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During a fellowship at INSERM in Paris I developed several frameworks to predict sexual behavior change.  They are discussed in the following article.

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USING THEORETICAL FRAMEWORKS TO EVALUATE THE EFFECTIVENESS OF HIV PREVENTION PROGRAMS: Determining factors related to sexual behavior change by stage of the HIV epidemic Mitchell Cohen 1 and Judith Chwalow 2
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INSERM U263, Paris, France INSERM U21, Paris France
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Abstract: Based on a systematic review of over 700 studies with sexual behavior as the dependent variable, those factors related to changed behavior are placed within three frameworks: Information Processing, Personality, and Normative. The Frameworks demonstrate how HIV/AIDS programs may be evaluated using these theoretical perspectives, and future directions for prevention programs are suggested. Within each framework, various social, psychological and structural factors are suggested to have distinct impact during the beginning, peaking, declining and tail stages of the epidemic. Information such as knowledge of serostatus of or awareness of friends or partners with HIV infection or AIDS do motivate change during earlier stages of the epidemic but have much less impact during later stages. Positive motivations for unsafe sex, such as intimacy, are likely to have a large impact on behavior, particularly late in the epidemic. Overall, peer and partner pressure are among the strongest factors related to change. Within the context of these frameworks, sexual behavior change is much more likely where governments funnel necessary resources into community based prevention and communities are strengthened to confront the epidemic. Keywords: HIV, AIDS, Sexual behavior, information, personality, normative, safer sex, unsafe sex, stages, risk, condoms, homosexual, gay, serostatus, testing, attitudes, beliefs, intimacy, policy, peer, partner
USING THEORETICAL FRAMEWORKS TO EVALUATE THE EFFECTIVENESS OF HIV PREVENTION PROGRAMS: Determining factors related to sexual behavior change by stage of the HIV epidemic Mitchell Cohen and Judith Chwalow, INSERM U21 & U263 Paris, France 3 INTRODUCTION: The Dynamics of the HIV Epidemic Amsterdam and San Francisco are two cities whose active gay communities have been extensively studied. Based on estimates from cohort data, about 40%-50% of San Francisco's approximately 50,000 self-identified gay men are infected with HIV (Grant et al., 87; Hessol et al., 89; Van Griensven et al., 91). In comparison, 15%-30% of Amsterdam's 30,000-35,0000 gay men are infected. In San Francisco more than 30% of the cohort were infected before 1982, before HIV was discovered and epidemiological research proved that unprotected anal intercourse was the major risk factor for gay men (Koblin, Van Griensven et al., 91; Van Griensven, Hessol, et al. 91). While the epidemic hit Amsterdam somewhat later, with the first cases of AIDS recorded in 1981, about half of those infected by 1990 were already infected by 1984. Figure 1 documents the drop in yearly incidence of HIV infection to less than 1% in San Francisco and Amsterdam by 1987. However there is evidence of an upturn in incidence occurring within the two cohorts as well as in other groups studied between 1988 and 1990 (Stall, Ekstrand, et al., 90; Ekstrand & Coates, 90; Hessol, personal correspondence; De Wit, Vroome, et al., 90a). While the similarities in the decline of the HIV incidence in gay communities is frequently noted, the patterns in Figure 1 indicate that there are significant differences. In San Francisco the HIV infection peaked between 1981 and 1982 with a yearly incidence approaching 20% and then declined dramatically. In Amsterdam, even at the height of the epidemic, between 1983 and 1984, the yearly incidence was under 10%. In Amsterdam, the overall decline was slower, and it was only after three to four years of infection rates between 7% and 9% that the HIV rate plunged. 4 While one reason for the change in HIV incidence is that those most likely to become infected did so early in the epidemic, another is that many men greatly reduced their risk through a dramatic change to safer sex (Stall & Paul, 89; McKusick, Coates, et al. 90; Van Griensven, Vroome, et al., 89a). The change in HIV incidence closely reflects the change in sexual behavior because seroconversion usually occurs within a three months after infection (Graff, Deipersloot, 89), and there is no question that change to safer sex is related to a declining incidence of HIV (Martin, 87; Coates, Stall, et al., 88; Coates, Calazavara. et al., 88; Van Griensven, Vroome, et al., 90; Carne, Johnson, et al.,87; Gruttola, Sage, et al., 89).
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Portions of this paper were presented at the VII International Conference on AIDS, Florence, 16-20 June 1991.
While the generalizability of the cohort studies that project these incidence rates may be questioned, for comparative purposes, both cohorts were recruited in a similar manner and they have a similar demographic profile.
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FIGURE 1A: HIV INCIDENCE Sources: Amsterdam: Van Griensven (988, 1991), DeWit (1991; N=1431; 685 Hepatitis B vaccine trial; recruited between november 1980 and november 1982, and 746 healthy homosexual men recruited october 1984 onwards from homosexual communities. San Francisco: Hessol et. al. (1989) and personal correspondence. N=320; Hepatitis B vaccine trial; Recruited through San Francisco City Clinic; seronegative for Hepatitis B at recruitment.
Any attempt to explain the reasons and rate of change in sexual behavior necessitates evaluating social and sexual networks, sexual behavior, HIV prevention programs and how individuals make decisions throughout the stages of the HIV epidemic. As shown in Figure 1B, stages are determined by the shape of the epidemic curve within a given community. The beginning stage is marked by an exponential increase in HIV infection, the peaking stage is marked by the year(s) where the number of new cases each year has peaked, the declining stage is marked by the point where the epidemic starts its decline, and the tail is indicated by the point where the annual incidence continues to be relatively stable at a low level. 5 In a community where the HIV epidemic is not greatly impacted by emigration or immigration, i.e. many urban gay communities in developed countries, the dynamics of behavior change are different in the tail of the epidemic than in the earlier stages (Cohen, 91a). Clearly, different sexual behaviors present at the beginning of an epidemic account for the more rapid rise in incidence. At the start of the HIV epidemic, gay men in San Francisco reported higher levels of anal sex with more partners than in Amsterdam (Koblin, Van Griensven, et al., 91). The faster decline of HIV incidence in the San Francisco gay community, however, suggests the communities faster and more widespread adoption of safer sex. This paper presents three theoretically based frameworks that have been revised from prior work (Cohen, 91a) 6 . Leviton (89) observes that "The threat of AIDS is too great for these implicit theories [creative or intuitive] to remain unquestioned, and formal scientific theories may help to counteract mistaken beliefs about AIDS prevention." McGuire (91) further notes that theory can "serve as correctives to the frequent tendency for ... educational campaigns to be atheoretical, negatively oriented and narrow, which characteristics may explain their disappointing outcomes."
