How Can We Identify the Behaviors and Contexts That Place Individuals/Communities at Risk for HIV?

Major Behavioral Risks

Research to date has identified the key risk behaviors for HIV transmission to be unprotected anal and vaginal intercourse, having multiple sex partners, and using nonsterile drug injection equipment. Although there are some documented cases of transmission through oral-genital sexual contact, methodological issues make it difficult to precisely determine risk. At the present time, oral-genital sexual contact is considered to be a somewhat less risky behavior for contracting HIV than anal or vaginal intercourse.

Contexts That Influence Risk

Important social and biological contexts and cofactors increase or decrease the likelihood of risk behaviors. A major contextual influence is the prevalence of HIV itself in the local population, which greatly influences the impact of any risk behavior. Other contextual influences include: individual factors such as age and developmental stage, early initiation of sexual behavior, sexual identity, self-esteem, untreated sexually transmitted diseases, use of alcohol, and use of other drugs; interpersonal factors such as sex with a partner of unknown HIV status, partner commitment, and negotiation of safe sex; social norms and values such as cultural and religious beliefs, gender role norms, and social inclusion versus marginalization of gay men, ethnic minorities, people of color, sex workers, women, and drug users; and political, economic, and health policy factors such as laws and regulations, employment opportunities, poverty, sexism, racism, homophobia, and availability of basic public health tools for protective behavior, such as condoms and sterile injection equipment.

Although many of the behavioral risk factors are quite well known, the contextual risk factors are only beginning to be understood. For example, intervention programs with younger gay men need to address the fact that some of them consider HIV to be a threat mainly to older men. Negotiation about safe sex practices is much more difficult for women in populations where there are cultural barriers to doing so. Programs targeting sex workers have been highly efficacious in other countries, but in this country would encounter cultural and political barriers. The impact of poverty on seeking treatment for sexually transmitted diseases is much greater in countries without access to universal medical care. These contextual factors combine in dynamic ways to increase behavioral risk.

Means of Identifying Behaviors and Contexts

Behavioral risks have been identified by combining data from epidemiological studies and data from studies of homosexual and heterosexual couples with only one HIV-positive partner. Ongoing measurement of biomedical transmission factors will continue to be important as the epidemic changes. Because contextual factors are more numerous and more difficult to measure than biomedical factors, a wide variety of methods have been used to identify and measure them, including qualitative, ethnographic, and observational techniques. This work is multidisciplinary and requires ongoing consultation with local community groups. Contextual information is essential for designing tailored interventions that respond to the needs and preferences of people in particular communities. In addition, if a particular intervention is not effective for some participants, this information could guide development of the next generation of interventions.

Changing Trends in Specific Behaviors and Community Contexts That Produce Elevated Risk for HIV Infection

A number of established and several new and emerging behaviors and community contexts increase risk for HIV infection. In general, youth in school are showing an increase in condom use at last contact, but a trend for decreased condom use as they get older. Among gay men, the infection rate is increasing among African-American, Latino, and younger men. Injecting drug users are at increased risk because of conditions in their communities, including unavailability of sterile injecting equipment, dealer provision of infected needles, and social situations that encourage multiperson reuse of needles and other drug paraphernalia. Women, particularly women of color, recently increased dramatically as a risk group in the United States and constitute 50 percent of those infected worldwide. Much of the growth in their risk is caused by sexual contact with partners whose sexual or drug use behavior put the women at risk. Vertical transmission from infected mother to infant continues to be a source of high risk for the infant, even with the treatment for mothers and infants that is now available. In addition, a variety of other special settings and subpopulations at increased risk, including incarcerated youth and adults, and individuals with chronic mental illnesses, deserve greater attention.

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