Preventive interventions in the now decades-old war against HIV infection seem to be plagued by a Sisyphean fate: Just when declining seropositivity rates in some populations suggest that the prevention message is making headway, the virus gains new ground in other populations where the prevention call has gone unheard, or perhaps unspoken.
For example, in the United States, there has been a trend toward declining AIDS incidence among nonminority, older homosexual men. However, infection rates have risen among young minority men and women, indicating the call to arms has not been sounded loud enough or with enough conviction in those populations to do just battle.
Without question, the emergence of life-saving antiretroviral therapies has been critical in the fight against HIV. But in the absence of sustained, consistent prevention efforts encompassing all at-risk populations, the successes will be diminished. "For too long, the debate has been framed as prevention versus treatment. "That's the wrong way to think about it." according to Joshua Salomon, Ph.D., of the Harvard School of Public Health in Boston. To reverse the epidemic, an "integrated and balanced" approach is critical, he said.
Ironically, achieving such integration and balance seems to have been made more difficult by the availability of effective therapies. More people than ever are living with--and living well with--HIV, thanks to such treatments. But the advances have also led to a sense of complacency. Because an HIV diagnosis is no longer the death knell it once was, the urgency of the prevention message seems to have lessened among those living with HIV/AIDS, as well as those at risk for it.
Furthermore, populations at risk for HIV are so diverse that there could never be a one-size-fits-all solution. The core messages may be the same--HIV is transmitted through unprotected sex and the sharing of contaminated needles, for example--but the manner in which the messages need to be delivered must be tailored to the needs of specific audiences.
For example, in addition to education and counseling about high-risk sex and drug use practices, preventive interventions must include efforts to improve access to and maintain linkages to appropriate care and services, while interventions for at-risk seronegative populations should enhance the basic preventive messages with information for modifying judgment-impairing alcohol and drug use.
Interventions for heterosexual men and women might debunk perceptions that because they are not gay, they are not at risk, and preventive efforts for high-school and college students have to focus on the risks, signs, and symptoms of sexually transmitted diseases, how and when to say "no," and where to go for help.
The prevention message for women--particularly adolescents and young adults under the age of 25, who are at higher risk for HIV/STD transmission than older women--must address the underlying reasons for the tendency among this population to have multiple sex partners and the fact that a diagnosis of another sexually transmitted disease, such as gonorrhea, syphilis, or chlamydia, increases vulnerability to HIV infection.
Finally, interventions for racial and ethnic minorities, who are disproportionately affected by HIV/AIDS in this country, must deliver the prevention message in a culturally sensitive manner.
According to the Centers for Disease Control and Prevention, as of 2003, 64% of males living with AIDS and 83% of females living with it were either African American or Hispanic. African American children represent almost 71% of all pediatric AIDS cases, and AIDS is the leading cause of death among African American men aged 25-44. To have an impact, behavioral interventions must take into account the myriad factors that could exacerbate their vulnerability--including poverty, racism, absence of social support, limited access to health services, and unhealthy living and working conditions. …