Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
S2l4 International Perspectives on Individual and Community Approaches to the Prevention of Sexually Transmitted Disease and Human Immunodeficiency Virus Infection Kevin R. O'Reilly and Peter Piot World Health Organization and Joint United Nations Programme on HIV/AJDS, Geneva, Switzerland Risks for sexually transmitted disease (STD) and human immunodeficiency virus (HIV) infection have been addressed in two categories: the individual and the population. Emphasis in STO and HIV prevention has largely been placed on the first, with interventions that address individuals and attempt to bring about changes in individuals being the norm. The relative ease of evaluating these interventions and the ability to know that they have been delivered as intended make these interventions attractive. Community interventions are more difficult to manage and to evaluate but are nonetheless commonly used. Structural interventions that address the environment in which risk behavior takes place are also possible but used much less frequently. In a comprehensive intervention program for STO and HIV prevention, it is necessary to consider opportunities for all three types of intervention approaches. Determinants of sexually transmitted diseases (STDs) and human immunodeficiency virus (HIV) risk have been classified into two categories: individual and populational [1]. In fact, these two categories may be better viewed as end points of a continuum. At one end of the continuum are those factors that relate to behaviors, more or less under the control of the individual, that influence or increase risk of STD: partner choice, frequency of partner change, and use of condoms, among others. At the other end of the continuum are those factors that lie outside the control of the individual and function more at the level of the community, society, or population. These determinants include sociogeographic, economic, and epidemiologic factors present in the community in which the individual lives. Attributes of communities such as poverty, substance abuse, nonns for sexual behavior, sex roles, and the prevalence of STDs and HIV infection can increase the frequency of and risk associated with individual behaviors that can facilitate or, more often, impede the ability of individuals to take preventive action. Viewing the determinants of STD and HIV infection risk in this way is useful in that it more accurately addresses our attention to the broad range of factors that contribute to the epidemiology of STDs, including HIV infection, in a community. However, the thinking about intervention options usually is not so broad. For example, although many of the factors that contribute to the epidemiology of STDs and HIV infection lie outside the control of the individual, the bulk of interventions for prevention focus only on informing, educating, and motivat- Reprints or correspondence: Dr. Kevin R. O'Reilly, Division of Reproductive Health Technical Support, World Health Organization, CH 1211 Geneva 27, Switzerland, The Journal of Infectious Diseases 1996; 174(Suppl 2):S214-22 © 1996 by The University of Chicago. All rights reserved. 0022-1 899/96/74S2--001 0$0 1,00 ing individuals to change the behavior they can control. Little if any attention is given to addressing those factors that are attributes of communities or societies. Here we describe interventions for both the individual and the populational determinants of STD and HIV infection. In the latter category, we describe both community interventions and structural interventions that, together with the more commonly encountered individual interventions, can form a robust prevention effort. We have, in most cases, restricted our attention to studies that attempt to show at a minimum an outcome of reported behavior change and have especially searched for those that show STD or HIV outcomes as well. Background The goal of all intervention approaches for STD and HIV prevention is to prevent new infections. Under the influence of disciplines such as clinical psychology and social work, the majority of intervention approaches have tried to do this through changing the behavior of individuals, usually by intervening with individuals. These activities are usually, but not always, conducted in clinical settings where individuals at increased risk might be found: STD clinics, family planning clinics, drug treatment centers, and voluntary testing and counseling centers. These interventions can be particularly efficient in delivering interventions exactly where they are needed, to high-risk individuals. Community-level interventions are less common. These interventions, influenced by the field of communications and disciplines such as sociology, community psychology, and anthropology, attempt to address and affect the behavior of individuals in a less direct manner. These intervention approaches attempt to change, among other things, perceptions of and norms about behavior so as to influence the behavior of individuals in the community at large. Community interventions take JlD 1996; 174 (Suppl 2) International Perspectives on STD Prevention place outside the clinical setting, in the community from which at-risk individuals come. These interventions may deliver a less intensive dose of intervention to anyone individual than do clinical interventions, but they can nevertheless be particularly effective because they are distributed across a large population that can include many individuals at risk. A newer avenue for STD and HIV intervention planning is structural-level interventions, also called "enabling approaches" [2]. These approaches are designed to address the determinants of risk most distal to the control of the individual. Enabling approaches are designed not to change the individual's behavior directly but to change the social or physical environment in which risk takes place. Little used in STD and HIV prevention to date, these approaches deserve further attention. Models from other areas in public health should be studied for