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The operationalization of stages can be based on historical data or models of HIV infection.
The revisions include greater focus on normative and structural factors based on increased evidence that these may be the most important factors related to adopting safer sex.
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FIGURE 1B: STAGES OF THE HIV EPIDEMIC
THREE THEORETICAL FRAMEWORKS The three frameworks shown in Figures 2 through 4 offer different, but not conflicting, theoretical perspectives. They are based on an extensive review of the literature and the data supporting the theories is largely from studies conducted in gay communities. The frameworks limit the predictors to those found to be most consistently related to safer sexual behavior in previous studies, and they "deconstruct" more complex behavior change models, such as the heath belief model (Becker, 74), theory of reasoned action (Fishbein, Middlestadt et al., 89), and social learning theory (Bandura, 77). They focus on relationships between the adoption of safer sex and personality factors, individual level information processing factors, and interpersonal interaction factors. While multiple interactive relationships can be hypothesized among the frameworks, this paper is limited to the direct relationship between sets of predictor variables and the adoption of safer sexual behavior, with the exception of the mediating influence of the perception of vulnerability to HIV on behavior change. Information Processing Framework The Information Processing Framework (Figure 2) asserts that change to safer sex follows a sequence of becoming aware of information about HIV/AIDS, then developing beliefs about the accuracy of that information and positive or negative attitudes toward safer sex. Awareness is defined as knowing about particular pieces of information. Beliefs refer to the degree of certainty that a piece of information is true, and attitudes refer to the positive or negative feelings about that piece of information. 7 Given that potentially the same HIV prevention activities are available to a population at risk, those who have not adopted safer sex by the tail of the epidemic have not been reached, do not
These three components are similar to the concepts articulated by Fishbein and Ajzen (75) and Fishbein and Middlestadt (89), and they are also comparable to the predisposing factors in Green et al.'s (80) PRECEDE model.
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understand the prevention messages, have not been persuaded that the recommended action is efficacious, or have decided to take a calculated risk based on their perception of becoming infected or belief that they have already have been infected. Alternatively, for many, information is not the key reason for maintaining or changing sexual behavior -- for them the factors included in other frameworks explained below my be more relevant to their sexual behavior. There are few studies about the impact of information in the beginning stages of the epidemic, during which the majority of change occurred in San Francisco, Amsterdam and other urban centers tracking HIV incidence levels such as New York (Martin,86), Chicago (Joseph, Montgomery, et al., 87), Paris (Pollak, 89), Oslo (Prieur, 90), London (Jenkins, 90), Sydney (Dowsett, 89) and Toronto (Coates, Calzavara, et al., 88). And messages early in the epidemic were much less certain about the fatal outcome; there was no consensus until after 1987 that those infected with HIV would, most likely, progress to AIDS and that AIDS was usually fatal, particularly in those cities where the epidemic among gay men started in the late 1970's and early 1980's. Some empirical studies begun at the peak or in the declining stages of the epidemic found a relationship between the amount of awareness of AIDS information and change to safer sex (Joseph, Montgomery, et al., 87; Parker, Guimares, et al., 89; Pollak, 89). Many others, particularly those done later in the epidemic, found no relationships between the amount of information and safer sex (Valdiserri, 89; Connell, Kippax et al., 88; Joseph, Montgomery, 87; Prieur, 90; Coates, Stall, et al., 88b; Fitzpatrick, Boulton, et al., 89; Martin, 86; Becker & Joseph, 88; Bochow, 90, Strader & Beaman, 91). What is clearly demonstrated, however, is that the association between unsafe sex and AIDS diffused quite quickly through gay communities. One plausible reason for finding few relationships between information and behavior change is that basic information about AIDS had saturated the middle-class, highly educated gay communities in which most of the studies were being conducted. Another reason for the lack of relationship between information and safer sex is that many researchers (and health educators) were working under a false premise that information can be measured by awareness alone and that awareness works like weights on a scale; the 'heavier' the awareness, the more likely the scale is to tip to safer sex. In fact, specific types of information may be far more important than others. For example, researchers and health educators often say that the awareness of someone who is sick or who has died of AIDS is a main reason for changing to safer sex. While some studies find the expected relationship (Stall, Ekstrand, et al, 90; Bochow, 90, Validserri, Lyter et al., 88, Ekstrand, Coates, 90), many studies, done quite late in the epidemic, do not (Connell, Kippax, et al.,90; McKusick, Coates, et al., 90; Ostrow, 89). One explanation is that the impact of knowing someone is dependent on the stage of the epidemic. The seven to ten year time gap between becoming infected and the manifestation of AIDS, means that there were relatively few persons with AIDS when the majority of people were changing to safer sex. However, within a few years after the peak period of infection, virtually everyone knew someone who had AIDS or who had died, and yet many continued to have unsafe sex. By that time, those not changing to safer sex had other reasons for continuing unprotected intercourse. Thus, being aware of someone with Cohen - 6
