At the time of writing over 37,386 Americans have been diagnosed with full-blown Acquired Immunodeficiency Syndrome (AIDS). (U.S. Department of Health and Human Services, 1987). Health officials estimate that for every person with AIDS, there are 10 people with AIDS Related Conditions (ARC) (San Francisco Department of Public Health, 1983). There are estimates that anywhere from one to two million Americans have already been exposed to Human Immunodeficiency Virus (HIV) (Curran, 1985; Sivak & Wormser, 1985). Thus, with an incubation rate of up to several years and with no effective vaccine, treatment or cure in sight, preventing the transmission of HIV has become the single greatest priority.
This article outlines an AIDS prevention program that the authors developed for gay and bisexual men. Concepts regarding the education of the general public are discussed, issues inherent in reaching different segments of the population are explained and finally specific suggestions for conducting effective prevention programs and their integration into practice settings are offered.
Educating the general public on lowering the risks of contracting or transmitting HIV has posed many challenges for professionals in AIDS prevention and risk-reduction efforts. Not the least of these challenges is how to reach diverse segments of the general population that are at risk. Gay and bisexual men, for example are not a single homogeneous group, even when living in a major urban center such as Manhattan or San Francisco. Some are deeply closeted or married, others have a number of concurrent sexual or romantic partners, or live in committed relationships with a single life companion or lover. Some gay men are very sophisticated sexually, while others are quite naive. Intravenous (IV) drug users, another population at risk, do not have an identified or unified community outside of residential therapeutic communities for those recovering from addiction. For some members of these two groups, sexuality and drug use may not be the major forms of identification.
Dr. Richard Keeling, Chair of the American College Health Association's Task Force on AIDS (reported in Gray, 1986) has cited a case that amply demonstrates the complexity of reaching everyone who needs AIDS prevention education. A female student who did not consider herself part of a risk group recently tested positive for HIV antibodies. She reported a three-week sexual relationship with a heterosexual male, who in turn had a two-night sexual relationship with another male. "He did not think of himself as being in a risk group and he would never define himself as gay or bisexual" Keeling says. "And that's exactly the way a lot of typically-straight males feel . . . that if it happened one or two times and it was on a camping trip and nobody knows about it . . . well then, that's not gay" (Gray, 1986, pp. 12-13).
Over the past two years, as consultants for AIDS service organizations, the authors have conducted AIDS prevention programs in the U.S. and Canada for over eight thousand people, most of whom were gay or bisexual men but some of whom were intravenous drug-using individuals or interested heterosexual women. We developed five working assumptions about doing risk reduction programs as social workers and health educators.
- 1. The rate and frequency of AIDS is growing.
- 2. AIDS is moving into all segments of the general population.
- 3. There is no effective treatment or cure.
- 4. I.V. drug users, bisexual men and heterosexually married homosexual men are the key links in the spread of AIDS in general U.S. population.
- 5. AIDS is a behavior-bound disease that is caused by high risk behaviors, and not by membership in particular risk group
AIDS can be prevented by changing behaviors. Practitioners undertaking AIDS prevention work with the general population need to discuss the specific behaviors that risk transmitting HIV--and not the risk groups. Such an approach helps to minimize the biases that affect gay or bisexual men or IV drug-using individuals, thus clearing the way to viewing AIDS and AIDS prevention as public health and not moral issues. Since contracting AIDS is behavior bound, it is a disease with which anyone can be afflicted.
Our model for AIDS prevention education is intended to help individuals from becoming infected with HIV. We believe it can assist people to manage their lives and even their illnesses should they already have AIDS, ARC, or are HlV-antibody positive. Our model is also meant to help mental health professionals in having cognitive and affective interventions ready to use with clients include large numbers of people at risk for contracting AIDS.
All who are at risk for AIDS should be encouraged to understand and internalize the following set of beliefs in order to promote change.
- They must recognize AIDS as a direct personal threat. Most often this occurs after someone they know has become ill or died from AIDS.