their effectiveness and relevance to prevention of STDs and HIV infection. In considering interventions and their mechanisms, it is helpful to draw a distinction between the agent and the target of the intervention. Some interventions we will describe are highly individual, in that both the immediate target of the intervention and the agent of the intervention are individuals. Voluntary counseling and testing is such an example. By the same token, some interventions are highly community; this is especially true of structural interventions described above. In these interventions, the agent of the intervention can be some mechanism within the community and the immediate target of the intervention is also at that community level. Change in the behavior of individuals is subsequent to the change at the community level. Other interventions, however, are a mixture of the two, with the agency of the intervention being community but the immediate target being individual. Although the activity may be taking place at the community level, the impact is expected immediately at the individual level and that is the focus of evaluation efforts. Peer education is an example of an intervention that blends individual and community approaches in this fashion. Drawing this distinction between agent and target of interventions can be helpful in focusing attention on the appropriate immediate outcomes to evaluate and in broadening the thinking about possible intervention options. Individual Interventions for Prevention of STDs and HIV Infection As stated above, individual approaches to the prevention of STDs and HIV infection can be defined in terms of delivery and evaluation. They may be defined as approaches delivered directly to individuals, usually in face-to-face encounters and often in clinical settings; individual approaches may be additionally defined as those that attempt to bring about changes that are measurable in the individuals who have been exposed to the intervention. Underlying individual approaches to interventions are a number of assumptions about the mechanisms through which they have their effect. For example, these approaches are prem- S215 ised on the assumption that the individuals who receive the intervention will make rational decisions about their behavior and be helped to implement those decisions through the individual intervention they received. Implicit is the belief that the individual has the power to make the necessary changes in behavior. Many factors, however, may impede an individual in his or her attempts to act on intentions for new or changed behavior. Substance abuse and poverty, for example, may diminish an individual's ability to act on intentions for new behaviors, despite how strong those intentions may be. For prevention of STDs and HIV infection, many of the most important behaviors are never under the control of one individual alone. Sexual behavior that is risky involves at least two people, meaning that one person may not have complete control over the sexual behavior. When a discrepancy in power about sexual decision-making does exist, it usually favors men, strongly so in some regions. Individual approaches to prevention of STDs and HIV infection face the challenge of assisting the individuals receiving them to change not only their own behaviors but also the behaviors of their partners, who may not have received a similar intervention. Individual interventions can bring about behavior change by addressing a variety of determinants of behavior, including increasing an individual's knowledge and awareness, perception of risk, or perception of their ability to change key behaviors. Perhaps the most common individual intervention is counseling. Counseling has been defined for HIV prevention purposes as an interactive process in which a trained counselor assists the client in developing and rehearsing a personal risk reduction strategy, including, if necessary, role playing of important steps that might be required [3]. Topics typically addressed in counseling for prevention of HIV infection include informing partners and introducing condom use into new and existing relationships. Voluntary HIV antibody testing and counseling (VCT), one special application of counseling, has been the cornerstone of the HIV disease prevention effort in the United States and several European countries since the mid-1980s. The literature on VCT has been extensively reviewed [4] and recently updated [5]. Virtually all of the studies reviewed used different measures of behavior change, different periods of observations, and different evaluation methods, making comparison of results and conclusions difficult. Nevertheless, the findings of those reviews of published and presented studies indicate that VCT has variable effectiveness for the different risk groups and the different risk behaviors for which it could be evaluated. Many unresolved questions remain about how effective it can be for the different groups for which it is used, the different behaviors addressed, and the different settings in which it is used and about what duration of effect can be anticipated. A few evaluations of the effect of VCT on subsequent incidence of STDs exist in the literature, but only from developed countries and only from STD clinics. VCT has been routinely provided as an intervention in US STD clinics since the late S216 O'Reilly and Piot 1980s. Otten et al. [6] followed subjects who had received pretest and posttest counseling and found that gonorrhea declined among HIV -seropositive subjects but increased among HIV-seronegative subjects 6 months after posttest counseling. Similarly, Zenilman et al. [7] found that 15% of STD clinic attendees who tested seropositive and 23% of those who tested negative developed or were exposed to a new STD I year after the counseling and testing. These studies suggest that VCT offered in STD clinics may have only a limited effect. It would be inappropriate to extrapolate from these studies in STD clinics to VCT as it is provided in freestanding clinics or as it is