HIV or AIDS is most likely to show a strong relationship during the peaking and declining periods but not in the tail period. Further, the closeness of the relationship may be another factor which has not usually been controlled in most studies. Figure 2 also suggests that awareness of serostatus is related to changing to safer sex. Those studies done during the peak and declining periods of the epidemic typically find that those who were aware of their serostatus were more likely to change to safer sex than those who were not (Bye, 88b; Winkelstein, Lyman, et al., 87, Fox, Odaka, et al., 87, McCrusker, Zapka, et al. 87; Van Griensven, Vroome, et al., 89b; Bochow, 90; Coates, Stall, et al., 88; Hull, Bettinger, et al., 88). The most frequent finding is that those who know that they are HIV positive change the most, followed by those who know that they are HIV negative, followed by those who do not know their serostatus. Notably, all the studies show a general adoption of safer sex by everyone regardless of their awareness of serostatus. Those measuring the effect of awareness of serostatus during the tail of the epidemic usually find no relationship between knowledge of serostatus and adoption of safer sex (Ostrow, Joseph et al. 87; Martin, Dean, et al. 89; Huggins, et al., 91). It appears that while awareness of serostatus might hasten the change to safer sex, it is not the cause of the change. No studies have been done to explain why those who know they are HIV positive would change the most. Possible explanations include a sense of social responsibility and beliefs about the detrimental impact of reinfection. To complicate the relationship, few of the studies took into account the independent effects of counselling or the fact that those who seek counselling may be predisposed to behavior change. One study which did take these factors into account (Ross, Rosser, et al., 89) found that both awareness of serostatus and counselling contributed independently to change. Many HIV prevention programs focus on communicating knowledge about safer and unsafe sexual practices. Based on Connell, Crawford, et al.'s (88) research, indicating that knowledge of safer sex and knowledge of unsafe sex represent two distinct dimensions, these are represented as separate boxes at the bottom of Figure 2. From a preventive perspective it is also useful to separate these two dimensions; HIV prevention programs emphasizing abstaining from the unsafe practice of unprotected penetrative intercourse are likely to be different from than those advocating safer sexual practices. Awareness that unprotected anal intercourse is unsafe is almost universal in gay communities. However, for those men who have positive attitudes about unprotected anal intercourse, changing to safer sex is more difficult. For example, those men who find that unprotected anal intercourse is "the only real form of sex" are significantly more likely to engage in unsafe sexual practices (Tielman & Polter, 88). Positive attitudes about unprotected anal intercourse are likely to lead to rationalizations about its risk (Bauman & Siegel, 87; McKusick, Coates et al. 90; Connell, Crawford, et al., 90; Hays, Kegeles, et al., 90; Jemmott & Jemmot, 91). A belief that there is a high likelihood of transmission from unprotected anal intercourse and, that it is the major form of transmission may contribute to the adoption of safer sexual behavior. If other types of behavior are thought to carry a similar risk of transmitting infection, for example oral sex or casual contact, then changing one risky behavior while keeping others would be, Cohen - 7
theoretically, less likely (Weinstein,89, Rhodes, et al., 90). Awareness of safer sexual methods is less universal than awareness of unsafe practices (Connell, Crawford, et al. 89). To further confuse the issue there is considerable ambiguity about the degree of safety of oral sex (van der Graaf & Deipersloot, 89), with some campaigns suggesting that it is safe while others suggest that it is not (Cohen, 91b). Even where there is widespread awareness of safer sexual practices, for example condom use, adoption is far from universal, and consistent use is rare. Condom use increases when there is a belief that they are efficacious against HIV infection (Robert & Rosser, 90; Ross, 92). It is likely that attitudes and beliefs are neither independent nor linear in relation to each other. Negative attitudes about methods of safer sex are likely to lead to beliefs that they are not effective prevention and, in the other direction, beliefs that they are not efficacious are likely to lead to negative attitudes. In general, inaccurate beliefs about safer sex methods are widespread (McKusick, Horstman, et al., 85; Joseph, Montgomery et al., 87; Pollak & Moatti, 89, Strader & Beaman, 91). For example, Bauman & Siegal (87) found that 70 per cent of the men in their study reported engaging in behaviors which they believed reduced their risk but actually made little difference. Inaccurate perceptions can often lead to rationalizations for continuing unsafe sexual behaviors, and even the most educated and knowledgeable persons misinterpret, selectively perceive, or rationalize information in order to confirm their own biases and behaviors. 8 Other misperceptions are based on an inaccurate understanding of transmission probability, such as reducing the number of partners without engaging in protected anal sex. In a community with an infection rate of 30-50 percent, reducing the number of partners is unlikely to reduce greatly the risk of HIV infection (Grant, Wiley, et al., 87). The largest number of incorrect beliefs appears to be based on the poor understanding of the eight to ten years it takes for HIV infection to manifest itself as AIDS. First, while many men report monogamous relationships as their response to reducing their risk, monogamy was often reported in terms of months, not years. Given the time lag involved, unprotected anal intercourse, practiced with short term monogamous partners who are seropositive, or of unknown HIV status, is a high risk activity. Second, some believe that they have developed immunity because they see and feel no disease within months or even years after infection. Third, for some young gay men, there is an inaccurate perception that AIDS is an older man's disease, and they fail to realize that many of those sick in their 30's were infected in their 20's. Finally, the lack of understanding about the lag between HIV and AIDS, combined with awareness of the falling HIV rate, is likely to interpreted by some as an end to the need for safer sex. Unfortunately, despite the fact that the number of seroconversions has declined from their peak, the probability of becoming infected from unprotected anal sex remains high because there continue to be large numbers of sexually active seropositive persons. Misperceptions can lead to rationalizations which contribute to the underestimation of the probability of contracting HIV and AIDS. The consequence is that many men make a "rational"
The process of selective perception is more fully described in McGuire (69), and the process of rationalization in Festinger's (57) theory of cognitive dissonance.
