Behavioral and Social Sciences
Research progress in this area includes:
At present, the most effective way to prevent or reduce the spread of HIV/AIDS is through behavior change. The majority of AIDS cases in the United States and globally result from two activities: unprotected sexual intercourse with an HIV-infected person and the use of HIV-contaminated injection drug equipment. The primary goal of NIH-sponsored AIDS-related behavioral and social science research is to discover how to change the behaviors that lead to HIV transmission -- including preventing their initiation -- and how to maintain protective behaviors once they are adopted. An additional goal is to reduce the negative impact of AIDS on HIV-infected individuals, their families, the health care system, and society.
The NIH sponsors research related to the following: developing, implementing, and evaluating behavioral and social interventions to reduce HIV transmission; strengthening our understanding of the determinants, trends, and processes of HIV-related risk behaviors and the consequences of HIV infection; developing and evaluating behavioral strategies for preventing or ameliorating the negative physical, psychological, and social consequences of HIV infection; and improving the research methodologies employed in behavioral and social science research. Cutting across these areas is a continued commitment to crafting better linkages among researchers, communities most affected by HIV and AIDS, and organizations responsible for providing HIV prevention and health care services.
Rapid advancement of meaningful and effective HIV-related behavioral and social science research requires further development of methodological tools. Although significant progress has been made by NIH-supported researchers in many areas, such as self-report data and network analysis, currently available methodologies constrain the ability of researchers to conduct large-scale, in-depth studies required to combat HIV and AIDS. As with other areas of HIV research, methodology represents the essential building blocks of HIV-related behavioral and social science research, and, therefore, it must be given special attention at NIH to allow for rapid advancement of both basic and intervention research.
In the past 15 years, much has been learned and accomplished in the area of HIV/AIDS prevention through behavior change interventions. Theory-driven intervention models have been developed and employed by researchers supported by NIH, and have demonstrated that preventive interventions work, even among "hard-to-reach" and socially disenfranchised populations. These interventions have resulted in marked changes in sex and drug-using behaviors most implicated in HIV transmission (i.e., engaging in unprotected sexual intercourse and sharing unsterile drug injection equipment) among such groups as rural gay men, out-of-treatment injection drug users (IDUs), homeless and runaway youth, and the seriously mentally ill.
For example, NIH-supported research conducted in New York City demonstrated that multifaceted risk reduction programs (including drug treatment and the provision of sterile injection equipment) can produce large and significant and sustained decreases in HIV risk behavior among IDUs, even among those who continue their drug abuse. Among actively injecting addicts admitted for detoxification, the use of potentially contaminated syringes declined from 51 percent of injections at baseline to only 7 percent of injections at followup. Further declines in unsafe injection practices were seen in addicts who participated in syringe exchange programs. This multifaceted approach translated into lower HIV seroincidence rates among needle exchange participants than among nonparticipants (1 to 2 per 100 person years at risk compared with 4 to 7 per 100 person years at risk).
Delaying the onset of sexual behavior and dissuading youth from engaging in drug use also have been important HIV prevention strategies developed and tested by NIH-supported researchers. In one study, 89 percent of abstinent youth who received HIV information and a skills-training intervention delayed initiation of sexual activity for 1-year postintervention, compared with 68 percent of those who received only the HIV information.
To date, most behavior change interventions have been tested in small groups, in a limited number of communities, and over relatively short periods of time. It is now important to replicate and refine the most successful of these interventions to test their effectiveness on a broader scale and over longer periods of time, and to develop new interventions to address behaviors that have proven most resistant to change. Where appropriate, interventions should be tested in randomized, controlled trials, and when possible, HIV seroincidence should be an additional outcome measure. NIH-supported researchers currently are engaged in multisite investigations to identify the most effective components of behavioral interventions for different populations, including IDUs, crack cocaine users, and STD clinic patients, and to assess their effect on both behavior change and HIV seroincidence in those populations. In addition, determining the cost-effectiveness and cost-utility of such interventions is an area of current exploration by NIH-supported researchers.
Research has shown us that in order to be successful, preventive interventions must be targeted to specific populations and must take into account the cultural and social contexts of different people's lives. NIH-supported projects informed by theoretical models from the behavioral and social sciences are uncovering the specific elements of social and cultural life that contribute to HIV risk and protective behaviors and that must be addressed in interventions. For example, one study investigated how different personal and social resources, threat appraisal processes, and coping styles affected the differential use of condoms among homeless African American and Latina women, and concluded that culture-specific strategies that attend to these differences are necessary to effect positive behavior change among these women.
Community-level interventions may be an important way to effect behavioral change on a broad scale. NIH-supported researchers have investigated the impact of community-level approaches both in the United States and abroad. For example, in a study of five cities in which HIV had entered a heterosexual IDU community but where HIV seroprevalence remained low and stable, three common prevention components were identified as responsible: beginning prevention early; community outreach; and access to sterile injection equipment. The researchers concluded that in low seroprevalence areas, such community-level approaches may limit transmission of HIV among populations of IDUs despite continuing risk behavior among a substantial proportion of the population.
Other important areas of intervention research at NIH include the following: the acceptability of both biomedical and behavioral interventions among different individuals and communities; the behavioral aspects of the adoption of new HIV prevention technologies, such as the female condom, microbicides, or the use of zidovudine (AZT) by pregnant women to prevent vertical transmission of HIV; and social and psychological factors influencing participation in study trials and adherence to medical regimens for the treatment of HIV and AIDS-associated disorders.