provided in developing countries. Fortunately, data do exist from some sites in the developing world. Evaluation of data from the AIDS Information Center in Uganda showed that the majority of clients seeking VCT were sexually abstinent at the time they sought testing [8]. Nevertheless, behavior change could be measured at 6-month follow-up. Those who tested seronegative were likely to return to sexual activity but with very high levels of condom use. The majority of those who were seropositive remained sexually abstinent, with the minority resuming sexual activity monogamously and with reported consistent condom use. Because of the difficulty of influencing the behavior of two individuals through an intervention that may be delivered only to one, the greatest potential effect of VCT may be with couples, when the issue of condom use in an established relationship can be addressed with the help of a professional counselor. Some studies of the impact of VCT for couples have been reported, in both developing [9, 10] and developed countries [11-14]. Studies in the developing world have demonstrated 20- [9] to 30-fold [10] increases in condom use after intervention. In the developed world, strong results have also been reported, with results from a European study [II] somewhat weaker than those from a US study that found no seroincidence of HIV [12, 13]. The European study was a multicenter trial, with more heterogeneity in the couples receiving the intervention (especially more injecting drug users [IDUs] in the trial) and more variety in the counseling provided [14]. In interpreting the results of these studies, two important considerations must be taken into account. First is the important distinction between people who seek out counseling and testing, indicating some readiness on their part to make changes, and people who encounter it in the course of seeking other services, as is the case when it is provided in STD clinics. As intention to change has been identified as an important predictor of actual behavior change [IS, 16], the first group should be expected to change more than the latter. The expectations of the amount of behavior change that can result should be lower for the STD clinic setting than for the freestanding VCT site, which specifically serves those seeking VCT. Second is the quality of the intervention provided. Though the term' 'counseling" is regularly used as if some standard for its meaning exists, it is, in fact, difficult to know exactly the content or the quality of the intervention message delivered. This applies as lID 1996; 174 (Suppl 2) well to the amount of intervention (i.e., the amount of counseling) that is provided in VCT. It is clear that more research on VCT is needed. The relatively greater cost ofVCT compared with that of other interventions for behavior change continues to restrict its use in many countries. While the cost of testing has decreased enormously, no similar decrease in the cost of counseling has occurred, and it is now by far the most expensive component of this intervention. The paucity of data from the developing world on the effectiveness of VCT for prevention as well as for care and support is another problem for rational prevention planning. A randomized controlled trial of VCT is underway [17], with four sites included, two East African, one Caribbean, and one Asian. Self-reported condom use and other risk avoidance behaviors are the major outcome variables, with incident STDs being used to corroborate the self-reports. Individual approaches, both with and without antibody testing, have also been used for IDUs, although no interventions from the developing world are reported in the literature. In the developed world, results from clinic-based interventions have been mixed. When positive results have been found (as they have in some randomized controlled experiments), individual interventions in clinical settings have generally been more effective at decreasing injection-associated risks than sexual risk [18 - 20]. Further research is needed in this area as well, and similar experiments in developing countries are clearly indicated. Community Approaches to Prevention of STDs and HIV Infection When discussing community-level interventions, it is helpful to define what one means by "community." In epidemiology, the term is often used the way political scientists or geographers use it, to connote an area that can be identified on a map. In applying this definition to epidemiology, it has its greatest strength when location is truly important, as in the study of point-source outbreaks or exposures to toxic substances. Its weakness stems from the fact that although people may live in the same jurisdiction, they may not interact equally with all people there. In sociology and anthropology, the term "community" can also be used to describe groups of people who interact in a substantive way with each other. This interaction can imply shared norms, beliefs, and values that influence behaviors. In epidemiology, this definition can be useful when social and sexual behaviors are important, as is the case with STDs and AIDS. The weakness of this definition is the inability to locate or enumerate exactly what the community is, as community identity is a product of ideology, not geography. The study of assortative mating and core groups in the epidemiology of STD and HIV infection is, to some degree, an attempt to identify the socially defined community within the context of the physically defined community. lID 1996; 174 (Suppl 2) International Perspectives on STD Prevention A community-level intervention, then, should be based on some explanatory theory or model of the behaviors under question. Of the various intervention approaches that have been tried at the community level, those that attempt to change social norms appear most promising. In earlier community interventions for chronic disease prevention, the importance of opinion leaders, role models, and reinforcers of prevention messages was recognized [21-23]. For prevention of STDs and HIV infection, this