLER (Senior Research Associate), National Research Council
JOHN A. NEWMEYER, Haight-Ashbury Free Medical Clinic, San Francisco
Liaison Representatives, U.S. Public Health Service
WENDY BALDWIN, National Institute of Child Health and Human Development
WILLIAM W. DARROW, Centers for Disease Control
LLOYD KOLBE (ChairJ, Centers for Disease Control
KEVIN O'REILLY, Centers for Disease Control
MARK ROSENBERG, Centers for Disease Control
STANLEY F. SCHNEIDER, National Institute of Mental Health
ERNESTINE VANDERVEEN, National Institute on Drug Abuse
RONALD W. WILSON, National Center for Health Statistics, Centers for Disease
Control
Consultants
MARION EATON, Program in Mathematical Methods in Educational Research,
Stanford University
ROBERT E. FAY, National Research Council
SUSHAMA GUNJAL, National Research Council
SAHR JOHN KPUNDEH, Department of Political Science, Howard University
BARBARA BRYAN LOGAN, College of Nursing, University of Illinois at Chicago
DEBORAH MALOFF, Hinsdale, Illinois
JOHN L. MARTIN, School of Public Health, Columbia University
LEAH MAZADE, National Academy Press
LAURA RUDKIN-MINIOT, Department of Sociology, Princeton University
STEPHEN SAUNDERS, Department of Psychology, Northwestern University
JEFF STRYKER, School of Public Health, University of Michigan
1V
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Preface
Statistics on the spread of the human immunodeficiency virus (HIV)
and, consequently, of acquired immune deficiency syndrome (AIDS)
tell a grim tale. As of November 14, 198S, 78,312 cases of AIDS had
been reported in the United States, and 44,071 people had died as a
result of the disease. Moreover, there is no end in sight: projections
of the number of AIDS cases and (leaths show large increases in the
years to come, and it is estimated that as many as 54,000 Americans
may die from AIDS during 1991 alone.
Yet HIV infection/AIDS is more than a biomedical phenomenon.
It is also a social phenomenon an epidemic rooted firmly, some
fear intractably, in human behavior. The vital need for data to
help in designing, implementing, ant! evaluating programs to curb
the epidemic's spread transcends numerical tallies of people infected
and lives lost. Understanding the human behaviors that transmit
HIV infection (and thereby AIDS), as well as the social contexts in
which those behaviors occur, calls for action by the disciplines that
constitute the behavioral, social, and statistical sciences.
The creation of this committee highlights the central importance
of behavior in the HIV/AIDS epidemic. Because HIV/AIDS is a
sexually transmitted disease, it must be opposed with behavioral
weapons education, counseling, and persuasion, among others a
fact that will not change even when effective therapies or vaccines
are discovered. In this respect, the HIV/AIDS epidemic is similar
to outbreaks of other, nonfatal sexually transmitted diseases. For
example, gonorrhea and syphilis persist in the United States, despite/
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Vi ~ PREFACE
the availability for the past 40 years of drugs that are effective against
them. The challenges facing us are great, especially given the severity
of the AIDS epidemic.
In its charge, the Committee on AIDS Research and the Behav-
ioral, Social, and Statistical Sciences was asked to
. describe what is known about the spread of HIV ant!
AIDS in the United States, with special attention to the
quality of the information at hand ant! to the kind of
additional information that is needed;
· identify critical populations and inclicate objectives and
tasks related to them;
. describe existing research findings in the behavioral and
social sciences that should be useful in planning and
choosing among interventions designed to control the
spread of HIV infection;
. describe existing research on (a) interventions intended
to facilitate behavior changes and (b) ways to evaluate
their effectiveness; and
. identify new research that should be undertaken to de-
sign, implement, and evaluate better interventions in
the future to control the spread of HTV.
This three-part report is the committee's answer to that charge.
Because it is important to know the prevalence and incidence of
HIV infection in planning strategies to control its spread, the first
part, "Understanding the Spread of HIV Infection," begins with a
review of the extent of HIV infection within the U.S. population
today. The two subsequent chapters discuss the sexual ant! IV drug-
use behaviors that contribute to transmission of the virus and thus
alter the prevalence and incidence of HIV in the United States.
The second part of the report, "Intervening to Limit the Spread of
HIV Infection," details principles of behavioral change that might
prove useful in designing and implementing intervention strategies
to slow disease transmission. A separate chapter discusses methods
for measuring the effectiveness of such interventions. The third part,
"Impediments to Research and Intervention," reviews the barriers
that may compromise the nation's ability to control the spread of the
disease. One chapter considers barriers to research efforts; another
chapter discusses obstacles that threaten to hinder effective AIDS
prevention.
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P REFACE ~ vii
As biomedical scientists continue to search for effective therapies
ant! vaccines to combat HIV/AIDS, behavioral, social, and statistical
scientists must invest their energies in understanding and affecting
the behaviors that transmit the virus. It is well to remember that, as
we write, HIV continues to spread. As part of the nation's response to
this complex disease and its devastating consequences for indivicluais
ant! for society as a whole, we confront the urgent task of turning
ignorance into understanding anc3 understanding into action.
Charles Turner, Heather Miller, and Lincoln Moses
Editors
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ACknOWIe-]gmenTS
r:
During the course of this stiffly, our committee has been assisted by
many scientists who took time to share their insights and expertise.
Without this generous assistance, the committee would not have
been able to complete its task.
