Although the percentage of HIV-infected individuals who are gay and bisexual men has dropped about 20% in recent years, the AIDS epidemic has been and remains a crisis of unmitigated proportions for the gay male community in the United States. Figures vary according to geographical location and population characteristics, but it is likely that 20% to 60% of homosexual men who are not in monogamous relationships are infected with HIV (Anderson & Levy, 1985; Jaffe et al., 1985). The intense concentration of the AIDS epidemic in the gay male community has exacerbated and complicated a variety of public policy issues related both to gay men and to the AIDS epidemic.
This chapter will focus on behavior change in response to the AIDS epidemic, and intervention techniques to prevent the spread of HIV primarily as these relate to gay males. This area is but a small part of the public policy issues that AIDS has raised. Historical perspectives have been articulated by Brandt (1987, 1988); health policy issues by Brandt (1985); social consequences by Cassens (1985); and legal and ethical issues by Bayer, Levine and Wolff (1986), Lamb, Clark, Drumheller, Frazzell, and Suney (1989), Melton and Gray (1988), and Melton (1988). In this volume Herek discusses social stigma and violence related to those infected with HIV and Dejowski and his colleagues have articulated the complexities of contact notification, historically the preferred tool of public health departments in dealing with sexually transmitted diseases. The psychosocial problems generated by the AIDS epidemic have been amply described (Bouknight & Bouknight, 1988; Carballo-Dieguez, 1989; Christ, Wiener, & Moynihan, 1986; Dilley, Pies, & Helquist, 1989; Gonsiorek, 1986; Morin, Charles, & Malyon, 1984; and Shernoff, 1990).
Valisseri (1989, p. 147) suggests that the AIDS epidemic is unique because prior to AIDS, behavioral interventions were not needed, as medical responses sufficed. This is not entirely accurate. Brandt (1987) has described the history of social and behavioral interventions regarding sexually transmitted diseases in the preantibiotic era. He documents that much of the current controversy about appropriate AIDS prevention strategies mirrors debates in the first half of the century pertaining to syphilis and gonorrhea. Unfortunately, current debates do not seem to have been informed or elucidated by errors in the past. We have focused this chapter on prevention because as Shernoff and Palacios-Jimenez (1988) have noted, prevention is currently “the only vaccine available.”
A BEHAVIORAL PERSPECTIVE AND ITS IMPLICATIONS
Behavioral approaches to health behavior problems have developed in recent decades and have been successful in a number of areas previously thought unamenable to behavioral intervention (Fordyce, 1966; Fordyce, Fowler, & De Lateur, 1968; Ince, 1976; Roberts, Dinsdale, Matthews, & Cole, 1969; Ullman & Krasner, 1965). From a behavioral perspective, programs attempting to modify health behavior should share a number of features:
- 1. The goals should be as simple as possible to achieve the desired change. Increasing the complexity of goals reduces the likelihood of success. Goals should be specific and concrete. Goals that are vague or global reduce the likelihood of success.
- 2. Behavior change should be accomplished in a gradual step-by-step fashion. This allows for Sne tuning of the program and, more importantly, allows for rewards and a sense of accomplishment throughout the process.
- 3. While mild fear-based messages can motivate target groups for behavior change, programs themselves should be reinforcement based, not punishment or fear based. The overwhelming superiority of reinforcement-based programs is without question. The only real application of punishment or fear-based behavior change programs is when there is substantial difficulty in finding reinforcements.
- 4. Behavioral intervention, in order to be effective in the long term, should have an ongoing follow-up component to address problems of relapse and recurrence of problem behaviors or new contingencies that may arise.
- 5. Behavioral programs should be carefully planned and individually tailored to the individuals for whom the program is intended. Different populations usually require programmatic changes.
