Promoting Health
AIDS
Government Objectives
HIV prevention and sexual health promotion
HIV prevention work needs to be targeted towards those most
vulnerable - currently gay men, African people from specific
sub-Saharan countries (and people with links to those countries)
and injecting drug users. Priority must also be accorded to the
specific health promotion needs of people living with HIV and
AIDS.
Targeted prevention work needs to be supported by public education. Sex education and sexual health promotion needs to be available to all sexually active people and young people considering becoming sexually active.
There will continue to be a need for general awareness work which aims to foster a positive social climate towards those with sexual health needs, particularly those already marginalised and discriminated against.
HIV prevention is best addressed when placed in the context of a broader approach to sexual health promotion. HIV must not be de-prioritised or downgraded by this approach.
There is a need to recognise the strengths of an integrated approach to HIV prevention and other sexual health problems. Prevention of sexual health problems will not only benefit the affected individuals, but will also save the NHS and society as a whole from significant costs.
Objectives of an integrated sexual health and HIV prevention
strategy may include:
A detailed examination of the elements of an integrated strategy, including indicators and targets through which the strategy could be monitored at a national and local level, is provided by the working paper Towards a Sexual Health Strategy for England (1998), produced by a group of national organisations including NAT.
Three basic messages
Misconceptions about HIV transmission also need to be debunked. For example: AIDS only happens to gay people and drug users. Mosquitoes spread the virus. Health care workers are at high risk. AIDS can be contracted by touching infected individuals or by sharing their office equipment (bachelor 1988).
Research on health workers has shown that they rarely become infected even after accidentally pricking themselves with a needle (Henderson et al 1990).
Many AIDS victims in America are gay men. This is probably because they tend to be more promiscuous and engage in high-risk sexual practices, e.g. anal intercourse (Darrow et al 1987).
The likelihood of transmitting the virus increases if other genital wounds are present, such as those received from syphilis, herpes, or chlamydia (Peterman 1990).
Many heterosexuals still have incorrect beliefs about the transmission of AIDS and frequently do not take appropriate precautions (Hernandez and Smith 1990).
90 percent of intravenous drug users know that sharing needles can transmit AIDS. Many are now using sterile needles, reducing their drug use, or using drugs in other ways such as inhaling (Das Jarlais & Friedman 1988). However this caution is not found in their sexual behaviour; many drug addicts do not use condoms (Krajick 1988). Many drug users are men and their sexual partners often are women who know about the risks but feel powerless and are willing to take the risk (Fullilove et al 1990).
There has been a dramatic change in gay sexual behaviour in America. In san Francisco gay and bisexual men significantly reduced several high-risk behaviours between 1982 and 1986, and this greatly decreased the spread of the virus: incidence rates declined from over 13 percent to about one percent per year (Catania et al 1991).
AIDS education with gay and bisexual men have produced "the most profound modifications of personal health-related behaviours ever recorded" (Stall et al 1988).
There are many reasons why people do not always take precautions against AIDS. They may have low self-efficacy, under-estimate the risk of infection, have misplaced trust in their partners, or believe a condom would ruin sexual pleasure and spontaneity (Aspinwall et al 1991). Although people know the risks they will often explain themselves by saying, " I know that's what they say but..." or, "but in my case..." (Maticka-Tyndale 1991).
Condom use.
In a study of 234 male and 91 female teenagers living in the San Francisco area, Kegeles et al (1988) found that the large majority of subjects agreed that using a method, which prevents both pregnancy and sexually transmitted diseases, was of great importance. In spite of this only 2.1 percent of females and 8.2 percent of males reported using condoms. The sample might have seen themselves as at low risk of HIV infection and saw condom use as having costs that outweighed the perceived benefits. One cost is interpersonal anxiety, as condoms can not be used without discussion. Interviews with women (Independent, 14 February 1989) who had attempted to persuade their partners to use condoms, usually without success, reveal that men complained about the lack of sensation. Some men did not know how to use condoms, so were probably making an excuse in an attempt to cover their embarrassment. Some of the women reported feeling unable to assert themselves or to resist their partners' implications that they would be responsible for reducing the men's pleasure. Many social processes may be involved in sexual intimacy, including negotiation, bargaining coercion and compliance. The costs are immediate and the benefits are in the future, and are uncertain (the virus may not have been contracted without using the condom).
