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Marking Time in Frameworks Explaining Sexual Behavior and Risk of HIV Infection

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This article later became a Chapter in Sexual Interactions and HIV Risk, published by Taylor and Francis in 1997.  It was conceived while on a fellowship at the Facultes Universitaries Saint-Louis in Brussels, Belgium and adds the dimension of time to my earlier work on frameworks that explain behavior change.

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(This draft was later published in Sexual Interactions and HIV Risk, Taylor & Francis, 1997.)
Marking Time in Frameworks Explaining Sexual Behavior & Risk of HIV Infection by Mitchell Cohen, INSERM U263, Paris & HIV Center, New York Michael Hubert, Facultés Universitaries Saint-Louis, Brussels
TABLE OF CONTENTS
I. INTRODUCTION .........................................................................................................................1
A. Time and the AIDS Epidemic ............................................................................................................................. 1 B. Time and HIV/AIDS Prevention......................................................................................................................... 3
II. TIME: SOCIETY AND COMMUNITY ..................................................................................4
A. Inter-generation cultural transmission of norms................................................................................................. 4 B. Intra-generation transmission of current trends and styles ................................................................................. 7 C. Stages of the HIV epidemic................................................................................................................................. 9
III. TIME: THE INDIVIDUAL ....................................................................................................12
A. The time frame for expected outcomes.............................................................................................................13 B. Sequence of developmental stages ....................................................................................................................14 1. Stages of decision making ...........................................................................................................................14 2. Life cycle stages...........................................................................................................................................15
IV. TIME: PARTNERS INTERACTION...................................................................................16
A. Social Norms, Attribution and Coorientation of Partners & Peers..................................................................16
V. DISCUSSION AND CONCLUSIONS ....................................................................................17
Marking Time in Frameworks Explaining Sexual Behavior & Risk of HIV Infection by Mitchell Cohen, INSERM U263, Paris and HIV Center, Columbia University, New York Michael Hubert, Facultés Universitaries Saint-Louis, Brussels I. INTRODUCTION Many communities 1 in the world are battling an AIDS epidemic where sexual intercourse is a major mode of transmission. Until a vaccine is developed, one goal of HIV/AIDS prevention programs is to reducing the future impact of AIDS by influencing present sexual behavior. Identifying those factors which are related to the adoption and maintenance of safer sex is one goal of HIV/AIDS prevention research. Once identified, HIV/AIDS prevention programs can develop interventions with individuals, partners and communities that emphasize those factors related to behavior change. The purposes of this paper are first to make explicit the place of time in determining factors related to sexual behavior change and, second, to suggest ways in which interventions can be more effective by taking into account time. A. Time and the AIDS Epidemic An epidemic occurs over time. In some instances, like the common cold, the virus is diffused throughout the population at risk over a few months, with those who contract the virus showing the symptoms of fever and running noses within a week or two. Within a community, the HIV/AIDs epidemic is much longer and severe, with nearly 100% of those infected with HIV dying of AIDS. The 5 to 10 year time lag between infection with HIV and the manifestation of AIDS means that a community can be highly infected before symptoms appear and the health care system acknowledges the severity of the problem. In Figure 1, the solid line A represent an HIV epidemic curve for a community in Europe with an existing prevention program. From this curve it can be inferred that a combination of viral saturation in the community and change in behavior between 1982 and 1984 resulted in a decline in HIV infection incidence, but there was an increase in unsafe behavior between 1989 and 1990 causing an increase in incidence.
"Community" is used throughout the text to refer to populations bound by some common self-identifying geographic and psychosocial trait. While HIV/AIDS prevention programs are often planned at a national level the most effective programs speak to the needs of specific communities effected by the epidemic.
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The goal of HIV prevention programs is to change the severity of the HIV infection in a community and/or to shorten the time and scope of the epidemic. For example, in the same community, if an HIV prevention program were more successful it might produce an epidemic curve like the dashed line B in Figure 1, reflecting a reduced yearly incidence of HIV, but an equally long epidemic. Everything else being equal, the sustained lower incidence level suggests a more rapid and consistent adoption of safer behaviors by many, but not all, of the at risk subpopulations. Several questions are suggested: •What types of behavioral changes cause the increase in incidence to slow? •What types of behavioral changes cause the incidence to continue among certain subpopulations at a lower but sustained level? •Why was behavior change sustained by some but not everyone? Another set of interventions in the community might produce an epidemic curve like the one represented by the dotted line C, which shows a rapid increase, then a very rapid drop in HIV incidence without a subsequent increase in infection during the tail. Everything else being equal, -2-
that scenario suggests a somewhat faster spread of HIV, but then a very rapid and sustained response by virtually all members of the population at risk. This curve begs the questions: •What behaviors caused the epidemic to explode between 1980 and 1983? •Did the virus saturate the community or was there a dramatic behavior change causing the plummeting decline in HIV incidence? •Why did virtually everyone in the community sustain the behavior change? Given that there is no vaccine to prevent HIV infection, both scenarios depend upon changing current social patterns and behaviors and sustaining the practice of safer sex in the community. The next section suggests that in explaining the factors related to change time is a key factor. B. Time and HIV/AIDS Prevention Sexual intercourse occurs between partners at a particular moment in time. While one explanation of why partners engage in "unsafe" sexual intercourse 2 is "the heat of the moment", few would suggest that sexual behavior can be understood by only investigating that instant in time where partners engage in sex. Many theories hypothesize that sexual behavior depends upon the cultural norms, individual information processing, and partner interactions that precede a particular sexual act. In almost all theories time is a crucial component -- yet the role of time is often unstated. Keeping an eye on time assists in determining what types of intervention are likely to result in a decrease in unsafe sexual behavior and a corresponding decrease in HIV incidence. Table 1 displays the different perspectives of time for various levels of intervention.