approach has been used to influence people's perceptions about what is acceptable sexual behavior. In the United States, this approach has been used with typically marginalized and difficult-to-reach populations such as sex workers, IDUs, female sex partners of IDUs, non-gay-identified homosexual men, and street youth in a series of demonstration projects using a core protocol [24, 25]. Significant differences between intervention and comparison areas on self-reported condom use were obtained for most cities and many but not all behaviors [26]. Also in the United States, popular opinion leaders were trained to deliver HIV prevention messages to gay-identified men in gay bars [27]. Unprotected anal sex declined 15%-24% after the intervention in the three small cities where the intervention was tried. Similarly, in the developing world, community interventions using peers have been widely tried but, unfortunately, rarely evaluated. In Nigeria, an intervention for sex workers relied on peers to train prostitutes, clients, and sex workers using outreach. In the uncontrolled evaluation, consistent condom use reportedly doubled in 1 year [28]. Larger increases in condom use were reported from similar interventions, also evaluated in an uncontrolled fashion, in Zimbabwe [29] and Ghana [30], both using trained peer educators. In the case of Zimbabwe, the intervention was able to reach a large proportion of the sex workers active in Bulawayo, Zimbabwe, the small city where it was conducted. In all of these trials, the lack of a comparison group makes it difficult to discount the possibility that the results obtained were due to the intervention used rather than to a social desirability bias or other cause. Mass media interventions have also been an important component of HIV infection and AIDS prevention efforts. These interventions can often be difficult to implement, as the concern about the content of specific messages in the public domain can often conflict with the public health need to communicate clearly and specifically about particular behaviors. Nevertheless, the mass media has been used in a number of countries, perhaps nowhere as consistently and extensively as in Switzerland. Beginning in 1986, the Swiss campaign used mass mailing to all households and public media to promote prevention of new HIV infections and solidarity in the face of the epidemic. As is characteristic of all mass media campaigns, however, it is much easier to demonstrate and attribute increases in awareness and knowledge than changes in behavior. In the Swiss campaign, knowledge about AIDS rapidly increased, as did condom sales and reported use of condoms with casual partners (figure 1) [31]. S217 Attributing behavior change to mass media campaigns is indeed difficult to accomplish. For example, over the same period of time as the campaign mentioned above, testing for HIV antibody in Switzerland also became common: by 1992, nearly one-half of the general population of the country was estimated to have been tested [32]. The problem of attributing behavioral outcomes to mass media campaigns is further complicated by studies that fail to demonstrate a correlation between levels of knowledge about STDs, HIV, or other harmful outcomes and what would seem to be the logical behaviors to avoid them [33, 34]. Nonetheless, the importance of mass media efforts in HIV infection and AIDS prevention is generally accepted [35]. The attribution of the observed effect to the intervention evaluated remains one difficulty in all uncontrolled evaluation studies. An equally difficult question is whether small-scale interventions can be done on a sufficiently large scale to bring about meaningful levels of risk reduction in cities where risk is greatest. One study in Ivory Coast has attempted to answer this question. The intervention consists of frequent large public community meetings in areas of sex work, with slide presentations and lectures. These meetings allow sex workers to see others like themselves facing issues of prevention of HIV infection. The evaluation, which compared the intervention areas to those that had not yet received the intervention, indicated that condom use at the last sexual contact was 90% for the intervention area compared with 67% for the comparison areas [36], although knowledge about STDs and HIV had not increased as significantly. The cause of the reported behavior change, one could conjecture, appears not to have been an increase in knowledge but in social norms about condom use that were reinforced by the group meetings. Recent criticism has identified the generally inadequate evaluation of all behavior change interventions as a major impediment to prevention planning [37]. In fact, some key questions about the effectiveness of behavioral interventions remain because too little attention in general has been paid to evaluation, especially in the developing world, where many behavior change interventions were developed as service projects, with no research or evaluation component included. Renewed attention to evaluation in some key, well-chosen projects could address some of these inadequacies. Frequently, however, attention has been focused on randomized controlled trials as a solution to the chronic evaluation problem that plagues behavior change interventions [38]. Caution is needed, however, when recommending this solution, as many behavior change interventions are not readily evaluated through this method. For example, evaluation of community-level behavior change interventions is difficult at best, if not completely impossible, by true experimental designs, as meaningful random assignment is extremely difficult, expensive, or simply not possible in some cases [39]. While conclusions about the effectiveness of communitylevel behavior change interventions may always be open to S218 JID 1996; 174 (Suppl 2) O'Reilly and Piot 0.5 14 0.45 12 0.4 10 0.35 til C ~ E 0.3 8 j 0.25 C'Il til E 0 6 0.2 'a C :::s f t/. Figure 1. Annual condom sales and reported use of condoms with casual partners, Switzerland, 1986-1991. 