AIDS and Behavior An Integrated Approach (1994) / Chapter Skim
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3 UNDERSTANDING THE DETERMINANTS OF HIV RISK BEHAVIOR
3 UNDERSTANDING THE DETERMINANTS OF HIV RISK BEHAVIOR
Pages 78-123
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From page 78... ...
Approaching them requires a cross-disciplinary effort that should include refined knowledge of their neurobiological, psychological, and social bases, and the manners in which they interact. This chapter presents an overview of findings and gaps in research on the determinants of HIV risk behavior and the application of that research to AIDS preventive interventions.
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From page 79... ...
Some outstanding issues include: identifying the neurochemical molecular substrates, if any, associated with sexual risk taking; determining how insights from the studies of the neurobiology of sexuality would relate to high-risk sexual behavior and to sexually transmitted diseases, including AIDS; and determining how society might best integrate the study of the biology of sexuality and sexual risk taking into the broader context of sexuality, sexual behavior, and sexually transmitted diseases.
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From page 80... ...
brain mechanisms mediate the primary, reinforcing, hedonic {pleasure-seekingJ aspects of drug abuse and that, with time, a second "adaptive" set of brain mechanisms antagonizes the first, necessitating higher doses to get the same subjective effect. The brain's adaptive response, however, also leads to a physiological reaction if the drug is withdrawn {Collier, 1980; Himmelsbach, 1943; laffe en c!
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From page 81... ...
It has been apparent for some time, for example, that dopaminecontaining neurons are required for the primary reinforcing effects of psychostimulants such as cocaine and amphetamines tGoeders anti Smith, 1983; Lyness, Friedle, and Moore, 1979; Roberts, Corcoran, and Fibiger, 1977; Roberts and Koob, 1982; Roberts et al., 1980; Routtenberg, 1972~. Details of biologic mechanisms may be illustrated by focusing on cocaine, which, along with heroin, plays a pivotal role in the AIDS epidemic.
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From page 82... ...
Neuroscience has now presented an opportunity to begin approaching the treatment of addictive drugs, including those used by injection and thus associated with HIV transmission such as heroin and injectable cocaine. Methadone has long been a successfu} treatment that can prevent injection of opiate drugs.
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From page 83... ...
Basic and applied psychological and social research have contributed much to an understanding of the psychosocial and cultural determinants of HIV risk behavior. PSYCHOSOCIAL PERSPECTIVES ON RISK BEHAVIOR Theoretical models {primarily psychological)
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From page 84... ...
, which tract been developed to explain health behaviors, were wiclely user! to identify determinants of HIV risk behavior.
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From page 85... ...
Two stage models of change have been adapted for use with HIV risk behavior: the AIDS Risk Reduction Mode! and the Stages of Change Model.
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From page 86... ...
The interpersonal networks of opinion leaders allow them to disseminate information and to serve as social moclels whose behavior may be imitated by other members of the system. Interventions basest on Diffusion Theory have focused on the training or persuasion of peer opinion leaders who may or may not be the same as community leaders.
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From page 87... ...
Unsafe sexual practices often are not the result of a deficit of knowledge, motivation, or skill, but instead have meaning within a given personal and sociocultural context. With the exception of Diffusion Theory, which takes gender and culture into account, current theoretical models of HIV risk behavior do not easily accommodate contextual personal and sociocultural variables.
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From page 88... ...
To date, models designed to explain or predict risk behavior tend to treat the social and environmental variables as independent variables, without considering that they may be interactive or mutually reciprocal. The models also tend to focus only on one level of analysis the individual without regard for other levels, such as the culture and community to which an individual belongs.
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From page 89... ...
First, some have argued, prevailing public perceptions of the AIDS epidemic as just punishment for the immoral anct dangerous behaviors practiced among devalued and stigmatized groups {gays, injection drug users, people with low-income, and racial/ethnic minoritiesJ result in a "blame the victim" mentality. From this viewpoint AIDS patients are held personally responsible for contracting the disease {Albert, 1986; Crystal and S chiller, 1993J.