- They must understand that AIDS is preventable.
- They must work through feelings of guilt about high-risk behavior that may have gone on before they learned how AIDS is transmitted.
- They must believe that they can learn to manage necessary lifestyle changes in order to not put themselves at risk for contracting or transmitting HIV.
- They must have peer support while undergoing these lifestyle changes.
- They must believe that they can subsequently have a satisfying sexual and/or drug-free life (Jacobs, 1986).
- If unable to believe that they can live drug-free, then they must believe that they can learn not to share IV drug-using paraphernalia such as syringes and cookers and how to properly sterilize such items between use.
Prevention and Target Populations
Interventions geared to preventing the spread of HIV need to be tailored to meet the specific needs of the group or individual being addressed. People have different knowledge levels about AIDS. While some will require basic education about specific means of transmission, others who already have this information will only require assistance on how to live with changes they will need to make if they are to no longer place themselves and their sexual partners at risk. We have adapted the tripartite model health educators use in dealing with other issues such as pregnancy and drug abuse. This approach was tailored to address the needs of a variety of individuals who require information about preventing the spread of AIDS. There are three levels of prevention: primary, secondary and tertiary.
The purpose of primary prevention is to prevent, reduce and delay the onset of HIV infection. There are two aspects of primary prevention: the first consists of actions designed to prevent the development of the disease. This is a series of macro and generational interventions. For instance the younger generation of people currently growing into sexual maturity would learn to only engage in safer sex as a way of life until they were in a committed relationship and both individuals tested negative for the antibodies to HIV. In addition, the next generation of IV drug users would learn how to use needles safely.
The second aspect of primary prevention deals with interventions designed to promote the idea that certain life skills can assist people in preventing exposure to HIV. For example, women who have shared intravenous drug using implements like syringes or "cookers" or who have been the sexual partner of someone who has shared drug using implements as well as those women whose love have been bisexual men, hemophiliacs or recipients of blood transfusions prior to the blood supply being screened for HIV are considered to be highly at risk for developing AIDS. Even when such high-risk women have accepted the need to use condoms, assertiveness training is one necessary component of primary prevention. Such interventions teach women how to negotiate for power and control in relationships with men who may have a history of being abusive. This is a psychosocial approach which helps people develop the necessary life skills to avoid transmission of HIV.
The goal of primary prevention is to provide information and education regarding transmission of HIV for the general population. Through this process, individuals will be enabled to determine whether they themselves may be at risk. Once this has occurred they can be helped to substitute low-risk behaviors for those that are high-risk.
Target populations for primary prevention are: the general public, health care workers, sex educators and mental health professionals, individuals at high risk for contracting HIV and sexual partners or needle sharing partners of individuals who are at high risk.
Secondary prevention is concerned with individuals who are ready positive for HIV antibodies. They may possibly be symptomatic for ARC or AIDS. The goal is to prevent them from being repeatedly exposed to HIV and from transmitting HIV.
For clinicians or educators working with this segment of the population it is important to help clients identify underlying issues. If left unexamined, these can prevent the person from believing in his or her capacity to adopt low-risk behaviors. A thought that is commonly expressed is: "I've already been exposed to HIV. So why should I bother to change my sexual or drug-using patterns?" This is best answered with the information that there is a growing body of evidence suggesting that repeated exposure to HIV may be necessary for active illness to progress.
The focus of secondary prevention is to provide information the nature of the illness in order to retard further progression of illness. Individuals who may be seropositive for HIV, have ARC or AIDS can learn to identify themselves so they can receive treatment and the progression and transmission of the disease can be slowed or interrupted.
Target populations for secondary prevention interventions are: individuals seropositive for HIV (these may be people who have a confirmed positive HIV antibody blood test or who simply assume seropositivity); individuals with ARC, AIDS and other HIV infections; sexual partners and needle-sharing partners of the above two groups, and members of the helping professions.
