Can prevention make a difference?
The unequivocal answer is yes. HIV prevention programs are doomed to failure if they are expected to protect 100% of people from disease 100% of the time.(1) No interventions aimed at changing behaviors to promote health have been or can be 100% successful. Driving deaths caused by drunk drivers declined from 57% in 1982 to 45% in 1992, and this was considered a major victory. In 1964, the Surgeon General first sounded an alarm about smoking; warning labels on cigarettes weren't mandated until 1984, and now, 30 years later, stop smoking campaigns are achieving some success even though smoking-related illness is the major cause of death for Americans.
In San Francisco, CA, new HIV infections reached a high of 8,000 in 1982. In 1994, the estimated number of new HIV infections was 1,000. Comprehensive community-based HIV prevention programs targeted towards gay and bisexual men in the early to mid-1980s certainly contributed to this dramatic reduction in new HIV infections.(2)
For prevention programs to work, cases of disease must be averted. As June Osborn, former Chair of the National Commission on AIDS said, "If we do preventive medicine and public health right, then nothing happens and it is very boring. We should all be praying for boredom."
A thorough review of research evaluating HIV prevention programs found 20 studies that demonstrated long-term behavior change.(3) Skepticism about the effectiveness of HIV prevention programs is not borne out by scientific evidence. The following are examples of scientifically evaluated prevention programs that have been proven effective.
What works for gay/bisexual men?
Small group counseling. Audio-visual presentations eroticizing safer sex, safer sex negotiation skills training, stress reduction training, and intensive group counseling have been shown to be effective at changing behavior on a short-term basis. In Pittsburgh, PA, one study resulted in an increase in condom use from 36% to 80%.(4)
Community interventions. AIDS education led by peers on a community level is effective at reaching higher risk men who don't often participate in small group counseling. In several medium-sized towns, the most popular people in social settings were trained to deliver AIDS risk-reduction messages to their friends and acquaintances in gay bars. As a result, fewer gay men practiced unprotected sex.(5) Another program found that using peers to support and encourage friends about safer sex was an effective approach to HIV prevention.(6)
What works for injecting drug users?
Community outreach. In Chicago, peer-led street outreach targeting social groups of injecting drug users (IDUs) not in drug treatment found a substantial reduction in sharing needles, from 100% to 14%. A four-year follow-up of this program also found an impressive decrease in HIV seroconversion rates, from 5% to less than 1%.(7) An HIV prevention media campaign aimed at a national audience was found effective at slowing HIV conversion among IDUs in Northern Italy.(8)
Needle exchange programs. A comprehensive report prepared for the Centers for Disease Control and Prevention reported 10 studies of needle exchange programs that showed decreases in sharing needles, the main route of HIV transmission, as a result of the exchanges.(9)
What works for adolescents?
Sex education. Although sex education for adolescents is still steeped in controversy, the preponderance of data has shown that age-appropriate school programs reduce risk behavior in the short term, and can actually decrease sexual activity for adolescents. An experimental sex education program helped students who were abstinent remain abstinent after a year and a half. Among those who did become sexually active, the program resulted in higher use of contraceptives.(10)
Small group counseling and skills building. For hard-to-reach adolescents at high risk for HIV, intensive and repeated education, skills-training and counseling sessions are effective. In New York, runaway youths in residential shelters who received 15 or more sessions, reported an increase in consistent condom use from 33% to 63%, and a decrease in high-risk sexual behavior from 20% to zero. As the number of intervention sessions increased, consistent condom use increased significantly and engaging in a high-risk sexual behavior decreased significantly.(11)
What works for adult heterosexuals?
Small group counseling. Patients in an urban primary health care clinic receiving AIDS education, skills-training and peer support reported a 40% increase in condom use.(12)
Couples counseling. Studies of discordant couples (i.e. where one is HIV-infected and the other isn't) have shown that when couples are counseled together about safer sex, condom use increases, and HIV seroconversion decreases. In one study, none of the couples who consistently used condoms seroconverted.(13) In another study, discordant couples who received repeated HIV testing and post-test counseling showed increased condom use from 3% to 57%.(14)
What kinds of programs work best?
Many characteristics of successful HIV prevention programs hold true across populations.
A comprehensive HIV prevention strategy uses multiple elements to protect as many people at risk for HIV as possible. We should learn from and promote the effectiveness of HIV prevention programs already in place, as well as continue to evaluate these programs. The standard for measuring success of HIV prevention needs to be addressed; 100% effectiveness could never be achieved. Finally, funding for prevention programs and research into prevention science needs to be tied to effectiveness and public health importance. Now that we know that HIV prevention works, and what kinds of programs work, we need to put them into practice, sustain and refine them.
References:
Prepared by Pamela DeCarlo
Reproduction of this text is encouraged; however, copies may not be sold. The Center for AIDS
Prevention Studies at the University of California San Franciso is the source of this
information. For additional copies of this and other HIV Prevention Fact Sheets, please call the
National AIDS Clearinghouse at 800/458-5231. Comments and questions about this Fact Sheet may
be e-mailed to prevention_factsheets@quickmail.ucsf.edu. ©1996, University of California
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