Prevention Works!

On June 5, 1981, the Centers for Disease Control and Prevention published an article in the C.D.C.'s official journal, Morbidity and Mortality Weekly Report, that described a minor outbreak of a rare and deadly form of pneumonia, Pneumocystis carinii. What was unusual about this outbreak was that it had occurred not in severely malnourished children or in adults who are undergoing chemotherapy -- where pneumocystis pneumonia might be expected -- but in five apparently healthy gay men, all living in Los Angeles. That brief article marked the beginning of a herculean international effort to characterize -- and contain -- what has become a worldwide epidemic of acquired immunodeficiency syndrome.

In those 15 years AIDS has grown, in the United States alone, from five cases in Los Angeles to more than half a million nationwide. AIDS is now the leading cause of death for all Americans between the ages of 25 and 44. Moreover, AIDS is a disease that holds a magnifying glass to some of America's ugliest social problems, among them homophobia, drug use, poverty, and racism. Once a disease seen only in gay men, AIDS is now a disease seen everywhere in everyone, as these statistics indicate:

• About 75% of the estimated 41,000 new HIV infections occurring each year in the U.S. are among injection drug users (IDUs), their sexual partners, and their offspring.
• Half of all new HIV infections occur in people under the age of 25.
• The number of new HIV infections ascribed to heterosexual contact alone is rising rapidly, especially among the sexual partners of injection drug users.
• This sharp rise in cases of heterosexually transmitted disease is reflected in a concomitant rise in cases among women.
• Although rates of HIV infection are decreasing among white gay and bisexual men in large metropolitan areas, rates are increasing among African-American and Latino gay and bisexual men -- and among young gay and bisexual men of all races.
• African-Americans and Latinos continue to be disproportionately affected by AIDS, regardless of means of transmission, age, or gender.

Fortunately, the last fifteen years have also seen a sharp rise in our understanding of how to prevent the spread of HIV. Over those years we have made dramatic advances in our understanding of who is at greatest risk for HIV and how we can most effectively reach those target populations. Prevention does work. It works best when innovative, audience-specific, culturally appropriate, sexually frank programs receive adequate funding, but it will work wherever well-intentioned men and women demonstrate a real understanding of the special needs of those who are at the highest risk of infection.

These are the emerging trends in HIV prevention -- programs that have proven effective in reducing the number of new infections in a wide range of situations, communities, and at-risk groups:

Legislation can make a difference.

In 1992 the state of Connecticut implemented a novel HIV prevention program: it did nothing, other than change an existing law -- but in this case doing next to nothing proved highly effective. Within eight months to a year after the state legislature passed a partial repeal of the law that made it illegal to obtain clean needles and syringes without a prescription, needle sharing among IDUs dropped dramatically. With drug users finally able to purchase paraphernalia in drug stores, pharmacy purchases rose from 19% to 78% of total purchases, street purchases fell from 74% to 28%, and needle sharing fell from 52% to 31% (1).

Prevention programs can be integrated into existing services.

An STD clinic in the south Bronx that primarily serves African-American and Latino clients tested two AIDS education videotapes -- one developed for, and vetted by, African-Americans; the other developed for, and vetted by, Latinos. Clients at the clinic were offered the appropriate videotape, or the videotape and an interactive group session, and all clients were given coupons that could be redeemed for free condoms at a pharmacy a block away from the clinic.

Coupon redemption did not increase substantially among African-American clients who only saw the videotape, but redemption did increase among Latino clients -- especially women (2). This may be due to the difference in the two videotapes. The tape made for African-Americans mostly targeted behavior change among men, whereas the Latino tape targeted men and women, and addressed gender roles and attitudes about condom use in relationships. In both groups the clients who saw the videotape and participated in group sessions were almost twice as likely to redeem coupons as those who did neither.

The most effective prevention programs for homeless people are situated where homeless people gather, such as at shelters, hotels, and clinics. "Sex, Games and Videotapes," a program for homeless, mentally ill men in a New York City shelter, is built around activities central to shelter life: competitive games, storytelling, and watching videos. For many of these men sex is conducted in public spaces, revolves around drug use, and must be conducted quickly. One component of the program is a competition to see which man can put a condom on a banana fastest -- without tearing the condom. This program has not only taught these men vital, potentially life-saving skills, it has reduced their high-risk sexual behavior threefold (3).

Drug treatment can equal prevention.

Injection drug use, not heterosexual intercourse, is the chief risk factor for HIV infection among female prostitutes. When free methadone maintenance was offered to heroin-addicted street prostitutes in southern California, most enrolled. After one year, personal income from prostitution and other crime dropped 58% and income from legal sources rose 86% (4). Illicit drug use, measured by urinalysis, dropped from 80% at baseline to 51%.

Peer education can be effective.

As a rule, effective prevention messages come from peers. In Oakland, California, and Atlanta, Georgia, successful sex-education programs for seventh and eighth graders used teenage peer educators to increase condom use among sexually-active students and to help abstinent students postpone sexual activity (5, 6).