"Unsafe sex" in this text refers to sex without a condom where the HIV status of the partner is not known for certain or one partner is seropositive.
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Table 1 :PERSPECTIVE OF TIME AND SEXUAL BEHAVIOR
LEVEL SOCIETY AND COMMUNITY TIME PERSPECTIVE Inter-generation cultural transmission of norms Intra-generation transmission of current trends and styles Stages of the HIV epidemic INDIVIDUAL The time frame for expected outcomes Sequence of developmental stages Decision making Life cycle INTERPERSONAL Sequence of interactions between peers and partners Sequence of relational stages
From the society and community level, sexual behavior is viewed from three perspectives: 1) as a consequence of cultural or traditional values passed from one generation to the next, 2) as a consequence of intra-generational events, and 3) as a consequence of the different stages of the HIV epidemic. From the individual level, sexual behavior is viewed from another two perspectives: 1) as the result of estimating outcomes based on "rational" decision making and 2) as the consequence of progressing through (a) stages of decision making and (b) life cycle phases. From the interpersonal-interactive level, sexual behavior is viewed from two perspectives: 1) in terms of sequencing of interactions between peers and partners and 2) as an effect of stages in a relationship. II. TIME: SOCIETY AND COMMUNITY A. Inter-generation cultural transmission of norms When designing an HIV/AIDS prevention program directed at modifying sexual behavior, a frequent bit of advice is "be culturally sensitive." This is short-hand for the recognition that sexual intercourse is often best understood within the context of traditions and customs -- the transfer of norms from one generation to the next. Clearly, there are vast differences in the way sex and sexuality is treated in different societies and, within those larger societies, different communities, and there are significant differences in the frequency and meaning of sexual intercourse between different social, religious, and ethnic populations. Time, in this context, represents an intergenerational consistency of sexual patterns and behavior. One of the strongest traditional values held by many communities is the high status associated with procreation. Often the positive status conveyed by offspring -- potent, powerful, vigorous, -4-
fertile, etc. -- is much greater than that conveyed by fidelity to a single partner. In these instances the function of sexual intercourse is primarily procreation. Where the status of men and women rest on their ability to produce offspring, the advice to use a condom or practice safer sex is likely to be ignored. Even for those women who are HIV positive, the cultural value of raising children is often much higher than the threat of perinatal infection or the perception of infertility. For example, in many communities in Africa, infertility often means the loss of a husband or the inability to attract a spouse and isolation from the community (AIW, 93; Lallemant, 92). In contrast, some communities have adopted a norm where pleasure seeking becomes the central function of sexual intercourse. As societies become more urbanized and children are viewed as more an economic burden than economic asset, there is evidence of a desire for smaller families. Also as child mortality decreases the necessity of large families to assure that the lineage continues is reduced. Increasing rates of abortion in some countries in Europe, for example, (CAN WE PRODUCE A CHART?) is one indication of a lower desire to have large families. Another symptom of the change in norms to sex-for- pleasure is an increase in sex work in urban areas in developed and developing countries. The cultural messages conveyed by the media emphasize sex ( ) and, as the demand for sexual pleasure increases, sex work becomes a major source of income for many who cannot find employment elsewhere or who find the pay higher than in other areas of work. From an HIV prevention perspective, those communities which have a norm of sexual intercourse for pleasure rather than procreation, would be more receptive to adopting safer sex. The diversity of cultural traditions has been documented in Africa, and it has been shown that a number of cultural differences effect the spread of HIV. In some Central African societies men traditionally prefer women having a dry vagina during intercourse. This leaves women more susceptible to lacerations which facilitate transmission of HIV (Carrier et al. ?). In some tribes in Western Africa, the tradition of the brother-in-laws `adopting' the wife of a deceased brother and consummating the adoption with sexual intercourse is particularly likely to increase the spread of HIV because many of the husbands' deaths are now due to AIDS (Caldwell, 89). In Rwanda, Taylor (90) found that there was a high value placed on the exchange of semen, and this value greatly limited the use of condoms, despite high awareness that they reduce the risk of AIDS. Other cultures also place a high value on the exchange of fluids while having intercourse ( ). In many communities cultural norms often reflect religious values. For example, some community members object to the use of condoms because their religion prohibits the use of contraceptives. In one instance, in Tanzania, the understanding of this cultural constraint by those establishing HIV/AIDS prevention programs led to a redefinition of condom use by the Muslim clergy from contraception to a method of disease prevention. In that context the religious leaders could encourage their congregation to use condoms. For orthodox Catholics the Pope's directive against artificial methods of contraception and his advocacy of procreation, creates a conflict between disease prevention and loyalty to the church. For those with strong religious ties, this creates a significant barrier to adopting condoms. Different cultural values related to homosexuality can greatly effect the effectiveness of HIV -5-