Tertiary prevention is concerned with preventing as many of the disabling aspects of AIDS as possible. Called the "Living with AIDS Model," the intent is to maximize the living potential of the person with AIDS, ARC or HIV infection. One person with AIDS explained: "You're only dying the final week of your life. Until then you're living with AIDS." Such an attitude helps prevent and manage some of the hopelessness and other transitional affective responses for the person who is ill, for their significant others and for the professional working with him or her.
Target populations for tertiary prevention are: people with progressive AIDS, ARC or HIV infection; care partners of the above group; and health care professionals involved with the ill person.
Development of the AIDS Prevention Program
Prior to the onset of AIDS, workshops on Sexually Transmitted Diseases (STD) for gay men were almost non-existent until it became evident that Hepatitis B was assuming epidemic proportions in certain segments of the gay population. The AIDS epidemic in the gay and bisexual men's community created numerous crises, one of the most significant being that new sexual behaviors had to be learned in order to adapt successfully to life in the age of AIDS (Martin, 1986; McKusick et al., 1986). This was a crisis similar to other developmental crises requiring new coping behaviors and strategies in order for the individual to adapt adequately (Mandel, 1986).
AIDS service organizations, gay health care professionals and gay media each began to provide lists of what sexual behaviors were high-risk. In the early period of AIDS prevention (1982-1983) the term "safer sex" had not yet been coined. Low risk sexual activity was called "healthy sex" a term itself fraught with moralistic overtones. At times information about preventing the spread of AIDS was presented in a highly-moralistic fashion. As a result, safer sex began to be viewed by some men as just another negative injunction. And in defiance of such injunctions many people refused to adopt to make peace with safer sex.
Sex and semen in particular began to be viewed as toxic. Many gay men began equating sex with death both consciously and consciously. It was precisely this internalized sense of toxicity which resulted in men feeling dirty, depressed and isolated. Thus many developed sex-negative or erotophobic attitudes. These tudes easily reinforced underlying homophobic feelings, especially since some Christian fundamentalists were suggesting that AIDS was God's punishment upon homosexuals. Combined with living through an onslaught of friends and lovers dying, a general level of depression, anxiety and lowered self esteem developed among certain segments of gay men's communities around the country.
Uncertainty having to do with which sexual practices were risk or how to change long-existing patterns of sexual behaviors contributed to this anxiety. Many men were angry about AIDS and the changes necessary to protect themselves and their sexual partners. Some felt trapped into choosing celibacy and became resentful or depressed when faced with this choice. Others felt defiant and simply refused to practice safer sex, feeling that there was no sense in having sex if they could not do whatever they wanted.
In June 1985, in response to the difficulties gay and bisexual in New York City were reporting in adopting the risk-reduction guidelines, an AlDS-prevention workshop called "Hot, Horny Healthy: Eroticizing Safer Sex" was developed by the authors to address these issues. Both are psychotherapists with substantial practices in Manhattan. As gay men who ourselves are at-risk for contracting or transmitting the AIDS virus we had to personally make the behavioral changes in our own lives that all gay bisexual men were being asked to do. This made us sensitive to empathetic with the difficulties inherent in being able to change one's pattern of sexual behavior.
The workshop was developed as a sexual enrichment seminar for all gay and bisexual men whether they were single, dating or in a long-term committed relationship. It was intended for people who were healthy, as well as for those who had ARC or AIDS, and for those who were both HIV antibody positive and negative, as well as those who did not know their antibody status. It was considered important not to divide the gay community into people who were well and those who were not to help avoid the development of a caste system based on health or antibody status.
We had recognized the need to teach that safer sex could be great sex that did not have to be either dull or limited. It was considered crucial for gay and bisexual men not to give up sex because the virus thought to cause AIDS was sexually transmitted. Essentially the seminar provided the participants with the opportunity to express their feelings about changing their patterns of sexual behavior. Through the use of large and small group exercises, discussions and role playing, participants were enabled to learn how to negotiate safer sex with a new or pre-existing partner. The participants were provided with strategies on how to make safer sex spontaneous, erotic, creative, satisfying and fun.