Applying this perspective to HIV infection prevention programs, one would argue that the programs most likely to succeed are those that have the most minimal goals possible to prevent infection; that an highly concrete and specific; that involve a gradual step-by-step process; that are based on reward and reinforcement; that have the capacity for follow-up to address the problems of relapse; and that are highly specific to the target population. Programs with the features suggested here have been implemented and initial data suggest substantial behavior change (Kelly, St. Lawrence, Hood, & Brasfield, 1989; Swarthout, Gonsiorek, Simpson, & Henry, 1989).
THE INTRUSION OF GOALS UNRELATED TO PUBLIC HEALTH
As has been the case throughout the history of prevention efforts for sexually transmitted diseases, issues unrelated to infection prevention hinder the ability to develop effective programs. Since AIDS is most typically transmitted either through sexual or blood exposure (from sharing intravenous drug paraphernalia), issues of morality pertaining to sexual behavior or drug use confound public health goals and effectiveness of infection prevention interventions.
At various points during the AIDS epidemic, health professionals have taken a role in this confusion. For example, Crenshaw (1987), an original member of the Presidential AIDS Commission, publicly stated that the only ways to stop the spread of AIDS were “monogamy, masturbation and abstinence.” This information is simply untrue, given the facts of HIV transmission. It also violates the behavioral principles noted above. Not surprisingly, Catania et al. (1989) have documented that men in San Francisco who attempted monogamy or celibacy frequently discontinued these practices. Gochros (1988) reported that during periods of sexual abstinence, men became depressed and anxious and increased alcohol and drug use. A behaviorist would say that such strategies are not sufficiently reinforcement based, or are more global than necessary, and therefore likely to fail.
Another example is the mistaken belief that quantity of partners is a primary risk factor for HIV. While many studies of HIV infection among gay men reflect that the number of sexual partners appears to have statistical significance as a risk factor, three recent studies found no correlation between multiple sexual partners and seroconversion for women who were sexual partners of men seropositive for HIV (Cohen ct al., 1987; Fischl et al., 1987; Padian et al., 1987). The majority of women who became infected did so after engaging in high-risk behaviors with one partner who was seropositive. Thus, women who believe that having fewer sexual partners reduces their risk of contracting HIV may be falsely reassured about their risk status, particularly if those few partners happen to share drug-using paraphernalia, have sex with men, or are already seropositive. Studies on gay men reflect number of partners as a risk factor only as an artifact, since research has repeatedly shown that it is specific behaviors that directly place an individual at risk for HIV infection. The number of partners may or may not be a risk depending on the specific behaviors in which the individual engages.
Brandt (1987) documents the failure of abstinence and monogamy strategies in reducing rates of sexually transmitted diseases during World War II. Current similar campaigns focused on adolescent sexual behavior are failures in reducing the sharply rising rates of teenage pregnancy and new cases of sexually transmitted diseases among adolescents. In general, HIV infection prevention programs have been hampered by the inclusion of moralistic, social policy, or other goals that bear no necessary relationship to HIV infection prevention: for example, the elimination of IV drug use, the elimination of same-sex behavior or adolescent sexual behavior, the encouragement of monogamy or sexual abstinence, or the attempt to alter the living habits of the urban poor.
Examples of interference from political goals unrelated to HIV abound. Perhaps the most egregious is the Helms amendment, which denies federal funding to any agency that promotes or encourages homosexuality. Only three U.S. senators voted against the amendment. Another example is Senator Helms’s attack on AIDS education materials developed specifically for gay men, as “smut” and likely to corrupt children. More recently, the Centers for Disease Control appear to be operating more to avoid offending right-wing political constituencies than to control disease. These are clear examples of bias or political agendas interfering with HIV infection prevention, in a way that will worsen the AIDS epidemic.