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From page 90... ...
Yet unemployment is not often represented as integral to the high rate of injection drug use among African American men and the subsequent transmission of HIV {Schneider, 1992~. Similarly, the lack of access to health care among many low-income and racial and ethnic groups means that many cases of HIV infection never reach the attention of the medical community for diagnosis and treatment, thereby ensuring both an underestimation of the AIDS epidemic in certain populations, and its spread to other group members.
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From page 91... ...
In addition, a number of male injection drug users engage in sustained relationships with women who |
From page 92... ...
Refusal to share needles is seen as implying distance, hostility, en cl mistrust, something that injection drug users can ill afford to engender in their partners, who are needed for material support {Des [arises, Friedman, and Strug, 1986~. Promotion of the use of clean needles and the avoidance of sharing needles must be understood in this context.
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From page 93... ...
Thus, social organization anct social context were shown to be critical factors in the reduction of risky behaviors {Schneider, 1992~. Effective lobbying and media campaigns by groups such as ACT-UP convinced the government and research community to accelerate the distribution of experimental AIDS drugs, prompted the establishment of needle exchanges in many cities, and served to change the nature of public discourse about AIDS, by bringing an informed discussion of the AIDS epidemic "out of the closet."
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From page 94... ...
Cultural Sensitivity The greatest rate of increase of AIDS cases is among racial and ethnic groups and women HIV is spreading fastest among African American and Hispanic/Latina heterosexual women and African American and Hispanic/Latino injection drug users {Singer, l991J. It is a commonly held belief that HIV informational campaigns and prevention and treatment services will not be effective unless they are carefully tailored to take into account the beliefs and practices of diverse cultural groups.
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From page 95... ...
Until and unless these concerns are directly addressed at least by open discussion efforts at HIV related behavioral change in racial/ethnic communities likely will be met with continued resistance. Women and Gender Dynamics A growing number of investigators are recognizing that gender differences influence HIV risk factors ant!
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From page 96... ...
Some suggest that research that places women at the center of analysis should investigate women's efforts to transform sexual relationships, among other topics {Schneider, 1992~. Research is needed to un~lerstand power relations between women anal men and how these play out in the negotiation of safer sex, as well as the role of physical and sexual abuse and its impact on HIV risk reduction.
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From page 97... ...
In sum, in the collective effort to prevent HIV infection, strategies employed without an un~lerstanding of the social conditions that facilitate HIV infection such as poverty, discrimination, and inequality between women and men may ultimately be ineffective. Increasingly, it will be important to investigate the interactions of such social conditions with psychological and neurobiological factors that possibly together influence the behavior of individuals.
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From page 98... ...
have been the standard outcome measures for determining whether or not a particular intervention has been successful. This theoretically based intervention research has identified some significant predictors of changes in sexual and drug-using behaviors among gay men, adolescents, and heterosexual adults, including: perceived social norms or social supports that favor behavior change, self-efficacy, accurate estimation of personal risk, alcohol and other drug-use patterns, HIV serostatus knowledge, and removal of structural barriers {for example, the provision of clean needles through needle exchange programs)
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From page 99... ...
Some adolescents, such as runaway youth, are particularly hard to reach with AIDS behavioral interventions. As part of an effort to reduce HIV risky sexual behaviors among such aclolescents, one group of researchers engaged runaway youths in resiclential shelters in intensive small-group AIDS education and coping skills training combined with indiviclual risk reduction counseling.
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From page 100... ...
, outpatient research clinic, Rwanda NIDA Men attending outpatient drug abuse treatment clinic {N = 103}, Risk reduction in sexual behavior: A condom giveaway program in a drug abuse treatment clinic Seattle, WA Calsyn, Saxon, Ineffectiveness of NIDA Female and Freeman, Whittaker AIDS education and male IDUs (1992) HIV antibody testing receiving or in reducing high-risk seeking behaviors among treatment injection drug users jN = 313)
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From page 101... ...