The workshop was different from other existing safer sex seminars insofar as it did not spend a great deal of time going into which behaviors were or were not high-risk. Our goal was to develop a psychoeducational model that would deal primarily with the cognitive and affective aspects of changing sexual behavior.
It should be noted that the workshop had been originally developed for a conference sponsored by Gay Men's Health Crisis in June of 1985 and has since become an essential component of that organization's AIDS prevention programs. We have written a facilitator's guide for running the workshop so it can be replicated by others and thus not be a trainer-dependent model (Palacios & Shernoff, 1987).
The workshop lasts between 3 and 3-1/2 hours depending upon the number of participants. Workshops have been conducted for as few as eight people and as many as four hundred at a single time. Consequently it is an inexpensive and highly-efficient macro intervention.
Yalom (1985) describes the eleven categories that help create curative factors in group therapy. While not a formal therapy group, the workshop uses such principals of group treatment to help participants achieve the desired goals of substituting low risk sexual behaviors for those that are high risk. The aspects of Yalom's theories that are especially relevant to this type of combined large and small group processes are:
- (1) installation of hope
- (2) universality
- (3) imparting of information
- (4) development of socializing techniques
- (5) interpersonal learning
- (6) catharsis.
The workshop is divided into four parts. The first aspect provides participants with the opportunity to express and process a variety of feelings. The focus is framed in terms of how to live as a sexually active and sexually-responsible gay or bisexual man. The blocks to accomplishing this goal are identified. Considerable time is devoted to issues around mourning the losses of old sexual patterns. Other affective responses such as anger, sadness and boredom are elicited and dealt with during this segment.
The second part is directed towards helping people identify and understand their options. This aspect focuses on affirming that new and desirable behavioral and attitudinal changes can indeed be made. Information on a wide variety of sexual options still available is provided in small group exercises. Participation in small groups is considered important in terms of enhancing a sense of sexual possibility and adventure as well as the ability to change old patterns. Since participants work on these tasks within the context of a small ongoing work group, peer support develops which helps create a climate of safety and fun within which these discoveries can occur.
This aspect of the workshop is also devoted to giving participants permission to explore various thoughts, feelings and actions, e.g. to be angry, sad, or relieved; to talk about sex; to miss high-risk activities; to be sexual in the face of the epidemic and to be verbally and erotically playful with a group of other men.
During the third part of the workshop we attempt to have participants integrate and accept change by discussing how to eroticize safer options. This occurs by helping participants let go of thoughts, feelings and actions that are erotophobic by providing a successful, sex positive experience in the small nonthreatening group setting. Participants often reveal that many of them entered the workshop feeling extremely negative about sex and being sexually active due to the fact that AIDS is sexually transmitted. The discussion of sexual options becomes in itself a joyful and sex-positive experience that provides an emotional foundation for participants to build upon after they leave the workshop. Thus the process undergone during the workshop itself is a metaphor for the changes we hope the participants will experience in their efforts to integrate safer sexual practices into their lives.
In the fourth part of the workshop we use role playing and values clarification exercises to help participants learn how to develop skills in negotiating safer sex agreements, maintaining these agreements and in setting limits. This increases feelings of self-confidence and thus prepares them to discuss safer sex in future encounters with potential partners.
During the first and second parts of the workshop the feelings that are most often expressed are those of anger, resentment, loss and general sex negativity. We acknowledge and validate these feelings pointing out that a lot of the men seem to be feeling similarly. By the third segment, participants begin sharing feelings of awe and disbelief that they are actually enjoying the process they are going through during the workshop. This appears to provide the hope that they can actually once again enjoy sex in an excited, enthusiastic, playful as well as safer fashion.
At the conclusion of the workshop, participants are asked, as a brief evaluative device, how their thoughts and feelings have changed as a result of their involvement. Generally, they report feeling much less anxious and depressed and more hopeful about being able to have a satisfying and risk-free sex life.