SOME COMPLEX EXAMPLES
Sometimes, however, these misguided efforts take a more complex guise. An instructive case is the confusion that has surrounded the relative risk of HIV transmission through fellatio. On a theoretical level, it would appear that fellatio is a reasonable method of transmitting HIV, as there are a variety of opportunities for semen and blood interaction. A number of studies (McCusker et al., 1988; Melbye et al., 1984; Scheckter et al., 1986; Winkelsteen et al., 1987) suggest, however, that transmission by fellatio appears to be trivial or nonexistent. The situation is further confused because other studies (Darrow et al., 1987; Melbye et al., 1986) suggest that fellatio can be a transmission route for HIV. The current state of scientific thought is that fellatio is a possible but unlikely and inefficient route of HIV transmission, especially when compared with receptive unprotected anal intercourse, which is an extremely efficient route of HIV infection, and receptive unprotected vaginal intercourse, which is an efficient route but less so than anal intercourse. Ingestion of semen increases risk; noningestion decreases it. Condom use in fellatio also decreases risk.
The response of the scientific community to this information has been peculiar. A scientist interested only in behavior change designed to reduce the likelihood of HIV infection would look at fellatio with its markedly lower risk, compare it with receptive anal intercourse with its drastically higher risk, and conclude that substituting other behaviors for receptive anal intercourse is a very high priority, whereas substituting other behaviors for fellatio is a lower priority. In attempting to balance simplicity of the goal and maintenance of a reinforcing pattern of sexual behavior with the most effective HIV infection prevention, the recommendations regarding fellatio become complex. One runs the risk of reducing the efficiency of attempts to reduce receptive anal intercourse by focusing on the less important goal of reducing fellatio. In addition, there is a risk of making the entire behavioral program less reinforcing by restricting more and more sexual behaviors. Yet unprotected fellatio is no! a safe behavior, and it does have a low but apparently possible risk of HIV transmission. Although a solution to this problem for the behaviorist is not simple, principles are clear. One behavior is highly dangerous. The other behavior is mildly dangerous. A continuum or hierarchy of the risk behavior is apparent. The most appropriate response involves an individualized risk management program that includes optimal reinforcement strategies and containment of behavioral vulnerabilities.
Instead, however, the response of most public health officials in the United States has been to place the risk of fellatio as very close to receptive anal intercourse. In exaggerating its risk, efficiency of all behavioral change and credibility of programs is reduced. It is noteworthy that public health authorities in Canada view fellatio as much less risky than do those in the United States (Canadian AIDS Society, 1988)
It is also curious that there is so little research to ascertain why fellatio, which ought to be a reasonably vigorous transmission route, is a weak one. It is likely that a political fear of “promoting” fellatio is interfering with legitimate scientific inquiry that is germane to HIV prevention efforts.
The scientific disinterest in fellatio has a parallel in the lack of scientific interest in women’s sexuality. For years, there has been ample evidence that unprotected vaginal intercourse is an effective method of transmitting HIV. Yet there has been little research on how and where HIV enters a woman’s bloodstream as a result of vaginal intercourse. The federal government began a multicenter cohort study of HIV transmission in gay men in 1983; the comparable study on heterosexual transmission did not begin until 1987. Current funding to customize AIDS prevention programs that have proven successful for gay men into relevant programs for heterosexual women is almost nonexistent. These are consistent with the historical lack of importance afforded to women’s health issues. As noted by a former women’s education coordinator at AIDS Action Committee of Massachusetts: “There is very little importance attached to the fact that women themselves are becoming infected in increasing numbers. The concern is simply there for women’s alleged role as vectors of transmission to either infants or men in the ‘general population”‘ (Irvine, personal communication, November 30, 1989). Women and gay men share a societal stigma in that their sexuality is viewed as unimportant and expendable. This stigma inappropriately distorts public policy decisions and even basic scientific research.
GOALS OF HIV INFECTION PREVENTION IN GAY MEN
A behavioral perspective is helpful in targeting the most appropriate goals for HIV infection prevention. For example, it would suggest that eroticizing safe, noninsertive sex (i.e., mutual masturbation, frottage, massage, etc.) is the core behavioral goal with gay men. Such behaviors are virtually without risk of HIV transmission. They are inherently reinforcing, simple, and concrete, and can be mastered by a step-by-step learning process. Implementation problems, such as lack of social assertiveness, are also amenable to behavioral interventions.