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decision, hoping to beat their perception of the odds -- which are, even without inaccurate information, often calculated in their own favor (Weinstein, 89; Memon, 91; James, et al. 91). Although the information processing framework suggests that awareness, attitudes and beliefs are likely to be related to practicing safer sex, other factors may be even more powerful motivators for engaging in safe or unsafe sexual behavior. In fact, quite knowledgeable persons often engage in unsafe sex to fulfill more immediate or pressing needs. Personality Framework The Personality Framework (Figure 3) emphasizes the relationship between a person's internal self-concept and his/her behavior change toward safer sex. Key components of self-concept frequently related to safer sexual practices include the belief that one has control over his or her environment, self identification with a "community", search for love and intimacy, and a level of anxiety which, at its extreme, is related to a feeling of fatalism. The top box in Figure 3 is an amalgam of Rotter's (66) 'internal locus of control' and Bandura's (77, 89) concept of 'self-efficacy'. The former refers to a generalized concept of being able to control one's health and the latter is related to controlling one's health in regard to HIV infection and AIDS. It appears that in this latter type of situation, self-efficacy is more strongly related to behavior change (Kelly, St. Lawrence, et al. 89; De Wit, Vroome, et al. 90b; Allison, 91). From the evidence in gay communities, particularly during the initial stages of the HIV epidemic, when HIV was spreading rapidly but had not yet manifested itself with the devastating diseases related to AIDs, men who felt they were in control of their own health were more likely to adopt what they believed to be safer sexual practices (Coates, Stall, et al., 88; Joseph, Montgomery, et al., 87b; Prieur, 90). As the HIV epidemic progresses, anxiety is likely to increase as persons fear for their own health and the health of friends and partners. Although little research is reported on the relationship between general levels of anxiety and preventive health behavior, Catina, Kegeles et al. (90) note that anxiety can lead to both seeking and avoiding information about safer sex. The more anxious men became about AIDS, the more likely they were to assess their risk, and men who perceived they were at high risk of HIV/AIDS were the most likely to adopt what they believed to be safer sex, 9 except for those who perceived themselves to be at the highest risk (Bauman and Siegal. 87). Some of these men often had feelings of fatalism, many believing that they were already HIV positive, and that this feeling was often related to continuing unsafe sexual practices (Johnson, Ostrow, et al., 88; Ostrow, Joseph, et al., 87). Denial may be another way to reduce levels of anxiety, with those men denying they could be infected more likely to continue unsafe sex (Joseph, Kessler, et al. 89; Prohaska, Albrecht et al.,
While safer sex strategies are not uniform today, in gay-related prevention programs they tend to emphasize the cessation of unprotected anal intercourse. In the mid 1980's safer sex, depending on the HIV prevention program, could mean reducing your number of partners, becoming monogamous, knowing your partner, and other strategies which were thought to be efficacious but still included unprotected anal intercourse (Wells, et al. 91).
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90; Coates, Stall et al., 87) While there is conflicting evidence about the relationship between self-identity and the adoption of safer sex (McKusick, Horstman, et al, 85; Siegal, Bauman, et al.,88; Joseph, Montgomery, et al., 87a), there are several dimensions associated with community self-identification. Kippax, Crawford, et al. (90) find there is a stronger public commitment to gay community among men whose attachment is either cultural or political rather than sexual. In terms of behavior change, community variables are the most important predictors of change -- particularly locale and attachment to gay community. Of the indicators, sexual engagement and social engagement are the most highly related to change in sexual behavior. To what degree safer sex is based on an internalized self-identification and to what degree it is based on modeling from others or peer pressure is unclear. Research done outside of the epicenters finds that for those men living in more rural areas, who are unattached to a political or social community and whose gay identification is predominantly sexual, the need to affirm this often covert aspect of their identity through unsafe sex can overwhelm known dangers about contracting the HIV virus (Bye, 88b; Prieur, 90; and Pollak, 89). In Figure 3, another internal need which is related to unprotected anal intercourse is a desire for intimacy and love. In anonymous and near-anonymous sex, the "vocabulary" of intimacy is largely physical, thus unprotected penetrative intercourse is likely to be seen as better fulfilling a need for intimacy (Prieur, 90). When longer term relationships are analyzed, many men started with safer sex but eventually expressed their desire for greater intimacy by engaging in unprotected anal intercourse, with the exchange of semen. In the latter stages of the epidemic, however, unprotected anal intercourse is most consistently observed within a steady or monogamous relationship. (Connell, Kippax, 90; McKusick, Coates, et al., 90; Bochow, 90; Tielman, Selma, 88; Bye, 87; McCrusker, Zapka, et al., 89; Martin, 89). Unprotected anal intercourse, as well as filling a need for intimacy, could also be a potent form of non-verbal committment to a relationship, and this is discussed later in the text within the context of the Normative Framework. While fulfilling internal needs can explain some types of sexual behavior, some persons may find that there are external influences which are powerful motivators of behavior. To more fully understand sexual behavior, understanding the communication between peers and among partners is essential. Normative Framework Perhaps the strongest predictors of sexual behavior are those reflected in the Normative Framework (Figure 4). Virtually every study that has measured the impact of partner and peer interaction has found it significantly related to sexual behavior (Valdiserri, 89; Weisman, 89, MacDonald, et al., 90, Catina, et al,90, Hunt & Davies, 91, Kelly, et al., 91). Several theories suggest the reasons why partners and peers have such a strong influence.
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On one hand, a person who conforms to the sexual behavior of his partner(s) or peers can be rewarded by their acceptance and the gratification of pleasing others. On the other hand, an individual who does not conform to the sexual behavior of his partner or peers risks the punishment of rejection and social isolation. Miller (80) notes, "it would be a mistake to underestimate the coercive potential of social approval and disapproval..." Traditional learning theories do not make any assumption about the cognitive process; each stimulus is evaluated on its power to reward, reinforce or provide punishment. S-R theories are the underpinning of many behavior modification programs, where peer pressure and public commitment are used to change strong habitual (or addictive) behavior, and peer support is used to reinforce change (Hergenhan, 82). Current variations of stimulus-response theory, such as social cognitive theory (Bandura, 77; Rosentock, Strecher, et al., 88) attempt to further explain the cognitive processes which mediate stimuli, and would suggest that learning comes first through the experience of safe or unsafe sexual practices and, second, through modelling the behavior of others. After personal experience, the most powerful stimuli are often external, coming from social groups, peers and sexual partners, rather than internal stemming from personal awareness of information (Rikert, et al, 91). However, these "external" stimuli are effective only to the degree that they are interpreted and understood by the individual. In Fishbein and Azjen's (57) theory of attitude change, the normative influence of others is a primary cause for attitude change