The goals of the workshop are:
- 1.To provide a safe and non-threatening environment in which emotionally-laden material about sex and AIDS can be explored and discussed.
- 2. To help gay and bisexual men identify negative affective responses induced by the AIDS crisis in relation to their sexuality and sex lives.
- 3.To help them work through these negative feelings in order to minimize any impairment in their psychosocial/psychosexual functioning so that low risk behaviors can be substituted for high risk ones.
- 4. To help participants view their reactions as appropriate responses that require new crisis-management skills.
- 5. To provide a structure in which participants discover and share information on how to be sexually active in low-risk way!
- 6. To help participants enhance and improve levels of sexual health and functioning.
- 7. To help them gain practice in negotiating and contracting safer sex.
Conclusions and Implications
It should be noted that the workshop described previously is not an appropriate intervention for all people who are at risk for AIDS. It is effective for gay and bisexual men who have a well enough developed gay or bisexual identity to seek out gay community events. One of the difficulties with using this workshop as an effective AIDS prevention strategy for broad segments of the gay men's community is that it requires individuals to be self- motivated. People who attend are usually self-referred. Consequently very closeted gay men are less apt to come to the workshop. Therefore national campaigns stressing that safer sex is for everyone regardless of sexual orientation are sorely needed to bridge this gap. Another suggested way of reaching this group of men is to advertise workshops on safer sex in local mainstream media for all men, and specifically not discuss gay or bisexual issues.
There are a number of recommendations for conducting effective AIDS prevention education for the general public, for specific groups such as those comprised of women and drug users and professionals involved in agency-based or private practice.
Information overloads should be avoided. People can only absorb much information at any single time. It is a mistake to think that because you have an audience they must receive comprehensive information on AIDS and risk reduction at one sitting.
- The message of prevention and change must be repeated over time.
- It should be relevant to the targeted audience.
- It needs to be revised when appropriate so that it speaks to women differently than to men and differently to gay and bisexual men than to IV drug using men who may be heterosexual.
- A variety of strategies and interventions must be developed.
- The message itself as well as specific "how-tos" of changing high-risk behavior should never be punitive.
- Strategies must always be empowering so that the desired behavioral and attitudinal changes can become acceptable to the person.
- It should always be geared to specific behaviors, i.e., unprotected anal or vaginal intercourse, sharing needles, etc.
- The message should occur in a context where the targeted individuals acknowledge that a problem exists and that there is a threat to their lives.
The environment for AIDS prevention should be one where the individuals' feelings, fears and resistance are able to be identified and examined by the targeted people themselves--and not force fed to them by a trainer or clinician. The interventions should motivate the targeted groups to change their behaviors. Fear should not be used as a motivator since it cannot be sustained for this purpose for lengthy periods of time.
When attempted for a mixed audience of heterosexual men and women the participants should be segregated by sex into small groups, otherwise the men and women are not sufficiently self-revealing about their feelings and sexual tastes for the workshop to achieve the desired goals.
When conducting AIDS prevention education for women there are special issues that need to be taken into account which this workshop format is not ordinarily able to address. For women who arc at high-risk, a "safer sex is great sex or fun sex" approach is often not relevant since many of these women report that even prior to AIDS sex was rarely a fun or enjoyable activity for them. Realistically, some women at risk are concerned with how to begin to have their partners use condoms without creating power struggles.
There are reports of women being raped within their relationships, being battered and being threatened with the loss of the security of "a meal ticket" when they have attempted to introduce the use of condoms.
Machismo can be another barrier to implementing safer sexual practices once women have been educated about AIDS prevention. In Haitian and Hispanic male-female relationships the man is traditionally dominant and only he may introduce new ideas about sexual practices. As a result, following one seminar a woman reported to us that she was beaten for having suggested the idea of using a condom.
