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
1. Safe sex. Selecting sexual partners carefully, avoiding practices that may injure body tissues, using condoms (unless in a long-standing relationship). Not everybody who has the virus know that they do, others who do know may not tell their sexual partners (Marks et al, 1991).
2. Do not share needles or syringes. If you do make sure they are sterile.
3. Women should test their blood before becoming pregnant. If found to be positive they should not become pregnant.
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.
‘Safe sex doesn’t mean no sex, it just means use your imagination’ (Bragg and Marr 1991). This comment perhaps reflects the population response to the threat of AIDS. For most, the practice of celibacy is not an option. Accordingly, health promotion initiatives have attempted to encourage safer sex practices rather than the avoidance of sex. Much work remains to be done. In a sample of North American heterosexual students, for example, Hawkins et al. (1995) reported that the most frequent ‘safer sex’ behaviour was the use of the contraceptive pill. The least frequent sexual practice, reported by 24 per cent of the sample, was the use of condoms or dental dams. These data, gathered after more than a decade of knowledge of the risks of unsafe sex, provide strong evidence that encouraging changes in sexual practice has not proven easy.
The low prevalence of safer sex practices may still, in part, be attributable to a lack of knowledge. Wenger et aI. (1995), for example, asked students and attendees at a sexually transmitted disease clinic about their last sexual behaviour and whether they considered this to have involved safer sex practices. Fifty-three per cent who considered themselves to have used safer sex practices reported having vaginal or anal intercourse without using a condom during that encounter. Clearly, there remains a role for public education in preventing the spread of AIDS. However, although such an approach may increase knowledge about safer sex practices (DiClemente et at. 1987), evidence that information alone is sufficient to change behaviour is lacking (Bellingham and Gillies 1993; St Lawrence et al. 1995).
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 cannot 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 where "shooting
galleries" are not prevalent (Watters 1989).
The association of chief police officers in Britain (2001) have called for legalised shooting galleries where registered drug users can get their fix of heroin in hygienic conditions without having to pay for it. This would not only reduce the risk of aids but also reduce drug related crime. See the Observer article. This would be termed a form of harm minimisation.
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:
Public
perception
AIDS is viewed as a problem of risk-groups rather than of risk-behaviours. There are two problems:
1. People who are not in the "risk-group" do not tend to take precautions.
2. Stigmatisation of "risk-group" (Phillips 1989).
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.
Fortenberry (2002) discussed issues relevant to effective, clinic-based programs that address responsible sexual behaviours. Three general classes of clinic-based programs are (1) clinic-based educational/counselling programs, (2) school clinic-based condom distribution programs, and (3) clinic-based sexually transmitted disease (STD) and HIV screening programs. Consistent condom use increases in response to clinic-based counselling; however, consistent use is often <20% of coital exposures. Extensive and personalized counselling interventions reduce the incidents of STDs by 10-15%. Some, but not all, studies examining school-based condom distribution programs report subsequent increases in responsible sexual behaviour. Screening programs for STDs are associated with decreases in rates of some infections. It is concluded that clinic-based programs can successfully increase responsible sexual behaviour.
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.
Ross and Williams (2002) discussed community interventions that
target specific groups of individuals at risk for sexually transmitted diseases
and HIV. Certain of these programs have demonstrated significant effects on
sexual behaviour. The factors that make these interventions particularly
effective include the establishment of community, maintenance of the
intervention post research funding, and buy-in by the community or target
group. The modification of risky normative beliefs through the use of opinion
leaders and role models and through intervention delivery by peer educators is
an important facet of such interventions. Interventions delivered by health professionals
but absent of a community base appear to be generally unsuccessful. Where
cultures or subcultures are targeted, the close involvement of such groups in
the design and delivery of messages is critical to their success. Diffusion of
interventions through existing social networks acts to reinforce and maintain
changes in peer norms toward safer sexual behaviour.
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.
Skills-based or problem-solving interventions seem more effective. Kelly et at. (1994), for example, compared a five-session skills-based programme with an education-only control group in a group of socially disadvantaged sexually active women considered to be at high risk for HIV infection. The intervention included risk education, training in condom use, practising sexual assertiveness, problem-solving and risk trigger self-management. At the three-month follow-up, women from both conditions reported having a similar number of sexual partners. However, what they did with those partners differed; women in the intervention group reported that more of their partners used condoms, and on more occasions.
Complex interventions may impact on groups frequently considered resistant to health promotion messages. Malow et al. (1994), for example, compared the effectiveness of a skills-based and an information programme with hard drug users. The skills-based intervention comprised a series of small group meetings, totalling six hours, designed to enhance knowledge and attitudes regarding HIV prevention, improve skills in condom use and needle sterilization, and to modify high-risk sexual and drug-related behaviours. Following intervention, participants in this group reported greater self-efficacy, condom use skills, and sexual communication skills than those in the comparison group. In addition, they reported significantly greater reductions on a number of measures of sexual HIV-risk behaviour than those in the information-only condition.