prevention programs. Because of the high probability of transmission of the virus though unprotected anal intercourse, several HIV/AIDS prevention programs are directed toward homosexual populations. Some of the first HIV prevention programs were designed by relatively self-contained gay communities, defined by their own social and communication networks (Abramson, et al 90; Connell, Stall...). Even within gay communities there are diverse norms. Pollak in France ( ) and Kelly ( ) in the US suggest that rural gay men are different in their behavior and attitudes than urban gay men. In part, the success of HIV/AIDS prevention programs has been the exploitation of those networks to diffuse prevention messages. These gay communities are, however, a fairly new phenomena of the twentieth century. Homosexual behavior has a much longer tradition. For example, in the Kalepom Island, New Guinea, homosexual behavior is part of a rite of passage where younger men are initiated with the seamen of older men (Gray, 92). In this instance there may be little threat of HIV transmission because the virus has not been introduced to that culture. In Latin and South America, homosexuality is practiced in a broader context of a larger sexual repertoire which includes bisexuality and frequently the insertive partner is not viewed as "gay". This "machismo" behavior co-exists with exclusively homosexual and transvestite subcultures (Parker et al., 91 [bisexual book]). When groups migrate from one country to another many sexual customs continue. Carrier, 71 and Parker 91 show that the homosexuality of African- and Mexican-American men differ considerably from that of Anglo-American men, and other studies of ethnic populations have shown that there are notable differences in sexual behavior between ethnic groups within the same country (...). In developing HIV prevention programs directed at homosexual behavior, these differences in subculture should be considered. Cultural biases about homosexuality may also effect prevention. For example, many health educators believe that only homosexuals engage in anal intercourse. Yet, in many communities anal intercourse is practiced between heterosexuals and it functions as a form of birth control, sexual pleasure, and rite of passage. Due to this bias, some communities have adopted the practice of anal sex as a way of preventing AIDS because prevention messages have mentioned only unprotected vaginal intercourse as risky sexual behavior. A general message, in addition to "cultural sensitivity", is, where possible and ethical, to integrate and adapt HIV prevention programs within existing cultural norms so that they complementary. This is generally more effective that establishing counter-cultural or entirely new habits into a community. There are, however, times when HIV prevention carry an agenda of empowering different at-risk groups, such as women, even in cultures where this is not the norm. The strategy recognizes that empowering women to take greater control in sexual decisions and ending sexual abuse to women will serve a to limit the spread of AIDS. For both men and women, this strategy involved a complex program of changing norms as well as sexual behaviors.
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B. Intra-generation transmission of current trends and styles Current trends and events are often a countervailing force to long held traditional norms. Every new generation is confronted with unique circumstances and crisis that have an impact on their sexual behavior. For the generation defining their sexuality in the late 1960s and early 1970s in Western developed nations the wide diffusion of the contraceptive pill and the wide use of antibiotics to cure sexually transmitted diseases permitted the valorization of "free love" with multiple sexual partners, "open marriage" and other "counter-cultural" sexual experimentation. The same generation saw the marked liberalization of policies in North America and Western Europe of laws prohibiting gay men from meeting in public places. The increased sexual networking in saunas and venues for sexual intercourse in the 70's and early 80's where seen as evidence of a more open self-proclamation of gay identity. An unfortunate side effect was that these venues provided the perfect environment for the spread of HIV. The adoption of new lifestyles can also increase the risk of AIDS. For example the rise in recent years of large intravenous drug use populations (IDUs) has caused a tremendous increase in HIV infection because of the efficient transmission of HIV through shared needles or solutions and the exploitation of sex to earn money or barter for drugs. The illicit drug industry was greatly expanded during the cold war as a way to finance clandestine political and military opposition in the South East Mediterranean, southeast and northeast Asia and South America. Drug suppliers found a ready market in both the urban ghettos of developed countries and among the large middle class "baby boom" generation in their late teens and early 20s. Over the past few decades drug producers and cartels have become an industry in their own right offering substantial economic benefits to those engaged in the drug trade, including distributors in low income areas who have no other economic opportunities. On the deamnd side, for those addicted to drugs, there is substantial documentation about the link between sex for drugs through commercial sex work or more direct barter agreements ( ). While drug treatment programs and needle exchange programs have proven effective in decreasing the spread of HIV infection ( ), programs which provide alternative economic and social opportunities for those involved in the drug trade are part of the longer term solution. Wars, famine and poverty are crisis which produce migration patterns where families are uprooted from their traditional support groups and sexual norms often change. Epidemics of STDs, including AIDS, often follow military campaigns where there is a lively market for commercial sex workers and, in many instances, where soldiers have raped and abused women. Neguma (92) tells how the border conflict between Tanzania and Uganda produced the key situational factors for the rapid spread of HIV: the available money from the highly mobil soldiers, truckers and black market entrepreneurs created a great demand for sexual partners. The active sexual networks, combined with great mobility and the introduction of the virus led to the rapid and wide spread transmission of HIV in Eastern Africa. Following the disintegration of the Soviet Union, The widespread migration patterns in Europe and the numerous civil wars throughout Eastern Europe and the former Soviet Republics are, in -7-
