In light of the ongoing spread and mortality of AIDS in the US and globally, public policies and health education initiatives need to be revamped. While governmental programs may discourage high-risk activities or prevent infection in other ways, the ultimate responsibility for prevention lies with individual behavior.
As of July 2000, the Centers for Disease Control and Prevention (CDC) in Atlanta, GA, found that 2 to 4 percent of American adults, or 4 to 5 million, continued to indulge in behavior putting them at high risk of contracting AIDS. In addition to unprotected anal and oral sex, these behaviors included having six or more sexual partners in the past year, sexual activity with someone known to carry the HIV virus, exchanging sex for money or drugs, or injecting drugs in the past three years.
Although condom use has increased since the 1980s, only 40 percent of unmarried people and 23 percent of drug users report using them. In a CDC study last year, almost half of nearly 3,500 young urban homosexuals reported having unprotected anal sex in the past six months — a behavior that increased risk of HIV infection five-fold. Having had sex with 20 or more men led to three times greater risk of HIV infection.
In a San Francisco-based study last year of homosexuals and bisexuals under age 23, use of amphetamines, ecstasy, and amyl nitrate was associated with increased frequency of unprotected anal sex. Among those 15 to 17 years of age, perceptions of peer norms supporting safer sex were related to less risky behavior.
“Adolescents are one of the groups at greatest risk for HIV infection, particularly minority inner-city youth,” says Geri Donenberg, PhD, an assistant professor of psychiatry at the Institute for Juvenile Research in Chicago, Ill.
Every 14 months, the number of HIV-infected adolescents in the US doubles, and teens account for one-quarter of new sexually transmitted diseases reported each year, according to CDC statistics cited by Donenberg.
“Youths are most likely to acquire HIV through sexual activity,” she says. As no vaccine is available, “the most reliable method of HIV prevention is to reduce risky sexual behavior — encourage abstinence and teach safe sex methods.”
Most teens learn sexual attitudes and mores from their parents, so HIV prevention must also focus on their families, Donenberg concluded in her study published in the June issue of the Journal of the American Academy of Child and Adolescent Psychiatry.
“Family-based prevention programs that teach safe sex methods while encouraging abstinence, improve parent-adolescent communication about risky sexual behavior, and empower parents as educators and resources for their children are essential to curb the spread of HIV in this highly vulnerable population,” she says.
As might be expected from Donenberg’s findings, runaway and homeless youth are especially likely to engage in high-risk sexual activity. Of nearly 900 sexually active runaways and homeless youth studied by the CDC last year, almost three-quarters reported at least one episode of unprotected sexual intercourse during a six month period, and almost one-quarter reported never using condoms.
Even when condoms are used properly, exactly how safe is “safe sex”? As the microscopic HIV virus can easily pass through invisible holes in a latex condom, abstinence is a far safer alternative.
“I believe there is probably an overemphasis on approaches that attempt to reduce the efficiency with which HIV is transmitted, like condoms, and insufficient emphasis on the other key strategy, which is to influence the contact pattern between infected and uninfected persons,” says John Richens, MSc, MBBS, a lecturer in sexually transmitted diseases at University College in London.
Condoms may give users a false sense of security, Richens explains, referring to a 1995 study. Men and women who reported using condoms every time they had sex had the same rate of sexually transmitted infections as those who reported never using condoms.
“My view is that these findings are probably explained by the condom users choosing their partners from a riskier population, as well as by condom failure and incorrect reporting,” Richens says.
Especially in the developing world, patterns of sexual behavior influenced by socio-economic factors may be easier to change, Richens says. In his opinion, “dismantling the single sex hostels surrounded by brothels in Africa would have much greater impact than giving out condoms to migrant laborers and the sex workers who provide services to them.”
Attitudes and social customs can thwart condom use even in those realizing that their lives may depend on it, according to a Johannesburg, South Africa study reported in the July 2001 issue of Social Sciences and Medicine.
Complex power struggles between prostitutes and their clients, pimps, police and even healthcare workers often interfered with condom use, as did violence and competition between prostitutes for clients who preferred unprotected sex. Other strategies to reduce HIV transmission may therefore be as effective, or more effective, than promoting condom use.
“We have numerous examples of rigorously evaluated behavioral interventions which reduce the risk of HIV infection or high-risk behaviors associated with infection,” says Landon Myer, MSc, a senior scientist with the South African Medical Research Council. In addition to promoting condom use for both men and women, these include reducing high-risk sexual contacts with prostitutes, and encouraging adolescents to remain abstinent longer.
“Making treatment for HIV infection available could greatly increase the number of people seeking voluntary counseling and testing, and would increase the ability of prevention programs to target HIV-infected persons with behavioral interventions to reduce transmission of the virus,” Myer says. “Making treatment for HIV-infection available within a country or even a single community may help to reduce stigma associated with HIV, thereby facilitating prevention efforts.”
While targeting sexual behavior, Myer also stresses the importance of behavioral interventions in intravenous drug users, which he feels “will be of crucial importance in limiting the nascent epidemics of South Asia and Eastern Europe.”
One of the most chilling ramifications of the global AIDS crisis is its devastating effect on newborns. Each year, 600,000 infants acquire HIV — 75 every hour or 1,800 every day — and more than 500,000 children die each year from AIDS.
“In 2001, it is known how to prevent mother to child transmission of HIV-1,” says Catherine M. Wilfert, MD, scientific director of the Elizabeth Glaser Pediatric AIDS Foundation, and a professor of pediatrics and microbiology at Duke University Medical Center in Durham, NC.
Giving combination drug treatment to pregnant women carrying the HIV virus reduces newborn infection rate to only 1.5 percent. In the United States, treating pregnant women has decreased newborn infection by an estimated 80 percent, with fewer than 200 babies with AIDS reported each year.
Worldwide, there are villages and nations where one-quarter to more than one-third of all pregnant women are infected with HIV. Without drug treatment, each infant born to an HIV-infected mother has a 15 to 30 percent chance of acquiring HIV.
Thanks to efforts of the Elizabeth Glaser Pediatric AIDS Foundation, CDC, and UNICEF, drug treatment programs for HIV-infected pregnant women are underway, combined with education campaigns and care of orphans who mothers died from AIDS,
“While this is a single facet of the epidemic, it provides a potential foundation to build upon to provide care for infected women and children,” Wilfert says. “We have a long way to go, but have seen progress recently.”