Ensuring the relevance and effectiveness of behavior change interventions for HIV prevention requires good understanding of the psychological, social, and cultural factors that contribute to HIV risk and protective behavior. Specifically, in the area of HIV and AIDS, NIH-supported researchers are investigating the mechanisms that influence risk behavior -- from neurobiological factors related to sexual drive and drug addiction, to psychological factors related to self-esteem and the ability to negotiate safe sex; to social and cultural factors related to laws, norms, and values about sexuality, drug and alcohol use, and HIV/AIDS itself. This basic research, including the development and testing of theories of behavior change and maintenance in the context of HIV risk, is the essential underpinning of primary prevention and early intervention efforts.
Studies of decision-making processes have identified psychological factors, knowledge, attitudes, and behavioral intentions as important in leading to behavior change among individuals. Most of these approaches focus on the individual at one point in time or at one stage of life. However, HIV risk and behavior change may be experienced differently by people at different stages of development and different points in their lives. This suggests the importance of including a developmental and a life course perspective in HIV prevention and intervention research.
Moreover, it has become apparent that the social nature of HIV risk behavior requires a broader focus than merely on the individual. NIH-supported research has demonstrated the significance of partners, social networks, families, and peer groups in influencing an individual's engagement in or avoidance of risk behavior. For adolescents, research has determined the important role both parents and peers play in decisions to initiate or postpone sexual activity. Among IDUs, personal networks have been determined to be both sources of HIV transmission and potential targets of HIV preventive interventions. In one study, for example, researchers found that higher total personal network density and larger drug network size were positively associated with needle sharing. Understanding the characteristics and dynamics of networks has led to interventions that interrupt such sharing practices.
Another area of particular importance for understanding HIV transmission is the overlap in HIV-related risk behaviors. NIH-supported researchers are investigating the complex interplay of alcohol use, drug use, and risky sexual behavior, including the situational factors that contribute to their mix. For example, one study determined that partner characteristic (steady, long term versus casual) moderated the relationship between alcohol use and high-risk sexual behavior among gay men. Individuals without steady partners were four times more likely to engage in risky sex (unprotected intercourse) under the influence of alcohol than those with steady partners.
Unfortunately, AIDS appears to be here for some time to come, and it will continue to have a significant impact on individuals and communities both domestically and globally. NIH-supported researchers have been engaged in studying the consequences of HIV and AIDS on individuals, their loved ones, and caregivers for some time now. These investigations span the sciences from neuroimmunology to social psychology, as they address such issues as the bi-directional relationship between stress, depression, and immune functioning in individuals, the psychological costs and benefits of caregiving, and the impact of bereavement on individuals' mental health.
As the AIDS epidemic devastates whole communities in some places, it has become increasingly important to investigate its social and cultural consequences. For example, NIH-supported researchers are beginning to examine the implications of the "stigma" of HIV/AIDS -- that is, as a disease that is generally fatal and whose transmission is characterized primarily by socially marginalized activities -- on the care and treatment of infected persons; the social and psychological status of orphaned children whose parents have died from AIDS; and the impact of HIV/AIDS on health care systems and economies of communities that have been most affected by the epidemic.
As advances in the range and type of research questions being addressed are made, so are advances in the methods being employed to answer them. Over the past 15 years, significant improvements have been made in ensuring the validity and reliability of self-report data, the outcome measure of many behavioral and social science-based preventive interventions. In addition to refining computer-assisted technologies that enhance veracity, some NIH-supported studies are collecting microbiological and disease outcome data (e.g., STD and HIV serological test results) as an additional measure to use in conjunction with self-reports.
Some behavior change interventions have been developed to the point where they now can be tested in quasi-experimental or randomized controlled trial designs to better ascertain their effectiveness. In addition to behavior change outcomes, HIV seroincidence data are also being collected as an intervention outcome measure.
Additionally, new techniques for improving our ability to quantitatively estimate the success of behavioral interventions in preventing the spread of HIV are being developed by researchers with expertise in mathematical modeling and biostatistics. For example, NIH-supported researchers have developed models to estimate the number of HIV infections averted through the implementation of a one-for-one sterile needle exchange program, and to estimate how effective a vaccine program would be in stemming the rate of HIV transmission in one city given various scenarios related to the level of vaccine efficacy, use of the vaccine, and behavior change. Continued support over the next few years should see further refinement in such methodologies that will produce better estimates for projecting the course of the epidemic in different populations and the possibilities for stemming it through specific interventions. In turn, this will improve our ability to determine which interventions are successful and which are not and to apply resources accordingly.
The evaluation of HIV prevention strategies and programs is a vital part of the behavioral and social science agenda at NIH. Conducting successful evaluation -- both program evaluation and cost-effectiveness/cost-utility evaluation -- requires well-honed methods, including the identification and operationalization of appropriate outcome measures. Further development of methods in this area will allow us to determine not only which interventions are most successful, but also whether particular components of interventions are more effective than others.
For more information on Behavioral and Social Science HIV/AIDS-related research at the NIH, contact:
Judith Auerbach, Ph.D.
Office of AIDS Research, NIH
Building 31, Room 4C06
Bethesda, MD 20892
(301) 402-3555 TELEPHONE
(301) 496-4843 FAX
Last Update: October 4, 1996
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