A program for young women, at an inner-city family health center serving a minority population, found that counseling by physicians resulted in increased understanding of the risk of sexual transmission of HIV, whereas peer education resulted in greater understanding of the risk of transmission through injection drug use (7).

Successful programs incorporate broader social issues.

"Hermanos de Luna y Sol," an ongoing intervention for gay and bisexual Latino men in San Francisco, attracts clients by appealing to Latin brotherhood and to the participants' shared sense that the gay community is a kind of extended family. The first group session deals with the common history of oppression among Latino gay men, including issues of homophobia, machismo, sexual abuse, racism, and separation from family and culture. AIDS and sexuality are discussed in the second of the four sessions (8).

The National Institute on Drug Abuse (NIDA) found that drug-using African-American men could be motivated to use condoms by appealing to their concerns about fathering an "AIDS baby" (9). Condom campaigns that target men in a positive way, encouraging them to help "protect the family," can benefit both men and women.

A successful program for young gay men in Eugene, Oregon, provided alternatives to the traditional bar scene through a variety of social and small-group activities designed -- and run -- by the young men themselves. An evaluation found that young men who were engaging in unsafe sex were more readily reached through activities -- like dances, movie nights, picnics, gay rap groups, and volleyball games -- than through workshops. Rates of unprotected anal intercourse dropped by almost 25% after the intervention.

Helping with more pressing needs enhances prevention.

People living in poverty, especially minorities, are disproportionately affected by HIV. For them, the struggle for daily survival may well take precedence over concerns about HIV infection. In San Francisco, an HIV testing program for homeless people was linked to specialized case management, which offered these clients access to primary care, substance-abuse treatment, and mental-health services. Case managers were able to maintain contact and build relationships with drug-using clients, many of whom were found to be HIV-infected, mentally ill, or both -- and therefore particularly dependent upon such services and relationships (11).

A program in New York City, "On the Streets Mobile Unit-Options," runs vans that bring food and friendship, clothes and condoms, HIV/STD testing and counseling, and clean needles to more than 4,000 street prostitutes. The operators of this program also help prostitutes get public assistance, drug treatment, and other social services. Rates of HIV infection among clients have declined from 36% in 1989 to 18% in 1995 (12).

After fifteen years of the HIV epidemic, it is time to put what we know about prevention to greater use, and to integrate prevention programs into existing medical and social services -- so that the next fifteen years will not see another half-million Americans infected with a disease we now know how to prevent.

References

1. Groseclose SL, Weinstein B, Jones TS, et al. Impact of increased legal access to needles and syringes on practices of injecting-drug users and police officers -- Connecticut, 1992-1993. JAIDS 1995; 10: 82-9.
2. O'Donnell LN, San Doval A, Duran R, et al. Video-based sexually transmitted disease patient education: its impact on condom acquisition. Am J Pub Health 1995; 85: 817-22.
3. Susser E, Valencia E, Torres J. Sex, games and videotapes: an HIV-prevention intervention for men who are homeless and mentally ill. Psychosocial Rehab J 1994; 17: 31-40.
4. Bellis DJ. Reduction of AIDS risk among 41 heroin addicted female street prostitutes: effects of free methadone maintenance. J Addictive Dis 1993; 12: 7-23.
5. Ekstrand M, Siegel D, Krasnovsky F, et al. A school-based, peer-led AIDS prevention program delays the onset of sexual behaviors among adolescents. Presented at Second International Conference on Biopsychosocial Aspects of HIV Infection, Brighton, UK, 1994. Abstract P004.
6. Howard M, McCabe J. Helping teenagers postpone sexual involvement. Family Planning Perspectives 1990; 22: 21-6.
7. Quirk ME, Godkin MA, Schwenzfeier E. Evaluation of two AIDS prevention interventions for inner-city adolescent and young adult women. Am J Prevent Med 1993; 9: 21-6.
8. Díaz RM. HIV risk in Latino gay/bisexual men: a review of behavioral research. Report prepared for the National Latino/a Lesbian and Gay Organization, 1995.
9. Rabin SA. A private sector view of health, surveillance, and communities of color. Public Health Reports 1994; 109: 42-6.
10. Kegeles SM, Hays RB, Coates TJ. The MPowerment project: a community-level HIV prevention intervention for young gay and bisexual men. Am J Pub Health 1996; 86: 1-8.
11. Brindis C, Pfeffer R, Wolfe A. A case management program for chemically dependent clients with multiple needs. J Case Management 1995; 4: 22-8.
12. Whitmore R, Wallace JI, Weiner A, et al. HIV testing rates in New York City street walkers have declined. XI International Conference on AIDS, Vancouver, B.C., July 1996. Abstract Th. C. 4684.

Pamela DeCarlo is from the Center for AIDS Prevention Studies, University of California San Francisco, San Francisco, CA.