which leads to an intention to behave. The normative process may act through peer pressure or modelling of the behavior of an opinion leader (Rosentock, Strecher, et al., 88). In gay communities in San Francisco, New York, Amsterdam, and other major urban areas, multiple partners and unsafe sex became, for a large number of men, the social norm during the 1970's and early 1980's. At the same time there was a growing cohesion within gay communities. As the HIV epidemic spread, those having the greatest number of unsafe sexual encounters were members of the group most rapidly changing to safer sex (Martin, 86; Valdiserri, 89; Aggleton, Coxon, et al., 89). The rapid decline in the HIV incidence in some gay communities may reflect the presence of gay 'ghettos' where there was a high level of social interaction. In theory, a more socially cohesive network may find it more difficult to accept behavioral change but, once started, the diffusion of change due to social norms and peer pressure may occur more rapidly. As new social networks began to be built around AIDS related organizations the norms of gay groups began to be centered around safer sex. For those men more committed to continuing unsafe sexual practices and for those men who had sex but who were not part of the gay community, saunas, movies and cruising areas provided an opportunity for unsafe sex when it was the norm. However, particularly within gay centers, these venues are now likely to reflect the safer sex norms of the wider gay community and there is likely to be far fewer episodes of unsafe sex. Cognitive theories, such as Heider's (58) balance theory, would predict that behavior would continue in an unaltered manner until it is challenged, for example by a disagreement between peers or partners. There is clear evidence that the best predictor of unsafe sex is the previous practice of unsafe sex (McCusker, Stoddard, et al. 89b,; Martin, 86; Connell, Crawford, et al., Cohen - 11
89). From Heider's perspective this would be an "understood" behavior between two partners, and, unless there is disagreement causing imbalance, the status quo behavior would be likely to continue. Once there was disagreement, the partner with the greatest influence is likely to persuade or coerce the other into safe or unsafe sex. Attribution theory (Heider, 58; Fisk, Taylor, et al. 84, Memon, 91) and Social Interaction Theory (Friedman, Levine, et al. 86; McGuire, 91) suggest that behavior can be explained in terms of one partner's perception or expectation of the other. For example, if one partner believes the other would be offended by condom use, condoms would not be used -- regardless of the partner's actual belief. The power of partners is suggested from many studies that indicate that more unsafe sex occurs within a primary relationship than between men who are not in a primary relationship or between men who also have sex outside their primary relationship (Bye, 87; McCusker, Zapka, et al., 89b; Martin, Dean, et al, 89; Connell, Crawford, et al., 88a). The Normative Framework suggests that a key motivation for that risky behavior may be an expectation by one of the partners that the other wants unprotected anal intercourse, or it may reflect one partner's expected reaction to the other partner about the use of safer sex. For example, one partner may believe that the other partner would interpret using a condom as admitting to infidelity or lack of trust. This perspective suggests the importance of clarifying expectations with a partner and, in some instances, negotiating safer sex. Each of the above cognitive models assumes that the individual or the social group is the major actor(s) responsible for changing sexual behavior to safer sex. However, there are many societal and political factors which can facilitate or limit the amount of information available or the possibility of adopting safer sexual practices. Policy and Community Factors The policy and community factors listed in Table 1 are often beyond the individuals' control and are determined within the legal and political systems. For example, the allocation of resources and availability of preventive information in a community are significant factors in predicting behavior change (Pollak, 89; Bunton, Murphey, et al., 91) and individuals living in lower socioeconomic communities frequently have fewer and weaker services (Holmes, 91). Pollak (89) presents convincing evidence from France that gay men in lower class rural areas have less access to information and change much more slowly than urban gays who have access to prevention information, and class is seen as significantly related to behavior change in Australia (Connell, et al., 91) and the US (Profumo, 91).
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TABLE 1: POLICY & COMMUNITY FACTORS EFFECTING HIV/AIDS RELATED BEHAVIOR
• RESOURCE ALLOCATION • DISTRIBUTION OF PREVENTION INFORMATION & AFFORDABLE CONDOMS • LEVEL OF CONSENSUS AMONG & BETWEEN POLICY MAKERS AND CBO'S • GOVERNMENT DISCRIMINATION POLICY • GOVERNMENT CENSORSHIP POLICY • GOVERNMENT REGULATIONS REGARDING TAXATION AND DISTRIBUTION OF CONDOMS • GOVERNMENT HOUSING, SOCIAL SERVICES & POLICIES EFFECTING SOCIAL NETWORKS • COMMUNITY SEXUAL MORES • COMMUNITY COHESION
One hypothesis as to why gay communities experienced one of the "most rapid and extensive (albeit still incomplete) changes in human behavior ever observed" (Joseph, Kessler, et al., 89) is that they utilized existing networks of organizations and newspapers to efficiently spread HIV prevention messages (Bochow, 92; Frutchey 89; Stall & Paul, 89), and that community based organizations (CBOs) provided the funding and structure for sustainable preventive action. While most CBOs started because the public health response was slow or ineffective, most organizations quickly evolving from small self-funding groups to larger HIV prevention and service providers funded by the government, for example AIDS Hilfe in Germany and the Swiss AIDS Foundation (Bochow, 92; Staub, 88). With increased government funding, however, also came increased restrictions on content. In many communities government allocation of resources has been accompanied by censorship over the nature of the messages. An example from the US was the Holmes amendment which forbade explicit sexual messages, particularly the display of sexuality between men. Instead of the "pragmatic" approach usually advocated by CBOs, some governments have aligned themselves with "moral" positions (Herzlich, Pierret, et al., 89; Clift et. al, 91). Such policies include exclusively promoting sexual abstinence or abstinence from insertive sexual intercourse, isolating HIV positive persons, and mandatory linked testing, often for the purposes of contact tracing. Eastern Germany, before unification, and Czechoslovakia prior to the revolution of 1989 are examples where these policies were the main themes of the HIV prevention programs (Bochow, 92, Svoboda, personal conversation). While health officials claimed that the low incidence of HIV was a result of these policies, Bochow (92) notes, they also reflect inaccurate reports of infection because persons in risk groups engaged in "illegal" activities are apprehensive about coming forward for testing or care. The diversity of prevention messages is often the outcome of competing voices within the community or between the community and public officials. For example, some gay organizations in Paris, Berlin, and San Francisco initially felt that safer sex rules were a ploy by government and unknowing collaborators in the gay community to deprive gay men of the hard won rights of sexual freedom. It is clear that a community's often justified fear of discrimination was heightened by recommendations for restricting sexual activity to combat AIDS (Bochow, 93; Cohen - 13