many ways, analogous to the experiences of Eastern Africa and are likely to provide fertile ground for the rapid spread of HIV. Young women migrating to urban centers find that sex work is the only means of survival, and in most situations the immediate needs of shelter and food far exceed the threat of HIV and AIDS. Drug use is spreading, as drug entrepreneurs find it easier to cross borders and demand is rising in southern and eastern europe. One expression of liberty in Eastern Europe is the liberalization of laws forbidding homosexuality. In these communities information about HIV and AIDS has been weak and greater sexual activity has accompanied new found freedom ( ). A dramatic increase in HIV infection is highly probable unless major intervention programs are begun. It would be tragic to allow HIV to become widespread in these emerging gay communities given that knowledge exists to mount effective prevention programs targeting gay communities. Never-the-less, the many higher priorities of those governments, lack of experience with community based organizations (CBOs), and poor economic conditions, are likely to mean the rapid spread of HIV infections. For the current generation the AIDS epidemic is a crisis that has caused changes in traditional sexual behavior. In many countries in Africa, for example, there is a trend where mature men are seeking intercourse with very young women because they fear contracting AIDS from the older partners they have traditionally sought. Because many of the men are already infected, the undesired result is a rising epidemic among very young women, but there is little doubt that the motivation for this new behavior was a desire by men to avoid infection. The media, both mass and interpersonal channels, create an environment where persons respond to the AIDS crisis. Evidence from hotlines throughout the developed countries indicate that major news stories and major HIV/AIDS prevention campaigns, such as the death of movie star Rock Hudson from AIDS, the HIV infection of sports superstar Magic Johnson, or the tainted blood supply in France, spark public concern and response ( ). While increasing public awareness is often the goal of public HIV/AIDS prevention programs, public response and subsequent actions are not always positive or in the best interest of public health. For example the stereotyping by the media of drug users and gays as those mostly effected by HIV led to continued high risk sexual behavior by other at-risk populations and provided a convenient rationalization -- "I'm not one of those". At the other extreme, the highly awarded Grim Reaper campaign in Australia caused an overwhelming response by the pubic to get tested; but the risk portrayed to the general public far exceeded the actual danger of the epidemic and thus lost credibility and may have been, in the end, counter productive to promoting change toward safer sex ( ). The tension between long held norms and current pressures to change sexual behavior cause many conflicts between generations and communities. To the extent that HIV/AIDS is perceived as a serious, real and immediate threat by individuals and communities, sexual behavior change is likely to be adopted. To the degree that safer sex is perceived of as "the other community's problem" or a vehicle by one part of the community to suppress another part -- for example viewing safer sex advice as a form of genocide by some African communities or as contraction -8-
in personal freedom from some gay communities -- the result is likely to be the continuation of long held sexual norms which provide a continued fertile ground for the spread of HIV. C. Stages of the HIV epidemic The unfolding of the HIV/AIDS epidemic itself may greatly effect sexual behavior. Time, in this case, is the underlying dimension in the stages of the HIV epidemic. Cohen (92) describes four stages of the HIV epidemic (Figure 2): The beginning stage of the HIV epidemic when the virus is introduced, the peaking stage when the HIV epidemic has peaked in a particular community, the declining stage, as the incidence of HIV infection declines and the tail stage where the epidemic continues to infect the community at a relatively low level. The concept of time underlying the stages of the epidemic is not calendar time, but rather time associated with the progression of the epidemic in a community. Even within the same country, different communities (as represented by neighborhoods, ethnic identification, sexual orientation, etc.) may have different HIV epidemics. Cohen ( ) suggests that different factors are related to changing to safer sex during different stags of the epidemic, and communities could maximize their prevention efforts by designing programs which emphasize those factors most related to change. Table 2 summarizes some of the observed factors related to change and, in a community with a relatively stable population, their varying relative effect over the different stages of the epidemic. 3 In the beginning stage of the HIV epidemic, due to the time lag between HIV infection and manifestation of AIDS, communities see few AIDS cases and there is little demand placed on families, partners, the community or governments for prevention or health care services by those infected with HIV. Ignorance of the epidemic is not usually the reason for lack of community and government response. Due to the international response to AIDS from the World Health Organization and international Nongovernmental organizations (NGOs), many communities in the early stages of the epidemic are aware of HIV and of rising levels of infection. Governments, often with international aid, act swiftly to insure the safety of blood supplies, but there is usually a far more moderate response regarding prevention (AIW, 92).
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This chart was developed as a result of a meta-analysis of the literature reported elsewhere (Cohen, 93).