0 u 0.15 4 0.1 2 0.05 o 0 1986 1987 1988 1989 1990 year some question, other research designs, sometimes referred to as quasiexperimental designs, may represent a feasible and effective alternative to both uncontrolled and controlled, randomized designs. These designs do not include randomization but are more rigorous than simple time series or pre-versuspost comparisons, including the use of comparison groups or communities as controls. In addition, the entire field of evaluation is undergoing reexamination by some who emphasize the need for a complete understanding of how an intervention was meant to work as the essential first step in evaluation [40, 41]. In the view of these writers, randomization can be a poor substitute for actually trying to understand the mechanisms through which community-level programs in particular are supposed to work. Although additional evaluation research is clearly needed, the general benefit of community interventions and their relatively low cost make them worthy of inclusion in prevention planning. Failure to use these intervention approaches in STD and HIV disease prevention activities now would seem ill-advised. Structural (Enabling) Approaches for Prevention of STDs and HIV Infection One of the shortcomings of the previously described interventions, whether aimed at individuals or communities, is their reliance on attempts to influence choices individuals make about sexual behavior. This approach has been the basis of most health education efforts and is rooted in rational theories of behavior. The approach works best when the behavior in question is completely under the control of an individual. For instance, it is primarily an individual's choice to use a seat belt, to smoke, or to take exercise. The use of a condom, however, must be negotiated with another individual, placing that decision outside the individual's exclusive control. In many regions of the world, the issue becomes more complicated, as great discrepancies may exist in the relative power of women and men to make decisions about sexual behavior. It is generally thought that in the developing world, men make the choices and decisions about sexual matters, particularly condom use, more often than women do. When these facts are taken together with the relatively lower priority assigned to health or even the common beliefs in some cultures that health cannot be controlled or influenced by an individual's actions, then the standard health education approaches that attempt to influence behavior lose some of their currency. Reducing risk of STOs and HIV infection without relying only on individual choices about sexual behavior is clearly needed in some settings. In other areas of public health, interventions have not been restricted only to those approaches that rely on influencing individual behavior and choice. For example, the area of injury prevention is augmented by injury control [42]. The first is primarily based on health education and entails informing and alerting people to the potential for risks. The second focuses on modifying the environment so that fewer opportunities for injury are presented. Bicycle safety programs for children are injury prevention; mandatory helmet laws for children are injury control. Likewise, smoking prevention programs are supplemented by regulating where persons can smoke and, in some countries, by high taxes on tobacco products [43]. Substance abuse prevention is effectively augmented by taxation and age limitations in the case of alcohol and regulations in the case of scheduled substances. The strength of these approaches is lID 1996; 174 (Suppl 2) International Perspectives on STD Prevention that they do not rely on individual decision alone but also attempt to reduce risk even if individual compliance or choice is lacking. Similar approaches bear consideration for inclusion in the mix of possible interventions for prevention of STDs and HIV infection. These approaches, actually a special subset of community approaches, have been examined, and two main areas of such interventions (sometimes called "enabling approaches") have been outlined: policy instruments and economic approaches [2]. Policy instruments can include both removing restrictive policies to enable reduced risk behaviors to be practiced (as in legalizing the sale and possession of sterile injection equipment) and erecting barriers to continued risk taking. Economic approaches can include taxation or pricing mechanisms that make risky behavior financially less attractive than reduced risk behavior, that make means of risk reduction truly affordable, or that offer economic empowerment to women. These approaches offer the possibility of shaping and influencing behavior when it is difficult or impossible to influence and persuade all people at risk to change. For women, this may be an important adjunct to the approaches outlined previously. Often, simply making essential services, including clinical services, more available and more acceptable can be an important but often overlooked step to enable people motivated to change their behavior to act on their intentions to change. Condom social marketing attempts to do just that: to promote new behaviors (i.e., condom use) and to increase the availability and affordability of the necessary commodities. Condom social marketing programs have been very successful in some places in Africa where this mix of increasing access and subsidizing purchase price has been particularly appropriate. In Zaire, for example, condoms distributed through social marketing channels increased sharply over a short period of time (figure 2) [35]. Approaches to enabling behavior change through the provision of clinical services in addition to other interventions have been tried in STD and HIV prevention. In Kinshasa, Zaire, an intervention for sex workers included regular STD diagnosis and treatment in special clinics, promotion of condom use by sex workers, and the involvement of bar and hotel owners [44]. Regular use of condoms increased from 11% to 68% over 3 