To determine whether injection drug Repeated users maintained positive changes in measures design sexual behavior over an 18-month Structured period. interview} At 4-month follow-up, drug use, needle sharing, and risky sexual behavior decreased among all three groups.
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From page 102... ...
, New York Hays, Kegeles, Coates Community NIMH Young gay and (1993) mobilization promotes bisexual men safer sex among {N = 303}, Santa young gay and Barbara, CA and bisexual men Eugene, OR Jemmott, Jemmott Increasing condom- NIMH Inner-city black { 1992)
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From page 103... ...
To assess the effect of a one-on-one Pretest-posttest There were significant AIDS educational session, which design increases in AIDS included a film, a discussion about (structured knowledge following AIDS risk behaviors and how to interview} the education session. change them, and voluntary AIDS testing.
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From page 104... ...
Kelly, St. Lawrence, Community AIDS/HIV NIMH Male patrons of Stevenson, Hauth, risk reduction: The gay bars in small Kalichman, Diaz, effects of endorsements U.S.
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From page 105... ...
Trained opinion leaders provided AIDS risk reduction messages to reduce high-risk sexual behaviors. To evaluate effects of a voluntary AIDS prevention program with didactic AIDS education, HIV antibody counseling/testing, and facilitated peer support groups to reduce risky IV drug use and sexual behavior.
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From page 106... ...
AIDS risk among IDUs jN = 93}, female sex partners of Long Beach, CA injection-drug users Rolf, Baldwin, Trotter, AIDS prevention for NIAAA Rural Native Alexander et al.
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From page 107... ...
To compare information-only control Multiple group, group and skills-building intervention randomized group for reducing high-risk sexual design behavior and increasing condom use. (structured interview} To evaluate the impact of an AIDS Quasieducational intervention for reducing experimental HIV risk behaviors.
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From page 108... ...
, four New York City schools Watters, Estilo, Clark, Syringe and needle NIDA Female and Lorvick (1994} exchange as HIV/AIDS male IDUs prevention for IN = 5,644}, San injection drug users Francisco, CA Wiebel, Jimenez, Johnson, Ouellet et al. {1993} Positive effect on HIV seroconversion of street outreach intervention with IDUs in Chicago: 1988-1992 NIDA IDUs not in drug treatment IN = 641}, Chicago, IL lowing up both three and six months later, researchers found a higher increase in condom use and safer sex among those who attended the intervention site than among those at the control site {Rotheram-Borus et al., 1991~.
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From page 109... ...
To evaluate the effects of an allvolunteer syringe exchange program on risky injection drug use. Community outreach workers provided AIDS education, bleach, and referral to drug treatment.
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From page 110... ...
A study in Rwanda that offered HIV antibody posttest counseling combined with AIDS education group counseling to cohabiting discordant couples pro |
From page 111... ...
However, it has not been determined that limited services to injection drug users will have lasting effects on modifying such AIDS-related risk behaviors as needle sharing and unsafe sex. Researchers have found mixed results from controlled clinical trials of individual and group counseling that provide skills training for people who inject drugs.
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From page 112... ...
There are indications that many of the traditional HIV prevention and intervention programs have not had a major impact in reducing high-risk sexual behavior among women (Sorensen et al., 1991; Weissman and National AIDS Research Consortium, 1991~. To date, the most common and effective risk reduction method is condom use.
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From page 113... ...
However, studies so far have been based on very small samples, and additional data are needed to further test the acceptability and efficacy of female condom use. Moreover, no studies have been conducted in the United States among women at high risk for HIV infection, such as commercial sex workers, injection drug users, or those who exchange sex for drugs.
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From page 114... ...