One particularly powerful method of changing behaviour is through the use of videos. These permit ways of handling conflict, embarrassment, and stress surrounding the potentially awkward social transactions required in sexual risk reduction to be modelled. Kolata (1987) reported a study involving gay men, in which participants discussed issues relating to safer sex following either provision of written materials or watching an erotic safer sex video. Those in the latter group evidenced increased use of safer sex practices in comparison with those who received only written materials. O’Donnell et at. (1995) compared the effectiveness of video-based interventions designed to promote safer sex among African-American and Hispanic attendees at a sexually transmitted disease clinic in South Bronx, New York. Attendees were randomly allocated to one of three groups: no treatment control, video, or video plus interactive group ‘skill-building session’. This comprised a 20-minute meeting in which barriers to condom use were identified and addressed through the provision of information, discussing condom options, and practising condom negotiation skills. All those participating in the study were provided with coupons redeemable for free condoms at a local pharmacy. In comparison to the control condition, those who saw the video were more likely to redeem condom coupons (21 versus 28 per cent). Participation in the interactive sessions further increased redemption rates to 40 per cent.
In a more radical study, Robert and Rosser (1990) compared the effectiveness of four interventions aiming to reduce unsafe sex practices in a sample of gay men. Each was randomly assigned to one of four conditions. The first involved watching a 15-minute video on AIDS, which provided information on and modelled a number of safer sex behaviours, including placing a condom on an erect penis and refusing to participate in unsafe sexual behaviour. The second condition involved 20 to 30 minutes of individual counselling in which major sexual concerns were discussed and standardized information on safer sex given. A third condition involved attendance at a workshop, which explored how to eroticise safer sex practices. The final intervention involved attending a workshop in which the social impact of HIV/AIDS and safer sex guidelines were discussed. Trend analysis revealed that individual counselling was most effective in increasing condom use, while the erotic safer sex group was the only condition to evidence a significant reduction in the frequency of anal intercourse. Of interest was the finding that the conditions which engaged individuals in active consideration of how to change their behaviour evidenced the greatest behavioural change, and that these changes reflected the topics discussed. That is, each intervention may have produced effects specific to the issues addressed within it.
Such specificity of outcome was also reported by Weisse et at. (1995). In their study, a group of young adults took part in an AIDS prevention workshop aimed at reducing embarrassment while purchasing condoms, and encouraging their use. Half this group then participated in an exercise involving the purchase of condoms at local shops. All participants evidenced greater knowledge about AIDS and more positive attitudes towards the use of condoms immediately after the workshop, but these changes did not persist. However, those who participated in the exercise reported less embarrassment during the subsequent purchase of condoms; a change which persisted over time. The authors concluded that these results indicate that AIDS prevention workshops may lead only to transient changes unless specific skills are considered and practised.
While problem-solving or skills-based interventions appear to be more effective than purely educational interventions, these need not be time-consuming. The Talking Sex project (Tudiver et al. 1992) compared the effectiveness of single and four-session discussion and skills-training groups with a waiting list control. Overall, both intervention groups gained more than the control group, but no substantial differences between the two types of intervention were found; if anything, any differences favoured the one-off group meetings. In addition, such interventions need not be conducted in formal settings. Blakey and Frankland (1995), for example, reported an intervention involving outreach contact with prostitutes in a Welsh city. Over a four-year period, a worker informally met prostitutes on the streets. On each occasion, she provided information about the prevention of HIV infection and other health matters, as well as providing condoms. In addition, she discussed strategies by which the women may be able to encourage safer sex with clients who asked for unprotected sex. Over the period of the intervention, the women reported increased use of condoms and safer drug use through needle exchange and reduced needle sharing. A third of the women also passed on HIV prevention information, including leaflets and comics with HIV prevention messages, to their clients. Such results suggest that long-term programmes working in the context of the individuals involved may prove highly effective. Working within such contexts also permits the use of existing social networks as a resource. Quirk et al. (1993), for example, found peer education was more effective in increasing knowledge about safe intravenous drug use than formal health care workers.
Elford et al. (2002) developed a peer-led HIV prevention
initiative, based on a diffusion of innovation model, for gay men attending
gyms in central London. Peer educators, recruited from people who used the gym
regularly, agreed to talk to gay men at their gym about HIV prevention,
focusing on sexual risk and steroid injecting behaviour. Outcome evaluation
revealed that the peer education program had no significant impact on the risk behaviours
of gay men using the gyms. Process evaluation suggested that while it was
feasible to set up a peer education program among gay men in gyms, attrition
was an important factor. Only 1 in 5 potential peer educators initially
identified remained with the project throughout. Those who did work as peer
educators reported barriers to communication within the gyms. It appears that
the critical mass required for diffusion was never established. This could
explain why the intervention had no significant impact on gay men's risk behaviours.
A person-time analysis demonstrated that the peer education program required a
substantial input from the health promotion team,
equivalent to 1 team member devoting 2.5 days/wk to recruit, train and support
peer educators over 18 mo. Peer education should not, therefore, be viewed as a
low-cost approach to prevention.
Use of the Internet
Keller et al (2002) looked at how the Internet promotes sexual health among
adolescents. Six key words were entered into three search engines producing
87,180 results. Three percent (n=36) were educational Web sites targeted at
teenagers and covered a range of sexually transmitted diseases (STDs). These
were content analysed using sexuality education and usability guidelines. All
sites addressed some STD information, but only two covered negotiation.
Navigability results were mixed; only one third offered a site map. Sexual health educators may
need to include more information on how to negotiate safe sex and improve Web
navigability for teenagers.
Paul Bennett
and Simon Murphy (1997), Psychology and Health Promotion, Open University
Press, 0-335-19766-3.