PREVENTION INTERVENTIONS: KEY TO REDUCING HIV TRANSMISSION
BY PREM MISIR
June 21, 2004
“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 feltso 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 behavioral prevention intervention programs. Clara’s declarations address stigma, risk behaviors, 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 first 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 behavioral prevention intervention programs, given the rapid transmission of HIV infection in the Caribbean.
Behavioral prevention interventions a must
In the absence of a cure for eliminating the AIDS virus, behavioral 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 behavior change. Therefore, efforts exerted to prevent HIV/AIDS depend on an understanding of the factors that affect behavior 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 behavior modification. Interventions now have to redirect their perspective toward shared safety where the focus is on the sexual behaviors of all sexual partners.
Therefore, behavior intervention efforts may have to incorporate customization principles in its design. Customization 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 behavior change.
In addition, interventions based on a formal theoretical framework have a greater potential for effectiveness and generalizability 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 engage in risk behaviors could result in the development of effective interventions to change that behavior. 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 behaviors. For instance, the probability is high that a given behavior will be effected, if the following conditions are present:
* The person has a strong intention or commitment to perform the behavior
* The person possesses the skills and abilities needed to perform this behavior
* The person faces no environmental constraints to perform this behavior
* The person has the belief that performing this behavior will result in positive outcomes
* The person accepts the norms regarding this behavior, 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 behavior, and then apply this information to design behavioral interventions.
Behavioral intervention trials
Over the years, a few randomized controlled trials were administered to assess the efficacy of some behavioral intervention strategies. Some studies showed decreased sexual risk-taking (primarily unprotected sex) while others demonstrated a reduction in new infections of STD (Sexually Transmitted Disease) and HIV (Wang & Celum). Behavioral interventions target a recognition of risk and the need to design effective risk-reduction strategies. Knowledge of a subject matter is not sufficient on its own to effect change. As an example, although we have a large stock of knowledge on the harmful health effects of eating fatty foods, complying with the diet is easier said than done. In the same way, knowledge about STDs and HIV alone is not sufficient to employ change in sexual behavior, as demonstrated in five randomized-controlled studies. We need factors other than didactic education to motivate change.
The National Institute of Mental Health (Multicenter), Project Respect Study Group (Multicenter), University of Texas (San Antonio), the Centers for Disease Control and Prevention, (Houston), and the University of California (San Francisco), together conducted such studies, utilizing STD incidence as an outcome. These studies provided ample evidence of a behavioral intervention’s efficacy and at the same time, showing that much more than education is needed to change behavior. In fact, behavioral interventions can produce reduced rates of contracting STD, and even short counseling sessions also can result in diminished STD rates. But is there a consensus in the Caribbean on what interventions to use and which interventions work?
Consensus statement on interventions
Some 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 behavior, 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 behavioral prevention interventions.
In the attempt to develop this consensus statement at this Conference, the following issues were addressed:
* Identify the behaviors and contexts that place individuals/communities at risk
* Identify the individual/community-based methods of intervention that reduce behavioral risks
* Determine whether or not reduction in behavioral risks lead to HIV reduction
* Determine how risk-reduction protocols can be implemented effectively
* Identify the research urgently needed.
There is consensus that behavioral 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 behavioral interventions. In fact, recommendations from the consensus statement will generate direct and instantaneous consequences for health care, according to the NIH.
Theory-based behavioral 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 behaviors, 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!! This ‘best practices’ intervention process, first would require, as a precondition, an effective coordination, assessment, and evaluation of the policies, programs, and projects, engaged in battling HIV/AIDS. History and time are not our side amid this deadly disease, if we are to boost national development!!