COMMUNITY-FOCUSED INTERVENTIONS Sexual Behavior Intervention research at the community level has employed peerled AIDS education to reach people at high risk for HIV infection who may not be willing to participate in small-group/programs {Kegeles et al., 1993) and to change norms in the community as a whole {Kelly, St.
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From page 115... ...
Condom distribution strategies have been widely used, but more careful study should be initiated to determine their efficacy in reducing HIV infections. Also, interventions should target steady partners of sex workers, since it appears that sex workers use condoms less frequently in their personal relationships than in their interaclions with clients {Dorfman, Derish, and Cohen, 1992; NRC, l990b)
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From page 116... ...
Social networks of injection drug users were also targeted for peer-led street outreach in the NADR program. In one study in Chicago, 86 percent of subjects stopped sharing injection equipment ancl HIV seroconversion rates dropped substantially as a result of the network-approach intervention, from 5 percent at baseline to less than 1 percent at the follow-up four years later {Wiebe} et al., 1993~.
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From page 117... ...
The variability in rates of maintenance of safer sexual practices reported in such studies might reflect differences in sampling methods, measurement of sexual risk, observation, time periods, number of observations, the effect of loss due to follow-up bias, and prevalence of risk-taking behaviors across different populations of gay men. However, one finding that is clear from all the studies, despite these important methodological differences is that some portion of gay men reinitiate riskier sexual behaviors after a period of safer sexual behaviors, and that this behavioral pattern could be the source of continuing HIV seroconversions.
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From page 118... ...
In addition to individual behavioral factors, certain social factors may influence nonmaintenance of safer sex behaviors, such as lack of community support for risk reduction, social support or pressure to take health risks, high reinforcement value for unprotected sex, and identification of unprotected anal intercourse as a favorite sexual act {Kelly, St. Lawrence, and Brasfield, 1991; O'Reilly et al., 1990; Stall et al., 1990J.
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From page 119... ...
That reductions in risk behavior among men who have sex with men have been maintained at all is a tribute to the successful interventions employed within these communities. However, successful HIV prevention requires long-term, community-wide maintenance of risk reduction which in turn calls for the development of new intervention models, especially those that target multiple risk behaviors.
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From page 120... ...
, and demography {i.e., population immigration, birth, en cl non-AIDS mortality ratesJ. In addition to incorporating behavioral variables, the models allow for incorporation of prevention program operalions as demonstrated by studies of needle exchange Kaplan and O'Keefe, 1993J, bleach distribution to injection drug users {Siegel, Weinstein, and Fineberg, 1991J, REV counseling and testing {Brandeau et al., 1993; Gail, Preston, and Piantatlosi, 1989J, and self-deferral from blood donation {Kaplan and Novick, 1990J.
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From page 121... ...
Assuming one could use the methods described above for estimating the number of HIV infections averted by the implementation of an intervention, one could then compare dollars saved in medical costs affiliated with those infections with dollars spent on con |
From page 122... ...
RECOMMENDATIONS FOR UNDERSTANDING; THE DETERMINANTS OF HIV RISK BEHAVIOR 3.1 The committee recommends that NIAAA, NIDA, and NIMH expand basic research on the biology of sexuality as it potentially relates to high-risk sexual behaviors. This might include research on the central nervous system {CNS, sexual systems that mediate sexual behaviors, the CNS neural systems underlying sexual behavior, and the molecular genetics of sexual behaviors.
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From page 123... ...
S: The Second Decade, 1990; AIDS' Sexual Behavior, and Intravenous Drug Use, 1989 but has not been attended to adequately.} 3.8 The committee recommends that NIAAA, NIDA, and NIMH expand funding for HIV intervention research initiatives, particularly those that: {1} have rigorous evaluation components; {2, investigate motivations, intentions, and barriers in addition to behavior change; {3) include outcome measures in addition to behavior change, such as HIV seroprevalence, STD rates, and pregnancy rates; and {4)
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