years. HIV incidence among regular users of condoms was one-third that of the irregular users of condoms. A similar approach has been tried in India. In Calcutta, the Sonagachi Project has been intervening with sex workers to teach condom use and negotiation skills and to diagnose and treat STDs in a clinic based in the "red-light" area. The project has also intervened with all members of the organized crime syndicate that operates prostitution in Calcutta to convince them to adopt a favorable policy towards condom use for their own economic self-interest. This has resulted in opening up access for prevention purposes to the brothels in Calcutta and bringing pressure for condom use on brothel owners and customers. Regular condom use among sex workers has increased S219 in Sonagachi from 1% before intervention to 47% at first evaluation; now more than three-quarters of all commercial sex acts involve condoms. Gonorrhea among sex workers has decreased 13%, to <4%, in the same time period, and incident syphilis by one indicator has decreased by half [45]. As an example of a prevention project that has been able to prevent STDs, including HIV infection, by working with the structure in which risky sex is practiced, the Sonagachi project is yielding promising results. In Thailand, the government instituted a policy of mandatory condom use in brothels in response to the AIDS epidemic in 1990. This policy was designed to address the core group for STD transmission in Thailand, sex workers and their clients. The policy is a partnership of brothel owners (who must ensure that customers use condoms), police (who enforce the policy through reprimands to owners and threat of closure), and public health clinics (which use incident STD in the sex workers as an indicator oflax enforcement of the policy in brothels). Regular and consistent condom use among Thai sex workers is very high since implementation of the policy (>90% in many provinces), and STDs among sex workers are now only a fraction of their former level. Surveillance data (figure 3) indicate that total diagnosed STDs decreased by three-quarters and STDs diagnosed among men decreased by >80%, while estimated condom use during commercial sex increased sharply during 1987 - 1993 [46]. Although these trends appear to be valid, it is possible that the decline in STDs in Thailand is attributable to some factors other than increased condom use in brothels. For example, the widespread availability of fluoroquinolones and oral cephalosporins, especially over the counter, could account for the decline in STDs. This availability of drugs, however, is not unique to Thailand but is true of many other countries in which little or no decline in STDs has been reported. An association between these declines and this mandatory condom use policy has been made [47], although it is difficult to prove definitively. Sharp increases in condom use rates can be attributed to other health promotional activities as well as this policy, making the cause(s) of the declining STD rates difficult to identify. Nevertheless, the strong results should draw our attention to this innovative intervention and to other similar intervention possibilities. Economic approaches may also be helpful in prevention of STDs and HIV infection. In Bangladesh, the Grameen Bank has been operating revolving loan schemes for rural women. Through this cooperative, women can borrow money to finance the development of self-employment activities. The loan schemes have been successful, with high rates of repayment of loans. In a recent evaluation [48], participation in the Grameen Bank scheme was positively associated with women's economic and social empowerment. Participation was also associated with increased use of contraception, which was expected, as women who participate in the scheme must agree to use contraception. Women who lived in villages where the O'Reilly and Piot S220 JID 1996; 174 (Suppl 2) 20 18 16 14 Ie c ~ 12 "I 10 E I Figure 2. Increase in condom sales through social marketing in Zaire. E 0 ~ c 0 8 u 6 4 2 0 1987 1988 1990 1989 1991 year Grameen Bank scheme operated but who did not themselves participate in the scheme also used contraception at a higher rate than women in villages without the scheme. The conclusions suggest that economic empowerment facilitates women's ability to control their personal decisions, including use of contraception. The evidence also suggests a diffusion of new norms from the successful participating women to other women 450000 1.00 400000 0.90 350000 0.80 0.70 300000 0.60 250000 0.50 200000 0.40 150000 0.30 100000 0.20 50000 0.10 0 ll) <0 ~ l8 ~ ..... <0 ~ ~ ~ m ~ 0.00 ~ ~ ~ e:-) ~ Figure 3. Reported STD cases (total and male) and estimated condom use in commercial sex, Thailand, 1985 - 1993. in their villages who did not participate. Economic approaches that may assist women in developing power over certain areas of their lives may be useful in assisting them to assert the control over their sexual behavior that they need to avoid STDs and HIV infection. Attempts to change cultural practices that may facilitate HIV transmission are other examples of enabling approaches. Practiced in some areas of East Africa, widow cleansing is a cultural practice that requires the spouse of a deceased person to be "cleansed" before they can remarry. "Cleansing" usuallyentails having sexual intercourse with someone in the family of the deceased spouse. Although the frequency of the practice may be low, the risk for transmission in areas of acutely high HIV seroprevalence and AIDS mortality is not insignificant. In Zambia, the Chikankata Hospital has worked with local village elders and leaders to change the practice of widow cleansing [49]. The team identified alternative, nonsexual cleansing methods (such as sitting on the lap of a male member of the deceased's family) that have been used in special cases such as pregnancy in the widow at the time of the spouse's death. Successfully shifting the existing cultural practice of cleansing through sex to the nonsexual cleansing