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TABLE 2: RELATIVE CONTRIBUTION OF FACTORS RELATED TO ADOPTING SAFER SEX STAGES OF THE HIV EPIDEMIC FACTORS Government response Self-Efficacy Community identity Partner/peer pressure Intimacy (negative relationship) Aware of PWA/HIV+ Knowledge, attitudes & beliefs about safer sex Aware of serostatus BEGINNING Low-Moderate Moderate Moderate Moderate Moderate Low Moderate Moderate-Low PEAKING Moderate Moderate Moderate Moderate-high Moderate High Moderate Moderate-Low DECLINING High Moderate-Low High High High Moderate Moderate-Low Low TAIL High Low High High High Low Low Low
In some communities the lack of response during the initial stage is because other health priorities and more clearly life-threatening diseases drain the resources of the public health agencies. A second reason is the battle for the type of HIV prevention waged between the "moralists" and the "pragmatists". Moralists advocate sexual abstinence, long term fidelity, and legal punishment for perceived "abnormal" behavior, and pragmatists tend to offer risk-reduction techniques such as condom use and nonpenetrative safer sex techniques (AIW, 92). Government policy serves to facilitate or constrain behavior change. Policy leads to resources and guidelines which permit access to information and services, and plays an important role throughout the epidemic. Equally important, policy effects the rights of individuals, and there is considerable evidence that those who fear being confined, isolated, or restricted in their access to housing, insurance, and health care because of their HIV status are much less likely to seek preventive advice and care ( ). As shown in the first row in Table 2, by the time the epidemic is peaking, AIDS service organizations (ASOs) that have been started are likely to receive government support for expanded distribution of prevention and care services. During the declining stage, HIV prevention programs are attempting to influence the more difficult-to-reach populations who are less involved with community based organization, consequently government sponsored programs tend to support the undeserved and unorganized populations in a community. By the tail stage, maintenance of safer sex may be as difficult as its adoption, thus continued programmatic and government support are highly related to maintaining safer sex. The second row in Table 2 is based on the fact that, in many communities, the first individuals to -10-
respond to the epidemic are those who have a strong sense of self-efficacy and who adopt safer sex in response to their perceived risk. A subset of those individuals have a strong affiliation with their community and start community based organization (CBOs) and AIDS service organizations (ASOs) which often evolve into major HIV prevention and care organizations (Cohen, 91a, O'Malley 92). During the initial period of the epidemic, the most effective response comes from those CBOs which perceive a threat to their constituencies and design programs to emphasize self efficacy. A tool used by many of these organizations is group discussions and workshops, and 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. Over the stages of the epidemic, the impact of community organizations is likely to shift from reinforcing self-efficacy to providing networks for peers and applying social pressure for change. As these organizations grow they encourage a greater sense of community identification, and they serve to contribute to peer networks where safer sex becomes the norm (Fisher, 88; Kippax et al __). Consequently, as shown in rows three and four of Table 2, by the tail of the epidemic programs emphasizing self-efficacy are relatively less effective (de Wit, Vroome, et al. 90b), while those emphasizing community identification and partner/peer pressure are more likely to promote change in behavior. The fifth row of the table indicates that programs which address a need for intimacy increases in importance over time. The need for intimacy remains high throughout the epidemic and is a leading cause of engaging in unsafe sex ( ). By the tail of the epidemic, those who maintain unsafe sex are the most difficult to reach and are very likely to say that intimacy with their partners is a main motivation in engaging in unprotected sex. Peer and partner pressure for safer sex are main counter pressures to this personal need of intimacy expressed through unprotected sexual behavior. The final three rows in the table represent HIV/AIDS interventions that convey primarily information particularly awareness, attitudes, and beliefs about HIV and AIDS, persons with AIDS (PWAs) or who are HIV positive, and one's own serostatus. Mostly during the initial stages of the HIV epidemic, information heightens anxiety and leads to the adoption of safer sex or a desire for 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. For any community, information about unsafe sex seems to more-or-less reach a saturation level by the tail of the epidemic. However, during the declining and tail stages continued unsafe sex is related to negative attitudes about condoms and misperceptions about the efficacy of different preventive methods ( ). Many working in AIDS prevention feel that the main motivator for sexual behavior change will be the personal awareness of someone infected with HIV or dying of AIDS. Studies indicate that, -11-
at the peaking stage awareness of a friend or partner with AIDS or who is HIV positive is likely to have a relatively larger impact on behavior change as it underlines personal vulnerability to HIV infection ( ). However, 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 who are aware of persons with AIDS (PWAs) and HIV positive persons 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 in several Western urban centers indicates that simply knowing someone is insufficient motivation for maintaining safer sex. Knowledge of serostatus is no magic bullet for AIDS prevention. A prevention strategy undertaken by many communities is to advocate HIV testing and counselling. 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, there is no evidence to suggest that knowledge of HIV status will lead to a substantial increase in the adoption of safer sex. In general, the trend over the epidemic reflects a diminishing impact of information and a heightening of factors such as peer, partner and community pressure toward safer sex increase. Programs that increase partner and peer pressure are likely to be strongly related to adopting 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. III. TIME: THE INDIVIDUAL Several theories of sexual behavior have, as their root, the idea that an individuals, over time, try to optimize their outcomes. From this "cognitive" perspective, sexual behavior, the outcome, is equal to an assessment of the the risk of AIDS and some combination of knowledge, attitudes and beliefs. For example, an equation might look like: Condom use = Perceived risk of AIDS + level of awareness about access to condoms + sum of the personal belief about efficacy of condoms + sum of the attitudes about condoms + beliefs about others' use of condoms + Skill with using condoms. A frequently cited theory in AIDS prevention research is the Health Belief Model (HBM) and there has been considerable research directed toward the goal of proving or disproving it (Robert, et. al. .., Pollak ?.;Porter et al ?; ). Like other optimization models, it suggest that individuals will optimize their long term outcome by making a rational choice to adopt safer sex -- once they understand that: 1) they are susceptible to the HIV infection, 2) HIV infection leads to the fatal disease AIDS, 3) through safer sex HIV can be avoided, and 4) that they have the resources to adopt safer sex.