By contrast, condom usage is a problematic and therefore lower priority goal, and best serves as a “backup” skill when an individual is unsuccessful at implementing other noninsertive safe behaviors. Proper condom use requires numerous behavioral tasks such as appropriate
storage, careful selection of lubricant type, proper fitting, careful removal, and attention during sexual activity to signs of tearing. This is a complex behavioral sequence, with numerous potential anxiety cues (e.g., to be alert for signs of condom tearing in the midst of sexual activity) that can attenuate the inherent reinforcing power of insertive sex with condoms. There are also more opportunities for interpersonal events to adversely intervene; for example, the receptive partner must initiate a series of assertive requests, and continue monitoring the process, as opposed to the fewer and simpler assertions needed to initiate and monitor mutual masturbation, for example. Finally, condom usage is a less successful HIV prevention strategy even when both parties follow the “correct” behavioral sequence, because condoms still tear or rupture. Withdrawal before ejaculation during insertive sex with a condom reduces these transmission problems, but creates other problems as it may reduce the reinforcing value of the act.
Ironically, both governmental agencies and many segments of gay male communities share a heavy reliance on condom usage as primary in HIV infection prevention. It is our observation that the usually vague public health messages regarding condom usage exemplify exactly the lack of behavioral specificity we find so problematic. We suspect that part of the message’s appeal is its vagueness. One can remain erotophobic, yet still be doing “something” (albeit ineffectual) to stop the spread of AIDS with such messages; a tenuous balance not possible with the more explicitly prosexual stance required to make noninsertive safe sex maximally erotic and reinforcing.
Alcohol and other drug use is another example of the usefulness of a behavioral perspective. Research indicates that alcohol and other drug consumption increases, at times drastically, the rate of unsafe sexual behavior (Research and Decisions Corporation, 1985; Stall, Coates, (Hoff, 1988). A goal of diminishing or, even more radically, eliminating alcohol and drug abuse is at times suggested. As desirable a goal as elimination of substance abuse is, success in achieving it has been mixed to poor. More importantly, it adds numerous goals unrelated to the task of HIV infection prevention, and the added goals themselves are vague, behaviorally complex, and difficult. The simplest–and therefore most preferable–behavioral goal is the separation in time of sexual behavior from alcohol or other drug consumption (i.e., sexual behavior and alcohol or drug consumption should be at separate times, with no overlap).
Both behaviorally and in terms of HIV transmission reduction, we propose that the two primary goals for gay men are the maximal eroticization of safe, noninsertive sexual behavior and the separation in time of sexual behavior from any alcohol/drug consumption (because the latter so clearly interferes with the former). Secondary goals include insertive sex with condoms and fellatio without exposure to semen. The secondary goals are advisable only as “backup” techniques should primary goals fail, and/or when insertive behaviors are the only reinforcing behaviors in the individual’s sexual repertoire. It is important with secondary goals that individuals recognize that some HIV transmission risk exists with them. Finally, gay men should have complete and accurate information about a continuum of HIV transmission risk behaviors, so that if there is a failure of both primary and secondary goals, then the least risky behaviors can be chosen (e.g., unprotected fellatio with semen exposure instead of unprotected anal intercourse).
Yet the official public health agenda is often almost the inverse of this. Gay men are urged to change sexual orientation, abstain, or masturbate alone, strategies known to fail; or grudgingly urged to use condoms. The most effective strategy behaviorally and in terms of HIV infection prevention, i.e., eroticization of safe sex, is difficult for many policymakers to endorse because it involves the exploration, affirmation, encouragement, and eroticization of a vigorous but safe gay male sexuality.