methods by working with the village elders and leaders may have lowered the risk of HIV transmission for some Zambian widows. Making available the means of risk reduction can be an important but overlooked step in prevention. In addition to condom social marketing programs described above, harm reduction for IDDs is another example. One form of harm reduction, the availability of clean needles and syringes, while controversial in some quarters, is perhaps the most effective form lID 1996; 174 (Suppl 2) International Perspectives on STD Prevention of prevention of HIV infection available for IDUs [50]. Delivery of health care services such as STD treatment may also have an effect on risk of HIV, even if those treated do not change their behavior. To some degree, this is the reasoning currently behind the mass treatment attempts and communitybased approaches for STDs that are underway or have produced results [51] in some areas in Africa: if the prevalence of genital ulcerative diseases can be decreased, then the risk of HIV transmission even for those who continue to engage in risky behavior should also be reduced. In this way, mass treatment of STDs and community-based STD management can be viewed as another example of an enabling approach. However, the possibility also exists that mass treatment trials may increase risk-taking behavior by inadvertently conveying the message to people that unprotected sex is acceptable as long as there is no genital ulceration. In this way, mass treatment alone (without additional behavioral intervention to decrease sexual risk taking) could be disabling or a barrier to HIV prevention. What these examples suggest is that thinking about STD and HIV prevention has been perhaps too limited. Holmes [I] places many of the factors discussed above out of the range of the individual's control, which is true. He also implies that these factors are out of the reach of intervention or at least of interventions that can have discernible effect in a relatively short period of time. The examples above would argue that enabling approaches not only are feasible but also can be effective in relatively short time. While these interventions are clearly not the single answer nor are they easy to implement, they may well represent an approach that has received entirely too little attention and that could be used with other approaches for STD and HIV prevention. Conclusions Under the influence of fields such as clinical psychology and health education, most thinking in STD and HIV prevention has focused on individual interventions. These interventions have the attraction of being relatively easy to monitor, control, and evaluate: it is easy to count how many individuals received an intervention, and although somewhat more difficult, it is still possible to measure the effect. Community interventions are more difficult to implement, monitor, control, and evaluate. They can be effective in bringing about behavior change, however, with large groups of people. Enabling approaches, operating through a different mechanism, are still little understood and even less used but promising. In a comprehensive intervention program for STD and HIV prevention, it is necessary to consider opportunities for all three types of intervention approaches. References I. Holmes KK. Human ecology and behavior and sexually transmitted bacterial infections. Proc Natl Acad Sci USA 1994; 91 :2448-55. S221 2. Tawil 0, O'Reilly KR, Verster A. Enabling approaches in HIV/AIDS prevention: influencing the social and environmental determinants of risk (editorial review). AIDS 1995; 9: 1299-306. 3. Rugg DL, MacGowan RJ, Stark KA, Swanson NM. Evaluating the CDC program for HIV counseling and testing. Public Health Rep 1991; 106: 708-13. 4. Higgins DL, Galavotti C, O'Reilly KR, et ai. Evidence for the effects of HIV antibody and testing on risk behaviors. lAMA 1991;266: 2419-29. 5. Choi KH, Coates TJ. Prevention of HIV infection. AIDS 1994; 8: 1371-89. 6. Otten MW, Zaidi AA, Wroten lE, Witte JJ, Peterman TA. Changes in sexually transmitted disease rates after HIV testing and post-test counseling, Miami, 1988- 1989. Am J Public Health 1993; 83:529-33. 7. Zenilman 1M, Erickson B, Fox R, Reichardt CA, Hook EW. Effect of HIV posttest counseling on STD incidence. lAMA 1992;267:843-5. 8. Moore M, Tukwasiibwe E, Marum E, Taremwa C, O'Reilly K, Rosner L. Impact of HIV counseling and testing (CT) in Uganda [abstract WSCI6-4]. In: Program and abstracts: IX International Conference on AIDS/IV STD World Congress (Berlin). London: WeIIcome Foundation, 1993:97. 9. Allen S, Tice 1, Van de Perre P, et ai. Effect of serotesting with counseling on condom use and seroconversion among HIV-discordant couples in Africa. Br Med 1 1992;304:1605-9. 10. Kamenga M, Ryder R, lingu M, et ai. Evidence of marked sexual behavior change associated with low HIV -1 seroconversion in 149 married couples with discordant HIV -1 serostatus: experience at an HIV counselling center in Zaire. AIDS 1991;5:61-7. II. Padian NS, O'Brien TR, Chang Y, Glass S, Francis DP. Prevention of heterosexual transmission of human immunodeficiency virus through couple counseling. 1 Acquir Immune Defic Syndr 1993;6:1043-8. 12. de Vincenzi I. A longitudinal study of human immunodeficiency virus transmission by heterosexual partners. N Engl J Med 1994; 33 I : 341-6. 13. Pad ian NS, Vittinghoff E, Shiboski S. Heterosexual transmission of HIV [letter]. N Engl 1 Med 1994;331:1718. 14. de Vincenzi I. Heterosexual transmission of HIV [letter]. N Engl J Med 1994;331:I718-9. 15. Fishbein M, Azjen I. Belief, attitude, intention, and behavior: an introduction to theory and research. Redding, MA: Addison-Wesley, 1975. 16. Prochaska 10, DiClemente Cc. Stages and processes of self-change of smoking: toward an integrative model of change. 1 Consult Clin Psychol 1983; 51 :390-5. 17. De Zoysa I, Phillips KA, Kamenga MC, et a1. Role of HIV counseling and testing in changing risk behavior in developing countries. AIDS 1995; 9(suppl A):S95-1 01. 