The birth of this study benefited from the support and goodwill
of many people. At critical moments in the study's gestation, Samuel
Thier of the Institute of Medicine and our former colleagues David
GosTin and Roy WidJus interceded to ensure that the project was
not stillborn. Kenneth Prewitt of the Rockefeller Foundation and
Eric Wanner and Peter cle Janosi of the Russell Sage Foundation
generously and quickly provided funds for the committee's start-
up costs. The Public Health Service provided subsequent financial
support for the undertaking, and their liaison representatives maple
important contributions to the committee's work. To all those who
have assisted us in our work, the committee extends its sincere thanks
and appreciation.
NOTE ON AUTHORSHIP
The list below identifies the persons who shared the responsibility
for preparing the first draft of each chapter in this volume. The
committee reviewed all contributions, and they have been revised and
edited in light of committee reactions 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 publisher! text. It should also be noted that, although the
i:
x
o
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X ~ ACKNOWLEDGMENTS
list covers major sections of this volume, these sections frequently
contain additional paragraphs or pages from other hands.
SUMMARY: This is the collective product of the deliberations of the
entire committee, and it presents our recommendations.
CHAPTER 1: Aron, BilIard, Brookmeyer, Menken, Moses, Spencer,
Stoto, Turner
CHAPTER 2: Gagnon, Lirl~lenbaum, Martin, May, Menken, Turner,
Zabin
CHAPTER 3: Barker, Brown, Des JarIais, FYiedman, Hubbard,
Lindenbaum, Miller, Newmeyer, Stryker
CHAPTER 4: Becker, Brooks-Gunn, Coates, Dawes, Lindenbaum,
Miller, Zabin
CHAPTER 5: Boruch, Dawes, Miller, Moses
CHAPTER 6: Miller, Turner
CHAPTER 7: Coates, Dawes, Jonsen, Miller, Turner, Walker, Zabin
Primary responsibility for the revision and editing of this volume was
shared by Charles Turner, Heather Miller, and LincoIn Moses.
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Contents
SUMMARY . . .
I UNDERSTANDING THE SPREAD OF
HIV INFECTION
..1
1 MONITORING THE EPIDEMIC 31
Prevalence and Incidence of HIV Infection, 33
The 1989 HIV Surveillance System, 50
Estimates of National HIV Prevalence and Inciclence, 62
Conclusion, 66
References, 70
SEXUAL BEHAVIOR A N D A ~ D S ..........................
Status of the Research Field, 73
Needed Data, 75
The Kinsey StucTies, 79
bends in Heterosexual Behavior in Adolesence and
Young Adulthood, 88
Adult Heterosexual Behaviors, 102
Trends in Sexual Behavior Among Persons of the
Same Gender, 113
Female Prostitution, 136
Methodological Considerations in Surveys of
Sexual Behavior, 147
X1
. . .
.... 73
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Xii ~ CONTENTS
Anthropology's Perspective on Human Sexual
Behavior, 157
Conclusions and Recommendations, 164
Bibliography, 169
3 AIDS AND {V DRUG USE...
Drug-Use Behaviors that Transmit HTV, 189
Risk Reduction Among {V Drug Users, 202
Conducting Research on {V Drug Use, 214
Measuring the Scope of the Problem, 225
Conclusion, 240
Bibliography, 240
II INTERVENING TO LIMIT THE SPREAD OF
HIV INFECTION
4 FACILITATING CHANGE IN HEALTH BEHAVIORS...
Education Programs, 262
Motivating and Sustaining Behavioral Change, 276
Social Support for Behavioral Change, 290
The Role of Planned Variations and Evaluation, 307
References, 308
.. 186
259
5 EVALUATING THE EFFECTS OF AIDS INTERVENTIONS 316
Dimensions of Evaluation, 317
Randomized Fielcl Experiments, 327
Special Concerns of Evaluation in the Context of
HIV Infection and AIDS, 337
Implementing Good Evaluations, 347
Bibliography, 350
III IMPEDIMENTS TO RESEARCH AND
INTERVENTION
6 BARRIERS TO RESEARCH
Collaboration in Research, 364
Federal Research Personnel, 367
References, 371
7 SOCIAL BARRIERS TO AIDS PREVENTION ....
Social Response to Epidemics, 372
Communicating About Sex, 375
Barriers to Action: Recent Examples, 376
Historical Lessons, 388
References, 399
.359
372
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CONTENTS I Xiii
APPENDIXES
A. RECOMMENDATIONS ......
B. SUPPLEMENTAL DATA ....
.............. 405
412
BACKGROUND PAPERS
On the Accuracy of Current Estimates of the
Numbers of Intravenous Drug Users
Bruce D. Spencer............................................
Monitoring the Spread of HIV Infection
Charles F. Turner and Robert E. Fay...
Cost-Effectiveness Analysis of AIDS Prevention
Programs: Concepts, Complications, ant! Illustrations
Milton C. Weinstein, John D. Graham,
Joanna E. Siegel, and Harvey V. Fineberg...........
Sexuality Across the Life Course in the United States
John H. Gagnon..............................................
Sex Counts: A Methodological Critique of Hite's
Women and Love
Tom W. Smith................................
Mends in Premarital Sexual Behavior
Albert D. Klassen, Colin ]. Williams.
Eugene E. Levitt, Laura Ru~kin-Miniot,
Heather G. Miller, and Sushama Gunjal
INDEX
. 429
....... 447
. 471
.500
. 537
.. 548
569
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SEXUAL BEHAVIOR AND
INTRAVENOUS DRUG USE
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