Stall, 93). One example of close government-CBO cooperation in developing policy is found in the Netherlands. The policy, based on a consensus between community groups and the government, included the distribution of information, discouragement of HIV testing and the de-emphasis of condom use in preference of recommending abstinence from anal sex (Wijngaarden & Coutinho, 88). In contrast, the policy of San Francisco was the result of substantial tension between the State and City government and gay groups. Initially resources from within the gay community were adequate to sustain various HIV prevention programs. By 1985 the city government was providing direct funding to CBOs for HIV prevention programs (Stall and Paul, 89). In San Francisco the resulting programs were much more diversified than in the Netherlands, with strong interpersonal and informational components as well as controversial health measures. One illustrative example of the two approaches was the policy on saunas - a venue where gay men frequently went to have anonymous or near anonymous sex. In San Francisco, after considerable debate which divided the gay community the city government closed the saunas because they were perceived to be a public health hazard. In the Netherlands saunas remained open because of the concern for personal liberty and the strong belief in the power of information. Policy makers felt that they provided venues for safer sex messages and if the danger of anal sex was known unsafe sexual activity, regardless of venue, would cease. Recall in Figure 1 that Amsterdam and San Francisco both showed declined in HIV infection rates, but at different rates. There is evidence that the Netherlands message of abstinence from anal intercourse had some impact; in Amsterdam surveys indicate that many gay men never started or abandoned anal penetration and the rate of anal sex was lower than in France or Germany. However, the lack of promotion of condoms was reflected among those who continued anal intercourse. For them the rate of condom use is much lower than in France or Germany, both of which had stronger condom promotion campaigns (Pollak, Debois-Aber et al., 89). Although there is no empirical evidence, in San Francisco the more rapid fall in HIV rates may reflect the more diversified approach to HIV prevention, including strong advocacy of condoms and testing. Last, there is often an impact of policy unrelated to HIV and AIDS prevention. (Wallace, 90) cites the policy of planned shrinkage whereby fires are allowed to burn themselves out in an urban slum area. As a result communities are dispersed and this "shedding of social networks" hastens the spread of intravenous drug use and AIDS. There continues to be strong argument that AIDS, like other diseases found primarily among the poor and among discriminated populations are the result of social inequalities and that establishing policy that addresses these inequalities will have a positive effect on lowering the HIV rate. The Impact of Factors over Time In communities with relatively stable populations, the factors in the Frameworks have a varying impact on behavior change throughout the HIV epidemic. Table 2 displays the relative impact of factors in each of the frameworks over the stages of the HIV epidemic.
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First, looking down the columns, it is apparent that in the beginning stage that most factors contribute a moderate amount to behavior change. At the peaking stage awareness of a friend or partner with AIDS or who is HIV positive is likely to have a large impact on behavior change as it underlines personal vulnerability to HIV infection. By the time the epidemic is peaking it the AIDS organizations that have been started and are likely to need resources and methods of distributing prevention and care services, thus policy and community factors take on increasing importance. By the declining stage of the epidemic the impact of awareness of friends and partners who are seropositive has largely saturated the community, and during the declining stage access to unsafe sex is more limited due to changing community norms and peer and partner pressure. Yet the need for intimacy remains high and is a leading cause of engaging in unsafe sex. During the tail of the epidemic, those who maintain unsafe sex are the most difficult to reach. They have a high need for intimacy that is fulfilled by unsafe sex and thus peer and partner pressure for safer sex are main counter pressures to this personal need of intimacy expressed through unprotected sexual behavior. During the tail stage, maintenance of safer sex may be as difficult as its adoption, thus continued programmatic and community support are highly related to maintaining safer sex.
TABLE 2: CHANGING TO SAFER SEX: Relative Contribution of Framework Factors
STAGES OF THE HIV EPIDEMIC FACTORS Personality Framework Self-efficacy ID with community Intimacy (neg relation) Moderate Moderate Moderate Moderate-Low Moderate Moderate Moderate-Low Moderate High Low Moderate-Low High BEGINNING PEAKING DECLINING TAIL
Information Processing Framework Aware of PWA/HIV+ KAB of safer sex Aware of serostatus Normative Framework Partner/peer pressure Policy & Community Government Policy Community cohesion Moderate Moderate High High High High High High Moderate Moderate-High High High Low Moderate Moderate-Low High Moderate Moderate-Low Moderate Moderate-Low Low Low Low Low
The relative contribution of individual factors are shown in the rows of Table 2. The top two Personality Framework factors suggest that self efficacy and self-identity with a community are each moderately related to changing to safer sex in the beginning of the epidemic. In those locations that were first to respond to the epidemic there were often groups of individuals who Cohen - 15
had a strong sense of self-efficacy and who changed their behavior in response to their perceived risk. In gay communities a subset of these individuals had a strong affiliation with their community and started community based organization (CBOs) which often evolved into major HIV prevention and care organizations (Cohen, 91a). As these organizations grew they encouraged a greater sense of identification with their community and with HIV prevention activities and, as shown under the Normative Framework factors, they served to contribute to peer networks where safer sex became the norm (Fisher, 88). The impact of community organizations was likely to shift from reinforcing the personality trait of self-efficacy and selfidentification to providing peer and social pressure for change. Self efficacy is likely to decrease in relative importance as the epidemic continues. Those individuals who change because they believe they have control over their own health will be more likely to adopt safer sex early in the epidemic. The evidence from San Francisco (Frutchey, 89) and other communities (de Vries, Margo, et al. 88; Boer, Kok, et al., 91) is that group discussions and workshops serve to increase self-efficacy through skills enhancement and thus promote change. However, by the tail of the epidemic there is unlikely to be a large change in self-efficacy among those who have not already adopted safer sex (de Wit, Vroome, et al. 90b). The relative contribution of the need for intimacy increases in creating behavior change over the stages of the epidemic. By the tail of the epidemic, those who continue to engage in unsafe sex name the need for intimacy with their partners as a main motivation in engaging in unprotected sex. The next three factors in Table 2 represent the Information Processing Framework. Awareness, attitudes, and beliefs about persons with AIDS, HIV positive persons and one's own serostatus appear to have the greatest impact in the peaking and declining stages, as this information becomes widely diffused throughout a community. Information about unsafe sex seems to moreor-less reach a saturation level by the tail of the epidemic during which continued unsafe sex is related to negative attitudes about condoms and misperceptions about the efficacy of different preventive methods. Although there is considerable evidence that knowledge of serostatus, particularly combined with counselling, can increase the rate of change, it seems to make little difference in adopting safer sex at the tail of the epidemic. While the availability of early treatment for HIV positive persons may lead to a continued emphasis on providing anonymous testing, in the tail of the epidemic it appears to have only a small impact on behavior change. It is clearly false that the change to safer sex is simply a function of people becoming aware of persons with AIDS or seropositive status. There is ample evidence showing that many persons know persons with AIDS (PWAs) and HIV positive persons but continue unsafe practices. While some of these unprotected practices may be a conscious decision among partners of the same HIV status, the recent increase in HIV incidence within gay communities indicates that simply knowing someone is insufficient motivation for maintaining safer sex. For some, information heightens anxiety and leads to the adoption of safer sex or a desire for Cohen - 16