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Once all the essential components are discovered, and the correct weights attributed, the goal of prevention programs, according to cognitive theorists, would be to emphasize those factors that explain the greatest amount of adopting safer sex. Notably, for these theories to be relevant, sexual behavior must be under the control of the individual -- a condition that often is not met among those populations at risk for HIV. A. The time frame for expected outcomes From the perspective of time, an essential part of cognitive theories is the clarification of competing needs for the individual and their proximity, in calendar time, to the individual. Perhaps the main reasons researchers find generally poor support for the model is that, unlike other diseases, the 10 to 12 year time lag between behavior which lead to infection and manifestation of AIDS many be outside the typical frame of action. Other considerations about physical appearance, approval of others, economic survival, and need for intimacy frequently take precedence over a long term and uncertain outcome of unprotected sex. For example an individual might ask him- or her- self what is more important... - My health in ten years or falling in love tonight? - Using a condom to protect my health or not raising suspicions about infidelity? - The chance of getting AIDS or feeding my family? - The change of getting AIDS or being made fun of by my peers? Even if the HBM were to work as suggested by their authors and individuals were motivated by the possibility of contracting HIV and AIDS, it has proven extremely difficult for individuals to correctly perceive their susceptibility and the severity of the AIDS ( ) and/or admit that the long term consequence of infection leads to fatal disease. On a more methodological level, the assumption of cause and effect is another criticism of the Health Belief Model (Moatti et al). They suggests that knowledge attitudes and beliefs are as much a consequence of behavior as the cause of behavior; he notes that correlational analysis used to prove the theory may actually represent rationalizations for behavior. Still another criticism of the HBM is that it does not account for cultural values. Porter et al ( ) notes that the operationalization of the model "does not measure cultural variables, which we expect to influence behavior, and has very few questions relating to social structure, except for standard demographic questions." In answer to that criticism, cognitive theorist note that regardless of "external" factors, the final decision to act is a product of the individual's perception of the environmental information and thus is a product of attitudes and beliefs, and the HBM does include perceptions of "external barriers". Bandura's social cognitive theory (SCT) ( ) is other cognitive model and differs from the HBM by adding the component of self-efficacy and suggesting that the individual's perceived ability that he or she can successfully execute safer sexual practices is a major factor in adopting safer sex. While the SCT allows for a person to be motivated to change their sexual behavior because -13-
of the realization of long term consequences of risk behavior, in the short term the SCT recognizes that peers and partners play an important role because they allow an individual to learn through observation and modelling. Consequently sexual behavior change can be explained as a short term imitation of behavior as well as a more distant calculated way to avoid AIDS. The application for HIV prevention is that programs should be designed to empower individuals by providing the skills and mind-set to control their own behavior. B. Sequence of developmental stages Most cognitive models place their emphasis on some assessment of outcomes by an individual. In the area of HIV/AIDS research the distant negative outcome of AIDS is what motivates persons to change their behavior. While static cognitive theories suggest similar outcomes given the same knowledge, attitudes and beliefs, developmental theories focus on sequential changes in the psychological structure of the individual which would cause him or her to interpret information differently. 1. Stages of decision making Catania's ( ) AIDS Risk Reduction Model (ARRM) introduces the importance of stages of decision making in adopting safer sex. The ARRM starts with the same criteria as most other cognitive models, that individuals perceive the risk of HIV infection based on their sexual behavior. From that point it diverges from static models by emphasizing three stages of decision making rather than the estimation of static levels of knowledge, attitudes and beliefs. The three stages are: 1) labeling high risk behaviors as problematic, 2) making a committment to changing high risk behaviors, and 3) seeking and enacting info seeking and obtaining remedies. The three stages are shown in Table 3. Catina et al ( ) does not speculate on the individual variation in the time it takes individuals to move through the stages, nor does he believe these stages are universal. However, he does suggest that HIV prevention programs can facilitate the passage form one stage of adopting safer sex to the next by motivating action by introducing moderate levels of anxiety, developing external motivation such a public health programs, and encouraging social networks to provide support for safer sex.
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TABLE 3: STAGES OF THE ARRM MODEL STAGES Labeling Committment HYPOTHESIZED INFLUENCES Susceptibility, Transmission knowledge, aversive emotions, social factors Aversive emotions, Perceptions of enjoyment, risk reduction, self-efficacy, social factors Aversive emotions, Sexual communication, help-seeking, social factors OUTCOME INDICATORS Risk assessment for becoming HIV+ Intention to engage in safer sex in "x" weeks. Practicing safer sex.
