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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-
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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
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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].
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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
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JID 1996; 174 (Suppl 2)
O'Reilly and Piot
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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
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JID 1996; 174 (Suppl 2)
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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
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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.
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