information seeking which may then lead to safer sex. Thus information is likely to have a marked impact during the initial stages of the epidemic. For others, safer sex is not the only way to reduce anxiety. Cognitive defense mechanisms often produce rationalizations which reduce perceived risk or lead to 'tuning out' undesired messages. Still others may welcome participation in a 'risky' situation. Finally, some may become fatalistic and continue with unsafe sex with full knowledge of the risk. As personality and information processing factors diminish in relative importance, external factors such as peer, partner and community pressure toward safer sex increase. Partner status and normative pressures have been shown to be particularly strong predictors of safer sex. Group sessions, safer sex workshops, participation in CBOs and other forms of interactive programs are likely to continue to be effective because they rely on peer pressure and support to encourage and sustain safer sexual behavior. The final lines in Table 2, are a reminder that while cognitive and normative factors are critical components to behavior change, government policy and community cohesion serve to facilitate or constrain behavior change. Policy leads to resources and guidelines which permits the access to and type of information and services available. These play an important role throughout the epidemic. Early in the epidemic the formation of community based organizations and community and/or governmental support of HIV prevention programs are critical factors in the adoption of safer sex. Later in the epidemic as change is introduced, public policy can support behavior change and provides an environment where normative pressure toward safe sex continues. Discussion After a decade where the need for immediacy of action has often led to lack of focus, and sometimes counter-productive efforts at HIV prevention, it is now time to assess many of the underlying assumptions of HIV prevention programs directed toward changing sexual behavior. The Information Processing, Personality, Normative Frameworks and the policy and community factors highlight different components affecting the adoption of safer sexual practices. The goal of HIV prevention programs should be to emphasize those factors most likely to be related to change, for a particular community, throughout the course of the epidemic.Individuals change in their ability to process information (Catania, Kegeles, et al., 90) and different factors are more likely to have an impact at different stages of the HIV epidemic. Consequently, in developing or evaluating an HIV prevention program designed to change sexual behavior, one of the first tasks is to target the subpopulation to receive the HIV prevention activities and to determine the pattern and phase of the HIV epidemic within that subpopulation. Three criteria should be considered in identifying target populations to receive programs directed at changing sexual behavior: first the likelihood of engaging in unprotected intercourse, second the prevalence of HIV in the group, third the parameters of social and sexual networks and, last, the ability to reach a selected population through their community. Epidemiology and social research is useful in defining these criteria provided demographic and lifestyle questions are asked when persons are tested and when AIDS cases are reported. General population surveys Cohen - 17
may be of use in providing population based estimates of high risk sexual behavior, but usually do not have sufficient and generalizable sample sizes within any single subpopulation to provide information about sexual networks or behaviors to provide specific estimates of risk of HIV, thus they are of little value for prevention directed at specific populations within communities at risk. Unfortunately many HIV prevention programs start with a generalized assumption of high risk among homosexuals, prostitutes, IDUs, and adolescents. Little epidemiological evidence is available to determine the stage of the epidemic in specific communities, and the frequent focus on "high risk" groups often excludes segments of the population at risk. Even within "high risk groups" difficult to reach subpopulations are often ignored. For example HIV prevention programs many programs directed toward gay populations in the US and Europe have focused on self-identified and accessible gay communities while under-representing non-urban and ethnic gay subpopulations. The value in targeting communities, rather than the broader general population, is that prevention programs can be created which meet their particular needs. Community organizations can be utilized to provide prevention services, and they are more likely to be perceived as credible than outside medical and health experts. Community based activities influence many of the factors mentioned in the frameworks: they often build community cohesion and act as vehicles to increase the perception of self-efficacy and community identity among paid and volunteer staff. These organizations can become the basis for new social networks centered around HIV prevention, and these networks often provide the peer pressure to change social norms. While CBOs can often be mobilized faster than government organizations and are often subject to fewer administrative and legislative restrictions, a disadvantage has been a lack the expertise to manage contracts and provide services. One of the resources which might be invaluable to newly initiated CBOs is management training along with financial, political, legal and social support. Many HIV prevention programs assume that the individual is the key element in the decision to engage in safer sex, and that sexual behavior is decided by a type of personal cost-benefit analysis. Typically these types of prevention programs rely on informing the individual of the severity of AIDS, consequences of unsafe sex or providing instructions on safer sexual behavior, particularly the use of condoms. Researchers have clearly shown that information alone is not the key to behavior change, although the suggestion that it has little influence is overstated. Information based prevention programs should start by creating awareness of the communities vulnerability to HIV infection, and clarify the distinction between AIDS and HIV and what is unsafe and safer sexual behavior. HIV prevention programs with a goal of changing sexual behavior should make absolutely clear what not to do. Anal and vaginal sex without condoms -not the number of partners -- is the major risk factor for HIV. Confusing language, such as "exchange of bodily fluids", should be avoided, and the very low likelihood of infection from oral sex and other practices should be made clear. A second part of a prevention program is to advocate what to do, what is safer sex. Perhaps the most widely adopted (and most misleading advice given) was that one should reduce their number of partners. During the height of the HIV epidemic for gay men, this precaution was often adopted but had actually provided minimal Cohen - 18
