Prevention interventions key to reducing HIV transmission By Dr Prem Misir
Guyana Chronicle
February 4, 2002

“My first boyfriend was a guy called Steve. We started to grow apart when we left school, and I started college. Just before my 20th birthday, my parents were diagnosed with cancer and I heard through my friends that Steve had started getting ill. Steve had barely reached 20 and I found myself at his funeral.

Three months after both my parents passed away, I went out with Daniel. He had known Steve and I from school. One night at a nightclub, he mentioned that his sister had told him that Steve had died of AIDS. I snapped back at him “No one knew Steve like I did and he would have told me.” Daniel made an appointment for me to get an HIV test. The night after I went for the dreaded blood test, I asked him “What will we do if I’m positive?” I should have guessed by his answer, “I’m banking on the fact that you’re not.”

Well, three days later, my life ended. I was so sure that it would be negative I had taken the wee girl I looked after with me. I phoned my sister-in-law to collect me, the news was bad. I was at my lowest and felt so insignificant. I told my previous boyfriends and their reaction was bad enough, as if it couldn’t get any worse. I was threatened and judged like I should have known Steve had AIDS - I was only 17 then for goodness sake. A child, that’s all I was. Daniel, my boyfriend told his parents, and that was it, I was alone with nothing left.” (Compiled by AVERT).

The voice of Clara resonates with the urgency for behavioural prevention intervention programmes. Clara’s declarations address stigma, risk behaviours, lost opportunities, and the snuffing out of life at an early age, all as factors associated with Human Immunodeficiency Virus (HIV) infection and Acquired Immune Deficiency Syndrome (AIDS).

The global scourge of HIV/AIDS continues to take its toll, even as we enter the third decade of this deadly disease. Since 1981 when the virus was identified, about 60 million people contracted the infection. Further, HIV/AIDS is the leading cause of death in Sub-Saharan Africa, and globally, it is the fourth leading executioner. The task here is to aggressively encourage the application and implementation of behavioural prevention intervention programmes, given the rapid transmission of HIV infection in the Caribbean.

Global HIV/AIDS statistics at end of 2001 Worldwide, about 40 million people today are nursing the HIV infection. Young adult men and women are more susceptible to new HIV infections in the poorest countries. About 33 percent of people living with HIV/AIDS are in the age group 15 through 24.

In Sub-Saharan Africa, 28.1 million adults and children are living with HIV/AIDS, 3.4 million are new infections, and 55 percent of HIV + adults are women. In Latin America, 1.4 million adults and children are living with HIV/AIDS, 130, 000 are new infections, and 30 percent of the HIV+ adults are women. In North America, 940,000 adults and children are living with HIV/AIDS, 45,000 are new infections, and 20 percent of HIV+ adults are women. In the Caribbean, 420,000 adults and children are living with

HIV/AIDS, 60,000 are new infections, and 50 percent of HIV+ adults are women. In fact, when compared to the rest of the world, both Sub-Saharan Africa and the Caribbean have the highest proportions of HIV+ women. In the Caribbean, the primary modes of HIV transmission are heterosexual transmission and sexual transmission among men having sex with men. These statistics are drawn from UNAIDS/WHO.

According to UNICEF, about 800,000 infants contracted the HIV infection, largely through mother-to-child transmission in 2001. Also, UNICEF reported that more than 10 million children currently under 15 lost their mother or both parents to AIDS. An infant born to an HIV-positive mother has a 25 to 35 percent probability of contracting the infection during childbirth or through breastfeeding, according to UNICEF. UNICEF also indicated that about 540,000 children became infected in this mode of transmission in 2000. UNICEF reported that recent studies demonstrated that a mother-to-child intervention package, including the use of antiretroviral drug treatment at the end of pregnancy, can slow down HIV transmission by 50 percent.

In Guyana, the cumulative total of reported cases of AIDS as of December 2001, were 1,615, with deaths totaling 377.