18. Des Jarlais DC, Casriel C, Friedman SR, Rosenblum A. AIDS and the transition to illicit drug injection: results of a randomized trial prevention program. Br J Addiction 1992; 87:493-8. 19. McCusker J, Stoddard AM. Zapka lG, Morrison CS, Zorn M, Lewis BF. AIDS education for drug abusers: evaluation ofshort-tenn effectiveness. Am.T Public Health 1992;82:533-40. 20. McCusker J, Stoddard AM, Zapka .JG, Lewis BF. Behavioral outcomes of AIDS educational interventions for drug users in short-term treatment. Am 1 Public Health 1993;83:1463-6. 21. McAlister A, Puska P, Pall onen U, Maccoby N. Mass communication and community organization for public health education. Am Psychol 1980; 35:375-9. 22. Meyer AJ, Maccoby N, Farquhar JW. The role of opinion leadership in a cardiovascular health education campaign. In: Ruben BD, ed. Communication yearbook I. New Brunswick, N.J: Transaction Books, 1977: 579-91. 23. Puska P, McAlister A, Niemensivu H, Piha T, Wiio 1, Koskela K. A television format for national public health promotion: Finland's keys to health. Public Health Rep 1987; 102:263-9. S222 O'Reilly and Piot 24. O'Reilly KR, Higgins DL. AIDS community demonstration projects for HIV prevention among hard-to-reach groups. Public Health Rep 1991; 106:714-20. 25. Centers for Disease Control and Prevention. Community-level prevention of human immunodeficiency virus infection among high-risk populations: the AIDS Community Demonstration Projects. MMWR Morb Mortal Wkly Rep 1996; 45(RR-6). 26. Higgins DL, Johnson WD, Guenther-Grey C, O'Reilly KR. The AIDS Community Demonstration Projects: early results indicate condom use and bleaching [abstract PC0479]. In: Program and abstracts: Tenth International Conference on AIDS/International Conference on STD (Yokohama, Japan). Vol 2. Tokyo: Japanese Foundation for AIDS Prevention, 1994:276. 27. Kelly JA, St Lawrence JS, Stevenson LY, et al. Community AIDS/HIV risk reduction: the effects of endorsements by popular people in three cities. Am 1 Public Health 1992; 82: 1483 - 9. 28. Williams E, Lamson N, Efem S, Weir S, Lamptey P. Implementation of an AIDS prevention program among prostitutes in the Cross River State of Nigeria [letter]. AIDS 1992; 6:229-30. 29. Wilson D, Nyathi B, Nhariwa M, Lamson N, Weir S. A community-level AIDS prevention programme among sexually vulnerable groups and the general population in Bulawayo, Zimbabwe. Harare: University of Zimbabwe, 1993. 30. Asarnoah-Adu A, Weir S, Pappoe M, Kanlisi N, Neequaye A, Lamptey P. Evaluation of a targeted AIDS prevention intervention to increase condom use among prostitutes in Ghana. AIDS 1994; 8:239-46. 31. Hausser D, Zimmerman E, Dubois-Arber F, Paccaud F. Evaluation of the AIDS prevention strategy in Switzerland. Third assessment report (1989-90). Lausanne, Switzerland: Institut Universitaire de Medecine Sociale et Preventive, 1991. 32. Jeannin A, Dubois-Arber F, Paccaud F. Hl V testing in Switzerland. AIDS 1994; 8: 1599-603. 33. Andersson-Ellstrorn A, Forssman L, Milsom I. The relationship between knowledge about sexually transmitted diseases and actual sexual behavior in a group of teenage girls. Genitourin Med 1996; 72:32-6. 34. Whitley B Jr, Schofield 1. A meta-analysis of research on adolescent contraceptive use. Popul Environ 1985-86; 8: 173-203. 35. Global Programme on AIDS. Effective approaches to AIDS prevention: report of a meeting (Geneva). Geneva: World Health Organization, 1992. 36. Kale K, Gnaore E, Mah-bi G, Tawil 0, Tiemele A, Djadji E. Evaluating a behavioral intervention in high risk settings in Abidjan, Cote d'Ivoire [abstract PB0741]. In: Program and abstracts: Tenth International Con- 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49. 50. 51. lID 1996; 174 (Suppl 2) ference on AIDS/International Conference on STD (Yokohama, Japan). Vol 2. Tokyo: Japanese Foundation for AIDS Prevention, 1994:182. Oakley A, Fullerton D, Holland J. Behavioral interventions for mY/AIDS prevention. AIDS 1995; 9:479-86. Peterman TA, Aral SO. Evaluating behavioral interventions: need for randomized controlled trials [letter]. lAMA 1993,269:2845. Susser M. The tribulations of trials-intervention in communities [editorial]. Am 1 Public Health 1995; 85: 156-8. Chen HT, Scriven M, Smith NL, Leviton LC. A panel on theory-driven evaluation and evaluation theories. Eval Pract 1994; 15:73-93. Chen HT, Rossi PH. Evaluating with sense: the theory-driven approach. Eval Rev 1983; 7:283-302. Gielen A. Health education and injury control: integrating approaches. Health Educ Q 1992; 19:203 -18. Sweanor D. Tobacco use: the role of pricing. Presented at the Expert Meeting on Behavioral and Social Factors in Disease Prevention, Committee on Population, National Academy of Sciences, Washington, DC, 14-15 June 1993. Laga M, Alary M, Nzila N, et al. Condom promotion, sexually transmitted diseases treatment, and declining incidence of HIV-I infection in female Zairian sex workers. Lancet 1994;344:246-8. Jana S, Khodakevich L, Larivee C. Changes in sexual behavior of prostitutes in Calcutta [abstract 346D]. In: Program and abstracts: Tenth International Conference on AIDS/International Conference on STD (Yokohama, Japan). Vol 2. Tokyo: Japanese Foundation for AIDS Prevention, 1994: 13. Hanenberg RS, Rojanapithayakorn W, Kunasol P, Sokal DC. Impact of Thailand's HIV -control programme as indicated by the decline of sexually transmitted diseases. Lancet 1994;344:243-5. Rojanapithayakorn W, Hanenberg R. The 100% Condom Program in Thailand. AIDS 1996; 10: 1-7. Schuler SR, Hashemi SM. Credit programs, women's empowerment and contraceptive use in rural Bangladesh. Stud Fam Plann 1994;25: 65-76. Williams G. From fear to hope: AIDS care and prevention at Chikankata Hospital, Zambia. Strategies for hope: number 1. Oxford, UK: ACTION AID,1991. Des larlais DC, Choopanya K, Vanichseni S, et al. AIDS risk reduction and reduced HIV seroconversion among injection drug users in Bangkok. Am 1 Public Health 1994;84:452-5. Grosskurth H, Mosha F, Todd J, et al. Impact of improved sexually transmitted diseases on HIV infection in rural Tanzania: randomised controlled trial. Lancet 1995; 346:530-6.