Intravenous drug use.
The proportion of AIDS cases accounted for by heterosexual Intravenous drug users has risen from one percent at the end of 1984, to 7 percent at the end of 1985, and to 15 percent at the end of 1986 (Conviser and Rutledge 1989). In both Scottish cities, in 1989, it was legal for pharmacists to sell syringes and needles to Intravenous drug users, but in Edinburgh police pursued a policy of arrests for those found carrying injecting equipment, whereas in Glasgow no such policy existed. Sharing of equipment occurs in both cities but because of this difference in policing, sharing occurred in small local groups in Glasgow, whereas in Edinburgh sharing existed between many more drug users in so-called ' shooting galleries'. In Glasgow the rate of HIV infection among intravenous drug users at the end of 1986 was around 5 percent while in Edinburgh the rate grew from three percent in 1983 to 50 percent in 1984 and in 1989 was endemic (Robertson et al 1986).
The use of "shooting galleries" also explains why in 1989, 50 percent of New York's intravenous drug users (ivdus) were infected, compared with 15 percent in San Francisco, "shooting galleries" are not prevalent (Watters 1989).
Harm minimisation.
This controversial program includes needle exchanges. An advantage is that this would bring addicts into contact with health workers. There is a hierarchy of behavioural changes for addicts to reduce the risk of HIV infection:
AIDS is viewed as a problem of risk-groups rather than of risk-behaviours. There are two problems:
People have an unrealistic optimism about health. As a result they underestimate the risk (Weinstein 1987).
Oxford undergraduates saw themselves at less risk! (Turner et al 1988).
Health belief model (Becker 1974).
Theory of reasoned action (Fishbein and Ajzen 1975).
Intention formed from privately held attitudes and socially determined subjective norms.
Problem - intentions do not always translate into actions.
Habits influence behaviour as well.
School-based education
It is clear that adolescents do require more information about HIV and AIDS (White et al 1988) but information is not enough: they also need the opportunity to make use of that information for risk assessment and decision making, and most importantly they need to acquire social skills that allow them to adhere to their decisions even in social contexts that exert pressures against those decisions.
Community programs.
Rather than aiming for educational messages suitable for all, which will often be unsuccessful, a social- marketing approach can stratify groups and develop messages that are tailored to the needs, interests and existing knowledge and beliefs of specific groups and communities (Lefebvre and Flora 1988). Ideas can be spread by social diffusion. A model derived communication studies (Rogers 1987) predicts that the adoption of new ideas such as "safer sex", takes time. Time taken is influenced by:
Studies suggest that Hispanic and black ivdus are at greater risk than white counterparts (Peterson and Bakeman 1989). Explanations:
Watters (1989) reports that in san Francisco there have been changes in behaviour that are attributable to community-based initiatives such as use of "outreach" workers to distribute condoms, bleach and information.
Many homosexual groups have reduced their high-risk activities such as receptive anal intercourse and by increased use of condoms during sexual activity, and by reducing the number of sexual partners (Becker and Joseph 1988). Many of these changes have come about because of social diffusion as a result of the well-organised social structure of these communities. In many instances the changes had begun to occur before public education campaigns had begun.
Remaining problems.
Some individuals continue to practice high-risk behaviours. A report in The Times 20/12/00 reports that many homosexuals are tired of constant warnings about safe sex and feel empowered by rebelling against them. The study by the British psychological Society was conducted by interviewing gay Merseyside men. Any earlier study found that 45 percent of homosexuals had unprotected anal sex. More than two-thirds knew nothing about the HIV status of their partners. Since 1996 the number of men having unprotected sex with more than one partner has risen by 6%. According to Dr Michele Crossley "the constant churning out of more and more messages promoting safe sex is making the problem worse by bringing out the rebellious streak in people". Some gay web-sites are promoting unsafe sex as an act of empowerment. Some health groups are no longer telling gay men to always use condoms but instead to make informed choices.
Dr Jonathan Elford studied data from 470 homosexuals attending a London clinic. He found that men who had three or more HIV tests were more likely to have unprotected sex with men who were HIV positive or status unknown. These men were also more likely to become infected.
Some individuals, who normally practice safe sex sometimes relapse, become recidivists.