It is clear that what is occurring is the intrusion of unrelated moral agendas into HIV infection prevention. We maintain that any deviation from the most direct attempts to single-mindedly reduce HIV transmission attenuates program effectiveness, increases program expense (as money IS wasted on ineffective programs), and directly contributes to the worsening of the AIDS epidemic.
HIV INFECTION PREVENTION EFFORTS IN GAY MEN
As Weinrich (1989) has noted, the idea that hundreds of thousands of men, particularly gay men, would be capable of reducing numbers of sexual partners, using condoms, and making substantive changes in sexual practices would have been absurd 15 years ago to public health specialists in sexually transmitted diseases. Yet, that is precisely what has occurred. Gay males have changed their behavior on an unprecedented scale. Becker and Joseph (1988), in their review of the literature on AIDS and behavior change, state, “Indeed in some populations of homosexual/bisexual man this may be the most rapid and profound response to a health threat which has ever been documented.” Similarly, Stall, Coates, and Hoff, in their review (1988), described the behavior changes reducing risk for HIV infection among bisexual and gay men as “the most profound modifications of personal health related behaviors ever recorded.”
These changes, however, are far from evenly distributed or stable. For example, Becker and Joseph, while describing the behavior change as rapid and profound, also note that it is incomplete and point to a number of longitudinal studies suggesting that the behavior change is unstable over time or that there are relapse problems. Stall, Coates, and Hoff amplify these cautions and suggest that these studies on gay men are not necessarily generalizable to nongay, nonurban, and nonwhite populations and specifically recommend further research to understand the role that alcohol and other drugs play in interfering with HIV risk reduction behavior changes. These reviewers note that even despite such optimistic changes, there remains a core group, albeit a minority, of gay men who have not made significant behavior changes. Relapse problems are documented and troublesome (Bartolomeo, 1990; Stall & Ekstrand, 1989).
From the broader perspective of health behavior change, comparing the HIV epidemic to other behavior change efforts in smoking cessation, cardiac risk management, weight reduction, and so forth, these findings are not unusual. Indeed, what is unusual is that the first wave of change efforts have been so successful. One would expect in a major health behavior change effort that an initial group of individuals for whom the first behavior change techniques are best tailored will be identified an(i make the most dramatic changes. There will be other groups, however for whom change is negligible or nonexistent. From a behavioral perspective, this may mean that the programs have not been sufficiently tailored to such individuals or that other technical aspects of the program such as the reinforcement or other components have been inadequately understood. Relapse, while troublesome, is also not a sign of failure. Behavior change has to be stable enough for relapse to occur Relapse, then, is a sign that initial desirable behavior change ha~ occurred enough that the deviation from the desired goal, not its acquisition, is most noteworthy. The most appropriate response to relapse is to design increasingly effective follow-up programs to understand and address the factors that cause relapse.
In general, then, the form that health behavior change programs .ln likely to take is that the first wave of programs will be successful with a segment of the target population but that a portion of this segment w ill have relapse problems. The second wave of programs must target relapse prevention as well as become increasingly creative and individualized in developing successful programs for the groups the first wave of programs have failed. As different kinds of programs are identified as successful for different kinds of people and as more and more sophisticated relapse prevention programs become identified, desired behavior change becomes possible for a greater number of individuals.
It appears likely that with regard to white urban adult gay men, we are completing the first phase of such a process. It is instructive to pose the question of why this successful change occurred in gay male communities. We would suggest at least two factors. The first is that gay male communities have developed behavior change programs from within. The decade of the 1980s saw a concentrated effort within gay male communities to develop a variety of education and prevention programs. These programs coming from within the affected community were viewed positively. Second, the gay male community approximated those behavioral principles noted above. Despite lack of funding or underfunding, political criticism, governmental interference, bigotry, and scientific scorn, numerous programs were developed within the gay male community. For example, the program developed by Palacios-Jiminez and Shernoff (1986) has been particularly well suited to the social and sexual mores of the gay male community.