Behavioural prevention interventions a must In the absence of a cure for eliminating the AIDS virus, behavioural prevention interventions today become the only means to reduce the spread of HIV transmission and reduce new HIV infections. However, HIV infection is preventable through behaviour change. Therefore, efforts exerted to prevent AIDS depend on an understanding of the factors that affect behaviour and behavior change.

However, significant social and psychological stressors have marred HIV prevention intervention outcomes over the years. The time may have now come for interventions to break away from the traditional models of behaviour modification. Interventions now have to redirect their perspective toward shared safety where the focus is on the sexual behaviours of all sexual partners.

Therefore, behaviour intervention efforts may have to incorporate customisation principles in its design. Customisation could include a cultural understanding of the social networks of the HIV-infected as well as those at risk. The notion of integrating the larger social forces influencing reduced HIV transmission into the intervention design, may be quite instrumental in effecting desired behaviour change.

In addition, interventions based on a formal theoretical framework have a greater potential for effectiveness and generalisability of outcomes than interventions built on informal and logical grounds (Coates, 1990).

Additionally, elicitation research used in needs assessment, can enhance the intervention design by its focus on group intervention strategies (Jemmott et al, 1993).

Explaining behavioral prevention interventions Fishbein (1997) argues that an understanding of why people have risk behaviours could result in the development of effective interventions to change that behaviour. The three theories that greatly impacted AIDS intervention research, according to Fishbein, are the Health Belief Model, the Social Cognitive Theory, and the Theory of Reasoned Action. Two other theories that have aided the behavioral intervention process are the Theory of Self-Regulation and Self-Control and Theory of Interpersonal Relations and Subjective Culture.

The first three theories are quite adequate to predict behaviours. For instance, the probability is high that a given behaviour will be effected, if the following conditions are present:

· The person has a strong intention or commitment to perform the behaviour

· The person possesses the skills and abilities needed to perform this behaviour

· The person faces no environmental constraints to perform this behaviour

· The person has the belief that performing this behaviour will result in positive outcomes

· The person accepts the norms regarding this behaviour, that is, norms that are accepted by people important to him

Fishbein points out that we need to identify all these factors that strongly influence a given behaviour, and then apply this information to design behavioural interventions. But is there a consensus in the Caribbean on what interventions to use?

Consensus statement on interventions
A few years ago I attended the National Institutes of Health (NIH) Consensus Development Conference on Interventions to Prevent HIV Risk Behaviors at the National Institutes of Health in Maryland, USA. This Conference attempted to review what is known about behavioral interventions that are effective with different populations in different settings for the following modes of transmission: sexual behaviour, mother to child transmission, and substance abuse. This Conference had in attendance social scientists, prevention researchers, statisticians and research methodologists, clinicians, physicians, nurses, social workers, mental health professionals, other health care professionals, and patients.

After presentations and audience discussion, a consensus panel reviewed the scientific evidence, and subsequently produced a consensus statement on behavioural prevention interventions.

In the attempt to develop this consensus statement at this Conference, the following issues were addressed:

· Identify the behaviours and contexts that place individuals/communities at risk

· Identify the individual/community-based methods of intervention that reduce behavioural risks

· Determine whether or not reduction in behavioural risks lead to HIV reduction

· Determine how risk-reduction protocols can be implemented effectively

· Identify the research urgently needed.

There is consensus that behavioural interventions today are still the most effective method to reduce the spread of HIV infection and slow the growth of new infections. As pointed out by the NIH some time ago, vaccines for future trials may yield moderate or unknown efficacy, and so the trials will require behavioural interventions. In fact, recommendations from the consensus statement will generate direct and instantaneous consequences for
health care, according to the NIH.

Theory-based behavioural prevention intervention is the way to go, and has been so for some time. It must inform policy formulation in health settings in any society ravaged by HIV/AIDS. Health policy makers in the Caribbean may need to consider developing a comprehensive consensus statement on interventions to prevent risk behaviours, to reduce the spread of HIV transmission, and to lower the rate of new infections. Caribbean policy makers need to agree now on what the ‘best practices’ prevention interventions are!! History and time are not on our side amid this deadly disease!!