reduction in risk in communities where the infection rate was high. Still today a frequently cited precaution against AIDS is monogamy -- regardless of its length or of serostatus of the partner. Another widely held misperception is the time lag between infection and the manifestation of AIDS. This contributes to ignoring or forgetting the long term impact of HIV infection when the immediate gratifications of love, intimacy, sexual pleasure, and partnership are particularly strong. For those prevention programs with a goal of conveying information, theory suggests that the cognitive process is complex and that increasing awareness is relatively easy compared to creating positive attitudes toward safer sex and the belief that safer sex recommendations are credible. Once basic information is disseminated, HIV prevention should focus on developing positive attitudes about safer sexual methods, including condoms. Positive attitudes are more likely to result from the association of safer sex with erotism, love, intimacy and concern for partners than from messages emphasizing the use of safer sex to prevent AIDS. Erotic formats and safer sex workshops assist in creating and reinforcing positive attitudes about safer sex. HIV/AIDs prevention programs must create believable messages and redress misperceptions about methods of safer sex; overstating the risk of HIV infection can be counterproductive because persons will not find the information credible and will, therefore, ignore the advice. For example, belief that there are high levels of condom failure should be countered with clear information about the strong relationship between condom use and seronegativity and the reasons for failure. Advice should be provided on the correct use of high quality condoms, including the proper use of water-based lubricants. The debate about the use of fear messages might be better framed as at what stage in the epidemic are fear messages most effective. Cognitive theories suggest that dramatic appeals may initially raise anxiety which is related to behavior change. However, programs which raise levels of anxiety must provide safer sex alternatives to unprotected intercourse in order to resolve the anxiety they create. Personal perception of vulnerability to HIV is likely to be a major factor for the early adopters of safer sex. Awareness of friends and partners with AIDS, one's own serostatus, and the perceived prevalence of infection in one's community will provide a basis for estimating personal vulnerability. Seroprevalence studies can alert individuals and policy makers to the community's vulnerability and anonymous testing with counselling will alerts individuals of their own serostatus. Counselling further has the potential to be a primary source of HIV prevention information. During the tail of the epidemic, serostudies have been used incorrectly to mark the end of the threat. There is a constant need to emphasize that, despite the fact that the number of sero-conversions are declining, the likelihood of becoming infected remains high because there continues to be a large number of sexually active seropositive persons. This information is especially important for young persons developing their sexual identity, where there is a considerable likelihood of unsafe sex, because, in part, AIDS is often perceived as an older persons disease. A mix of mass and interpersonal channels which reinforce each other is necessary. While the Cohen - 19
mass media have a large potential role in disseminating information, if the past is a guide, they will rarely cover AIDS during the initial stages of the epidemic, and then only from a predominantly moral and medical perspective (Albert, 88; Herzlich & Pierret, 89), rather than preventive aspects. In general HIV prevention recommendations have largely been the domain of advertisements, brochures, billboard and other promotional rather than editorial aspects of the media. By the tail of the epidemic, interpersonal programs are among the most important reasons for adopting safer sex. Thus HIV prevention programs should be developed that enhance partner and peer communication. Attribution theory suggests that barriers hindering the adoption of safer sex include the belief that safer sex is an indication of infidelity or lack of trust. Consequently, the positive values of safer sex, such as safer sex being a act of caring and intimacy, should be stressed. Interpersonal programs such as the STOP AIDS Project and safer sex workshops may be particularly effective because they rely on peer support and pressure. The longer term objective of HIV prevention programs should be to create a social norm of safer sex. Once this is accomplished, the opportunity to have unsafe sex will be greatly reduced, regardless of one's level of knowledge. Even where programs are successful in conveying clear messages about unsafe and safer sex, it is wrong to believe that all those who continue to engage in unprotected anal intercourse do so because they do not understand the risk. Many make "informed" decisions and others engage in unsafe sexual practices because it fulfills more immediate needs, such as the need for social approval or intimacy with one's partner. Among steady partners there is a need to rethink the definition of unsafe sex. For example, within the gay community "unsafe" sex is usually defined as any unprotected anal intercourse. Yet unprotected anal intercourse among two persons with the same serostatus in a steady relationship does not fuel the epidemic. Prevention programs should provide the information that allows partners to make informed decisions about their sexual lives instead of excluding unprotected intercourse under any circumstance. Admittedly a more situational definition of unsafe sex places a good deal of faith in the honesty of the partner, but there is ample evidence that partners are much more likely to have safer sex outside of their steady relationship while continuing unsafe sex within the steady relationship. Partners should be encouraged to explore the meaning of safer sex in their relationship and strategies have to be defined which recognize that the need for intimacy is often more immediate and stronger than protection from HIV. Given the multiple factors that effect change to safer sex, policies that encourage mixed approaches has a better chance of succeeding than policy with a single focus, such as informing a community of risk. Thus mass and interpersonal programs and a variety of safer sex alternatives should be available.
The thrust of many HIV prevention programs has been to place the burden of adopting safer sex on the individual. Yet, in many instances public policy makes this difficult. Public policy is often the main determinant of the distribution of resources that assure that individuals have access to the information and means of prevention and it is unreasonable to deny access to prevention programs and then expect behavior change. Public policy must also be congruent with Cohen - 20
prevention recommendations. There is also a need to look beyond specific HIV prevention policies to general policies regarding discrimination, education, and availability of resources for health services. Policies which discriminate and stigmatize subpopulations such as gay men, IDUs, or sex workers are counterproductive. On one hand community leaders within these populations have often slowed prevention efforts because the expectation of further discrimination, stigmatization, and repression outweigh potential advantages of certain prevention programs. On the other hand, those not identifying with the "high risk" population tend to adopt a false sense of security, even if they are practicing high risk behavior; for many the group rather than the behavior is misperceived as the cause of AIDS. For example, in the US HIV prevention programs often encourage testing but insurance, banking and employment laws in many states continue to discriminate against HIV positive persons. When testing is advocated, there must be assurances against discrimination in all sectors. While by no means exhaustive, this last section demonstrates that these multiple frameworks, combined with an awareness of the stage of the HIV epidemic within a particular community, can assist in developing and evaluating HIV prevention programs. It cautions against expensive mass media awareness campaigns late in the epidemic, when most persons are already aware that unprotected sexual intercourse is a major cause of AIDS and that condoms are a means of prevention. Within the Information Framework it recommends a strong emphasis on building positive attitudes and beliefs in the efficacy of safer sex, and the correction of many persistent misperceptions. Equally important the frameworks emphasize the need for prevention program with a focus of building community cohesion and self-empowerment, involving those at risk in prevention. Last, the Personality Framework emphasizes that any prevention program will stand a far greater chance of success if its recommendations not only inhibit the transmission of HIV, but also fulfill a strong personal need for intimacy.
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