At the end of July, the Centers for Disease Control (CDC) held its 2003 National HIV Prevention Conference in Atlanta. The 3, 400 attendees included people living with HIV/AIDS, community workers, researchers and public health staff. With several hundred presentations and poster sessions over two and a half days, it was impossible to have access to all the information as it was presented. As I began to sort out the avalanche of notes, conversations and abstracts that piled up on me at the conference, I realized that the message that relationships matter permeated the conference.
Whether we look at sexual, drug-using, maternal, religious, medical or familial groupings, when it comes to prevention of HIV, the quality of social relationships is essential. They affect willingness to ask for, believe in and apply information to action.
Power differentials -- where one person or one group holds more social power than another -- can be detrimental to HIV prevention. Negative attitudes about people's ethnicity, sexual behaviors, age and drug use undermine goals of increasing testing and treatment. People with the least social currency, specifically young people of color (particularly young men who have sex with men), women of color, drug users and the homeless seem to face the most significant barriers to protecting themselves from infection, obtaining resources and enjoying significant social support if they are HIV positive.
Prevention programs that have been effective often make use of multiple group sessions, peer counseling, voluntary counseling and testing and harm reduction techniques (Schwartlander et al., Science, 2001). These all depend on good dialogue. A number of presenters who worked with groups that identify as minority by virtue of ethnicity, legal status, sexual orientation or gender addressed the critical nature of empowerment that comes through a greater understanding of individual and cultural strengths. There were frequent recommendations for programs that were "process-focused" rather than "information-focused." Stephen Morin, Ph.D., University of California, San Francisco, reported that a message he has ascertained from his research with men who have sex with men (MSM) is a desire for motivational theme regarding prevention -- "we know what we need to do, just motivate us to do that." Loneliness, depression, stigma and cultural histories of being devalued require positive relationships and more than brief encounters to overcome.
Several researchers touched on the power of establishing community standards that value HIV prevention. Stephen Fallon, Ph.D., from Ft. Lauderdale, cited a 1989 study by Gordon Mansergh, Ph.D., that found that "perceived community norms" influence behavior more than any other intervention. Perhaps this explains the success of programs that incorporate a social focus, peer education and counseling and are culturally specific. Perhaps it is also community norms, but different norms, that underlie the reported increase in unsafe sex and rising HIV and syphilis rates associated with sexual contacts initiated in Internet chatrooms.
Whether prevention messages should be directed toward HIV-negative or HIV-positive people is an ongoing debate, but Dr. Fallon cut to the chase when he commented that the choice is similar to being asked if you want a car with brakes or a car with an engine. You want both. Dr. Carlos Del Rio addressed this point a bit differently in the opening plenary when he said that there are three parts to reducing transmission. You decrease the source of the infection, you decrease the susceptibility of the host and you reduce risk-taking behaviors. A combination of biomedical, social and psychological factors combine to increase or decrease transmission. The greatest impact on transmission seems to come from using as many resources as possible and arming everyone involved with the most options.
The final plenary of the conference was a study in contrasts with David Holtgrave, Ph.D., from Emory University's Rollins School of Public Health receiving a standing ovation. His powerful presentation evaluated HIV prevention program effectiveness and assessed what is needed to meet the CDC's goal of cutting HIV infections in half by 2005. He called for $300 million more per year to meet the goal, backed syringe exchange programs and labeled the failure to put adequate funding into scientifically supported prevention programs "public health malpractice." The temperature in the meeting room chilled noticeably when Claude Allen, deputy secretary of Health and Human Services, spoke in place of CDC director Dr. Julie Gerberding. The former press secretary to Jesse Helms and nominee for a federal judgeship represented an administration that has been criticized for the removal of scientific information from federal web sites, for banning needle and syringe exchange and for letting value statements crowd out science.
The research shows that HIV prevention programs have slowed the spread of HIV since the onset of the epidemic, but a concerted scientific effort needs to be made in order to bring it even lower. Researchers continue to develop creative interventions based on successful models, but moralizing, stigma and inadequate funding may be roadblocks to more dramatic declines in transmission.
The most impressive statistic I heard at the conference was Dr. Holtgrave's remark that "96% of persons living with HIV do not transmit the virus to a seronegative partner in a given year." That speaks to education, application and motivation on the part of many people living with HIV and their partners. Now if only the Bush Administration would be so committed.