It is also important to note that the problem with populations who are nongay, nonurban, nonadult, and nonwhite is a technical one in terms of the particulars of the programs and not a characteristic of the population. In other words, behavioral scientists have not yet determined the most effective methods to reach other populations. There is no reason to believe that these populations are inherently more difficult to reach. Keep in mind the pessimism with which public health officials viewed sexual behavior change in gay men 15 years ago. The core problem is that racial/ethnic minorities, the uneducated, and the poor have been virtually ignored by basic health care and behavioral science research. Not surprisingly, successful health behavior change programs in these populations are almost nonexistent. For example, the dramatic decrease in adult cigarette smoking has been almost entirely confined to educated or middle-class and above segments of the population–the poor and poorly educated smoke as much as before. No one yet knows how to do health behavior change with nonwhite, nonadult, and non-middle class populations because almost no one has tried.
Despite this neglect, and a comparable neglect of women’s health care, a literature on AIDS prevention for communities of color and women is emerging. It is again noteworthy that this literature tends to come from within the affected communities, not from the health care and public health establishments.
Since its inception, the AIDS epidemic has disproportionately affected black and Hispanic communities (Bakeman et al., 1987). Strategies for AIDS prevention have been described for Hispanic gay men (Caraballo-Dieguez, 1989); Mexican-American IV drug users (Mate & Jorquez 1989); black communities in general (Mays, 1989); black males in general (Bouknight & Bouknight, 1988); black and Hispanic males (Peterson & Marin, 1988); native American groups (Tafoya, 1989); Asian-American populations (Aoki et al, 1989); Hispanic women (Amaro, 1989); black and Hispanic women (Mays & Cochran, 1988); women in general (Cochran, 1989), and others.
It would be a serious error to view these efforts as “addenda” to HIV infection prevention strategies developed for gay white males. Rather, it is important to recall that successful efforts for changing gay male risk behaviors derived from an understanding of the social, political, and cultural context of gay males, followed by an analysis of appropriate goals, optimal reinforcers, and specific relapse vulnerabilities within this context. Comparable analysis will be required with each target population, and no particular set of strategies is superior a priori. The only reasonable criterion for program superiority is effectiveness in reducing HIV transmission in the target populations.
Yet, a double standard in public health departments persists to this day. For example, Valiserri (1989), in his discussion of traditional public health partner notification programs, is quite forgiving of the lack of strong empirical follow-up data to justify them: “While there are limited data as yet on the efficacy of voluntary partner notification, the process . . . has potential benefits” (p.224). Later in the same volume (p. 263), he states, “when testing the use of controversial prevention modalities . . . only a clear cut demonstration of improved efficacy and outcome can enable policy makers and legislators to support the promotion of such approaches.” If this latter standard had been applied to traditional partner notification procedures, it is likely they would have been abandoned during their consistent failures in the first half of this century. lt is clear that many in traditional governmental public health agencies a r. more interested in the acceptability of public health approaches to the general public and politicians than their efficacy with target population; a most peculiar–and negligent–definition of public health, indeed.
SOME BROADER ISSUES
There is a suggestion in the literature that a positive self-image with regard to homosexuality is a foundation upon which gay men successfully participate in and implement HIV infection prevention strategies (Prieur, 1989; Shernoff & Bloom, in press; see also the chapter by Gonsiorek and Rudolph in this volume). It is likely that those gay m. t with the highest self-esteem and the most positive sense of gay identity are the most likely to make effective behavioral changes. To the extent that a positive gay-affirming sense of identity for homosexual individual’s is unacceptable to society, the most efficacious behavior change programs run the risk of being compromised.
Altman (1986) noted that the AIDS epidemic lays bare institutional structural weaknesses, even when not directly related to AIDS. We would like to suggest an area of institutional weakness that is not often clearly articulated–the uneasy and paradoxical status of public health departments in the United States.