Enactment
2. Life cycle stages Another developmental sequence is suggested by Peto et al ( ). She suggests that individuals pass through life cycle stages as they mature and that unsafe sex and risk of HIV is more likely during some stages than others. The stages include: 1) discovery of sexuality and love; 2) searching for a way of life and partner; 3) stabilization of a relationship; 4) deterioration of a relationship, and 5) the life a person who wishes to live without a primary relationship. This model focuses on psychological and developmental attributes over time rather than on information processing and optimization of outcomes suggested by most cognitive models. Life cycle models have received some empirical support in the domains of personal growth ( ) and religion ( ), but the suggested stages have not been tested in the realm of HIV/AIDS. Hypothetically, during the discovery stage, knowledge and self-efficacy to engage is safer sex are likely to be relatively low. Individuals engaged at this early stage have a biological drive to experience sex and often a cultural expectation to find "love". Both of these drives place individuals at risk because they are more vulnerable to their partners' wishes and less interested in the probability of contracting AIDS. As the individual enters the second stage of searching for a partner, many continue to be at high risk. As stable relations become a possibility, suggesting the use of a condom may be seen as a sign of lack of trust, an indication of fidelity, or an obstacle to love. Ideally, if the environment were supportive, safer sex would be part of the negotiation about becoming sexually involved. Unfortunately this is rarely the case, and the desire to search for a partner may require unsafe sex as a statement of trust and love. During the third stage of a stable relationship the individual probably has the lowest risk of becoming HIV positive because the number of partners is limited and there is less sexual experimentation. Some risk continues because, while a person may be monogamous, past partners may have infected one of the partners. Also it is not uncommon for at least one partner -15-
to have sexual relations outside their primary relationship. Research has shown ( ) that unprotected sex in stable relationships is very likely to occur before the latency period of HIV is passed or before the partners determine their serostatus and do not engage in any continued risky activities. In cultures permitting multiple marriages or which place a value on multiple partners, this stage may continue to have substantial risk of contracting HIV. As relationships dissolve and one or both partners re-enter the sexual marketplace, there is again a high risk. There is some indication ( ) that although most of these partners are knowledgeable about HIV and AIDS, the habits of unprotected sex practiced in the relationship are difficult to break and the lack of familiarity with condoms and other types of safer sex leave those reentering the sexual market more likely to have unsafe sex. The notion that an individual passes through defined temporal stages require research to test the various hypotheses. If they are true, then prevention programs can identify the individuals or groups likely to be in one stage or another and target messages to influence the sexual behavior associated with each stage. IV. TIME: PARTNERS INTERACTION A. Social Norms, Attribution and Coorientation of Partners & Peers Several theories suggest that behavior is the result of an interaction between peers and partners. 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. Each, however, require a sequence of interactions and an expectation of an outcome. Unlike the long term negative outcome of contracting AIDS, the positive and almost immediate outcome of social acceptance and the gratification of pleasing others or the equally immediate negative outcomes of social rejection and isolation may be powerful reasons to engage in unsafe sex or adopt safer sex. The immediate reward of social acceptance is 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). Partners and peers can also be role models. After personal experience, the most powerful stimuli often come from social groups, peers and sexual partners, rather than stemming from personal awareness of information (Rikert, et al, 91; Bandura, 77; Rosentock, Strecher, et al., 88). 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., 89). From Heider's -16-
perspective this would be an "understood" behavior between two partners, and, unless there was a disagreement causing imbalance, the status quo behavior would be likely to continue. Once there was disagreement, the partner with the greatest influence would be 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). A key motivation for behavior for these theories is an expectation by one of the partners that the other expects safe or unsafe sex, 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. In relationships, this perspective suggests the importance of clarifying expectations with a partner and, in some instances, negotiating safer sex before unsafe practices become the default behavior. B. Relational Stages Another interpersonal interpretation of sexual behavior hypothesizes that different sexual behaviors are related to stages of a relationship. Petro et al ( ) suggests three stages: 1) seduction, 2) familiarity, 3) denouncement. During each of these stages the type of relationship and the experience of each partner in practicing safer sex is likely to effect the practice of safer sex. MICHAEL PLEASE ADD HERE.... V. DISCUSSION AND CONCLUSIONS To understand the reasons an individual and partners adopt safer sex their past, present and (expected) future have to be examined. As times passes the context and meaning of sex changes for the community, an individual and partners. At the community level, sexual behavior is often less the result of a collective rational decision based on the potential danger of contracting AIDS, than the outcome of past customs and traditions about the rites of passage to adulthood and childbearing. What is clear from the past decade is that the advice to have protected sex runs counter to powerful traditional values placed on fertility and procreation, the demands of the church, and the exchange of seamen. Incorporating traditional values and customs and habits is often a key to developing successful HIV prevention programs. An essential part of a HIV prevention program is understanding the value that is associated with insertive intercourse in a community and determining if other means -17-