Some at risk women have reported that if their partners find condoms offensive or uncomfortable and refuse to use them, rather than leave these relationships, women stay and submit to high risk behaviors at the risk of their own life. Therefore, teaching certain women safer sex interventions can create new and additional problems for them in their often already chaotic lives.
Other areas of resistance encountered with AlDS-prevention grams for women are religious and cultural. Many of the high risk women are Haitian or Hispanic and may have been raised as practicing Catholics. Accordingly, the official Catholic opposition to artificial birth control is another barrier that must be taken into consideration. Thus, the special and unique issues of AIDS prevention for high-risk women still needs to be addressed, and additional interventions must be developed to meet their needs.
With regard to drug users there is a pilot program in New City developed by a group called ADAPT (Association for Abuse Prevention and Treatment) that enlists former and recovering IV drug users to educate active IV users about safer sex and needle use by going to parks, abandoned buildings, ''shooting galleries," and other locations where addicts congregate to use or buy drugs. They also convey the message that there is treatment and cure for drug addiction currently available in New York City at methadone programs and therapeutic communities.
It is noted that active addicts are allowing the ADAPT people into the areas where drugs are being bought and used, and are engaging in conversations about AIDS and drug abuse. This approach is now being used by both the New York City Department of Health and the New York State AIDS Institute who have made funds available to hire recovered and recovering addicts and other street wise people to do this kind of AIDS prevention education.
Finally, the urgent need to insure that people reduce high risk behaviors has resulted in our introducing social health education as one aspect of our private practice. Thus, with every sexually active adult who is not in a relationship that has been monogamous for at least nine years we bring up the issue of AIDS in relation to their sexual practices. There are understandable concerns regarding the introduction of this material into treatment. Questions of whether the interview content becomes overstimulating for the client or "inappropriately eroticized" have to be weighed on a case by case basis. Many clients are not comfortable with issues of sexuality and thus may feel uncomfortable by its discussion.
For social workers in any part of North America engaged in individual, couple or group work with sexually active single adults, a newly separated or divorced person, a teenager just becoming sexually active, or any gay or bisexual man, it becomes appropriate to ask: "How do you feel about the fact that AIDS is sexually transmitted?" and "What are you doing to protect yourself from becoming infected? These kinds of questions can raise many feelings including intense anger. These arise most often because any discussion of the subject shatters the client's denial that AIDS can not touch him or her. The anger can also emerge when the client perceives the question itself as a parental negative injunction.. Negative transferential feelings that arise provide fertile ground for exploration of a variety of related issues like taking care of one's self, self image, the consequences of impulsive behavior as well as an examination of the transference itself.
When anger or shock dissipates, asking clients to explore how they might need to change their sexual practices can be fruitful. Feelings about condoms, and what can be done to eroticize their use need to be explored. The authors have worked with clients who have become sexually abstinent in response to AIDS. Following initially successful experiences using condoms on a date, these clients often immediately began a phase of treatment where there was an idealized transference towards the therapist as a result of resumption of sexual activity. Ultimately, this has to be worked through for treatment to progress.
We have asked clients to imagine specific sensate focus exercises where they touch or are being touched by a sexual partner in ways that will not put either of them at risk. It is not necessary that the specifics of what these acts are to be verbalized to the therapist Similarly, the therapist can ask the client to imagine safer ways oi doing a variety of sexual practices. Having a client role play how to initiate a conversation about safer sex during a session has also proven to be a helpful exercise. Clients have reported that these exercises proved helpful in improving the quality of their sex lives since it taught them how to better focus on their own sexual needs and wants as well as those of their partner.
In summary, a format and process for providing AIDS prevention education for the general population has been outlined. A particular approach that has been useful in addressing the needs of openly gay and bisexual men has been detailed as an example. Given the confines of the current conservative political environment we note the challenge inherent in how to proclaim the message that prevention is the only vaccine available for AIDS.
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Published in The Journal of Social Work & Human Sexuality, V.6, No.2, 1988
©1988 Michael Shernoff & Luis Palacios-Jimenez