We are not alone in this concern. The Institute of Medicine (1988), in their report The Future of Public Health, stated:
Tension between professional expertise and politics can be observed throughout the nation’s public health system. Public health professionals rely on expert knowledge…. A central tenet of their professional ethic is the commitment to use this knowledge to fulfill the public interest in reducing human suffering and enhancing the quality of life…. The dynamics of American politics, however, make it difficult to fulfill this commitment…. Decisions are made largely on the basis of competition, bargaining and influence rather than comprehensive analysis. The idea that politics can be restricted to the legislative arena while the work of public agencies remains neutral has been discredited. (p. xvi)
Historically, public health departments in the United States have been instruments of political policy. Those in charge of public health agencies, usually politically appointed administrators, have functioned more like political operatives than health care professionals. This is in contrast to the rank and file staff of public health agencies who are typically more aligned with the values of science and professionalism typical of health care professionals, and of the ethical standards of the American Public Health Association. Indeed, health department “front line” staff have at times been remarkable in their ability to resist ill-conceived political initiatives through their unions, professional associations, and at times even sabotage. Nevertheless, politically appointed administrators and their managers set the agenda.
One of the hallmarks of an independent profession, be it public health, medicine, social work, psychology, nursing, or other, is that its members are held to a code of ethical and professional conduct that supersedes the requirements and demands of any particular employer. For example, health care professionals must and do take a strong interest in confidentiality, even if it means opposing inappropriate government initiatives to reduce confidentiality. We maintain that the history of public health departments in the United States has been first and foremost articulating the political agendas of governmental administration, by far the primary employer of those in public health, and only secondarily promoting public health. Until administrators of public health departments are freed of political control, public health will not emerge as a truly independent profession. More work needs to be done to develop and enforce a code of conduct that addresses the differentiation between governmental expediency versus the highest standards of public health practice, and the obligation to operate via the latter. Until then, public health departments will continue to be an impediment in the fight against AIDS and, for that matter, any disease to which political agendas are attached.
Further, it is crucial that public health department administrators and appointees be drawn solely from the ranks of health professionals Finally, we question the wisdom of government in having public health staff politically appointed at all. Until such changes occur, we fear that public health departments will continue to occupy an incongruous, ineffective, and untenable middle ground between political operative and health care profession.
Despite the enormous toll the AIDS epidemic has taken on gay male communities, gay men in the United States have developed, with virtually no outside support, creative, successful, and innovative programs for HIV infection prevention that are community based and somewhat surprisingly also based on reasonably sound behavioral principles. The initial success rate of these programs has been promising. Nevertheless, significant problems remain. Some segments of the gay male population have not yet adequately changed risk behavior, and a second generation of problems related to relapse is emerging. An ongoing program to extend the depth and breadth of such behavior change efforts is required. While what works best for adult, white, middle-class gay men will probably not be specifically applicable to other populations, the principles of program development articulated here are likely to be helpful.
Despite discomfort in some segments of the public with such procedures, the most effective HIV infection prevention behavior change programs for gay men rest upon a foundation of valuing, supporting, and affirming gay men and their sexuality. The most effective program goals involve encouraging and eroticizing noninsertive gay male sexual behavior, and separating in time the use of mind-altering substances, a~ primary goals. Secondary goals are those that are less efficacious from behavioral and transmission reduction perspectives, such as condom use, and middle-level risk behaviors, such as fellatio, to substitute for-the highest-risk behaviors (receptive unprotected anal intercourse! when the primary goal fails.
Throughout the AIDS epidemic, traditional public health measures have been minimally effective. A historical view of public health departments would suggest that they have not been able to develop behavioral strategies to reduce epidemics but rather have served a muddled social/political agenda until such time as medicine successfully intervened. Because of the particular characteristics of HIV, a medical deus ex machina is not likely soon. A major restructuring of the nature of professional conduct within an independent profession of public health and a depoliticization of public health departments are needed.
Category: AIDS/HIV Articles