of safer sex can be substituted and fulfill the same cultural needs. A major barrier in HIV/AIDS prevention is overcoming traditional discriminatory views rooted in religious traditions. Bolstered by the incorrect labeling of the epidemic as isolated among gay, prostitutes and intravenous drug users, "moralists" have used AIDS as a symbol of the consequences of a "deviant" life style (using as a referent a normal monogamous, heterosexual, child bearing couple). The unsubstantiated, but often cited, argument that condoms promotion encourages promiscuity is rooted in these types of beliefs. The persistent belief shown in surveys that people assume they are not at risk because they are not homosexual, a drug user, a prostitutes or a client of a prostitute confirms the resonance "moralist" theme has with many communities. Moralists use current trends in more open homosexuality, rising drug use and public sex work as evidence of decaying moral core and suggest that AIDS is some form or restitution for immoral behavior. Many public health officials do not refute the argument that HIV is concentrated in so-called deviant populations, but they argue that HIV will spread from prostitutes, drug users and bisexuals to the general population and therefore must be arrested before the spread of HIV to "innocent victims". Countering this "moralist" perspective is a "human rights" perspective which believes that all persons have a right to health services including HIV prevention and care. The human rights advocates emphasize the changing trends in society as evidence of a failing public health system. They observe the rising rate of teenage pregnancies and STD's who must, therefore, be targeted for HIV/AIDS prevention. Sex work is understood as a symptom of a society that offers few other economic incentives particularly to many women who have migrated to urban settings and, therefore sex workers should be given the information and resources to avoid HIV infection. Drug use is viewed as a symptom of poverty and, while viewed as harmful, IDUs have a right to treatment and clean needles to reduce their risk to HIV. Gay and bisexual lifestyles are viewed as a legitimate alternative to heterosexual relationships and therefore should be provided the tools to limit HIV infection. In many instances the response to AIDS has been sparked by critical event. Sports stars and movie stars confessing that they have HIV or have died of AIDS or major newspaper articles about AIDS, has heightened public interest and demand for prevention. While increasing awareness is generally beneficial, raising anxiety among the worried well often drains resources away from these most in need of services. The main source of information has been the mass media, and while the mass media have a large potential role in disseminating information, if the past is a guide, they will rarely consistently cover AIDS during the initial stages of the epidemic, and then only from a predominantly moral and medical perspective (Albert, 88; Herzlich & Pierret, 89). In general HIV prevention recommendations have largely been the domain of advertisements, brochures, billboard and other promotional rather than editorial aspects of the media. From a community perspective, perhaps the most powerful stimulus for community action is stages of the epidemic itself. However, the belief that the epidemic is self-regulating once persons are aware of other with AIDS has proven not true, and there is evidence that continued -18-
prevention in the tail of the epidemic is necessary to maintain the adoption of safer sexual practices. In some ways it is unfortunate that the short term consequences of risky behavior is not more severe as perhaps the greatest obstacle to prevention is having persons place priority on the 10 to 12 year outcome of HIV infection. While effective early action when the epidemic first appears in a community could minimize its impact. Unfortunately, most communities and governments respond late in the HIV epidemic, and given the time lag between HIV infection and AIDS, by the time AIDS becomes a public health issue, the HIV epidemic is well established in the community. Many HIV prevention programs provide information to individuals which allow them to make a rational decision that today's unsafe sexual act has a good chance in resulting in a fatal disease, AIDS, in 6 to 12 years in the future. Monogamy (although usually advocated without the necessary condition os mutual fidelity over several years) and the practice of safer sex, usually condoms, are advocated as the best means of prevention. Unfortunately, researchers have clearly shown that information alone is not the key to behavior change, although the suggestion that it has little influence is overstated. 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. For programs based on the premise that persons will "rationally" process information, 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. Once basic information is disseminated, HIV prevention should focus on developing positive attitudes about safer sexual methods, including condoms. Shortening the time frame from action would be another strategy to improve HIV prevention programs. Emphasizing shorter term consequences of safer sex such as associating safer sex with erotism, love, intimacy and concern for partners rather than only emphasizing protection from the longer term consequence of AIDS may result in more persons adopting safer sex. Erotic formats and safer sex workshops assist in creating and reinforcing positive attitudes about safer sex. 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 possible outcomes. 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 -19-
rethink the definition of unsafe sex. For example, "unsafe" sex is usually defined as any unprotected intercourse. Yet unprotected 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. From the individual perspective, the work by Catania et al ( ) suggests that the individuals are at different stages of readiness to personalize HIV prevention messages. He suggests that different strategies should be established to facilitate the knowledge of the outcomes, the committment to the behavior change, or the actual adoption and maintenance of the behavior. Programs based on a progression of developmental steps have shown success in pilot studies ( ).7 Another developmental approach is to direct programs at groups in different life cycle stages. The work by Petro et al ( ) suggests that there are different risks for persons exploring sexuality than those in stable relationships. (ADD HERE) From the perspective of partner and peers, HIV/AIDS prevention is an outcome of the sequence and types of interactions. Attribution theory suggests that barriers hindering the adoption of safer sex include the perception by one partner that other partner will believe 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 expected outcome in a relationship will be safer sex, and the opportunity to have unsafe sex will be greatly reduced, regardless of one's level of knowledge. Finally relationships themselves go through stages and identifying what stage the relationship is in may provide clues to the most effective HIV/AIDs prevention. While by no means exhaustive, this last section demonstrates that taking account to time is a necessary part of any HIV prevention program. Understanding how time is incorporated into theories of behavior change and accounting for past values, current trends, and projected future outcomes increases the chance that program can be designed which maximize the adoption of safer sex and decrease the impact of the AIDS pandemic.
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