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Human Immunodeﬁciency Virus (HIV) infection, the cause of Acquired Immune Deﬁciency Syndrome (AIDS) has become a signiﬁcant threat to global public health faster than any previous epidemic (Mann and Tarantola 1996). The genetic nature of HIV evades the development of a preventive vaccine and a cure for HIV infection remains a distant hope. HIV is transmitted through direct contact with HIV infected blood, semen, and vaginal secretions. Although HIV is transmitted during birth from mother-to-infant and through contaminated blood products the majority of AIDS cases in the world have resulted from HIV transmission between adults engaged in high-risk practices. Behavioral interventions therefore remain the most realistic means for curtailing the spread of HIV infection. Eﬀective HIV risk reduction interventions target two principle behaviors: (a) sharing HIV contaminated drug injection equipment and (b) decreasing exposure to HIV infected semen, vaginal secretions, and sexually derived blood. Interventions to change injection equipment sharing and high-risk sexual practices can, therefore, dramatically eﬀect the spread of HIV. In this research paper, factors associated with HIV transmission risks and interventions directed at reducing risks associated with injection drug use and sexual relations are examined.
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1. Factors Associated With HIV Transmission Risks
Eﬀective HIV risk reduction interventions are tailored to the immunological, epidemiological, cultural, and social correlates of HIV transmission risk behaviors. HIV transmission risk is aﬀected by both biological and sociocultural co-factors.
1.1 Biological Co-Factors
A variety of genetic subtypes of HIV exist, with each having its own unique features relevant to trans-mission susceptibility. Genetic subtypes of HIV also diﬀer in their geographic distribution. Therefore, genetic subtypes of HIV that are most eﬃciently transmitted during vaginal intercourse are more prevalent in some regions of the world than others and partially account for the regional diﬀerences in epidemic patterning (Mann and Tarantola 1996). Sexually transmitted infections, particularly syphilis, chancroid disease, and gonorrhea, cause ulcers and degradation of mucous membranes increasing both HIV transmission and susceptibility. Another biological factor associated with HIV transmission risk is the infectious state of infected persons. Individuals with lower blood concentrations of HIV, or viral load, may be at lower transmission risk than persons with greater concentrations. Therefore, the availability and use of HIV suppressing medications may inﬂuence the transmission of HIV. These biological inﬂuences on HIV transmission risks will likely interact with speciﬁc prevention strategies targeted by given risk reduction interventions.
1.2 Sociocultural Co-Factors
Culture and social structures create a context for HIV transmission risk. Gender biases, power in sexual relationships, social norms supportive of risk and protective behaviors, poverty, drug addiction, and homophobia are known factors that inﬂuence HIV subepidemics (Kalichman 1998). HIV transmission occurs in personal relationships. Therefore, the social connections between persons, or social networks, play a critical role in both risk producing and risk reducing behaviors (Friedman et al. 1999). Social environments necessitate tailoring behavioral interventions to subpopulation characteristics. Also, behavioral interventions must adapt over time to the ever-changing social context of HIV-AIDS.
2. Interventions For Injection Drug Use Risks
HIV and other diseases are spread through sharing contaminated needles and syringes for injecting drugs. Tainted injection equipment, therefore, not the drugs themselves transmit HIV. The use of sterile needles and syringes assures prevention against HIV and other diseases. Syringe access and exchange programs have demonstrated substantial reductions in new HIV infections among drug injectors (NIH Panel 1997). Another eﬀective means of preventing HIV transmission via injection drug use is availability of drug treatment on demand. Obviously, when one stops injecting drugs the risks for injection-related HIV also ceases. Yet despite the known public health value of providing access to syringes and to drug treatment, political forces and limited economic resources have prohibited policies for wide-scale implementation of these intervention strategies (National Academy of Sciences 1995). Cleaning injection equipment is considered a reasonable alternative when sterile syringes are unavailable. Behavioral interventions have shown success in training injection drug users in proper needle and syringe hygiene skills.
HIV risk reduction for injection drug users, therefore, occurs along a spectrum of health objectives. Drug treatment is the ideal intervention because it addresses the risks posed by drug addiction as well as HIV infection. Persons who do not receive drug treatment, however, can reduce the harm of drugs by using sterile injection equipment. When sterile equipment is unavailable, persons are advised to practice needle and syringe cleaning. The philosophy of accepting incremental steps to reduce risks when risks cannot be eliminated is called harm reduction and has been highly eﬀective in framing the expected results of HIV risk reduction strategies.
3. Interventions For Sexual Relationship Risks
The vast majority of AIDS cases in the world have resulted from exposure to HIV in sexual relationships. Interventions designed to reduce sexual risk practices that permit HIV transmission—vaginal, anal, and oral intercourse without condoms or other barriers—have occurred at three primary levels: individual risk reduction counseling, small group workshops, and community mobilization campaigns. In each case, eﬀective interventions that reduce high-risk behavior almost universally include three primary elements: educational information about HIV and how it is transmitted and prevented; motivation to induce individuals to make behavioral changes; and interactive exercises to improve risk reduction behavioral skills, such as sexual assertiveness skills and condom use skills (Fisher and Fisher 1992).
3.1 Components Of Sexual Risk Reduction Interventions
Skills enhancement interventions consist of education, sensitization, and instruction in speciﬁc behavioral skills to reduce risk for HIV infection. Educational exercises and activities designed to help individuals take steps toward risk reduction are tailored to reﬂect the context, values, customs, and language of targeted populations. Therefore, similar intervention content is used for men and women of various backgrounds, but the contextual issues and examples vary accordingly.
3.1.1 HIV Risk Information And Motivation Enhancement. HIV prevention interventions provide basic in-formation related to HIV transmission, illness, and prevention. Risk education can include facts about viral transmission, local prevalence of HIV and AIDS, clariﬁcation of misconceptions, dispelling AIDS myths, and description of HIV antibody testing. Discussions often couch information in personal life situations, relationships, risk behaviors, and increased motivations to reduce risk. Education also encourages individuals to assess their own behavioral risk histories and initiate discussions of individual life-situations that have placed them at risk. Theoretically, increased understanding of risk and personalization of vulnerability to contracting HIV are believed to increase one’s readiness to change and enact behaviors to reduce risks.
3.1.2 Behavioral Self-Management Skills. Behavioral self-management skills related to HIV risk reduction are acts that individuals can perform to reduce their risks for HIV infection with minimal involvement of their sexual partners. Individuals are instructed in techniques for examining their risk and cues that precede sexual risky situations. For example, persons are instructed in ways to identify environmental and cognitive-aﬀective cues that serve as ‘triggers’ for high-risk situations, including mood states, substance use, settings, and sexual partner characteristics. Strategies for avoiding or managing high-risk triggers and situations are discussed with individuals generating their own risk avoidance behaviors. Coping strategies for high-risk situations may include performing safer sex acts, redirecting sexual activities toward safer sex alternatives, carrying condoms, and avoiding sex after substance use. Identiﬁcation of barriers to risk reduction, such as substance use and access to condoms are placed in the context of problem solving.
A key to behavioral self-management skills is condom use during sexual intercourse. Interventions educate individuals about the eﬃcacy and proper use of condoms, but the skills training component goes beyond education by including safer sex exercises. Instruction, modeling, practice, and guided feedback desensitizes individuals to condoms, capitalizes on changing negative attitudes toward condoms. Increased experience with condoms has been shown to decrease rates of condom failure, a potential beneﬁt of condom skills training. It should be noted, however, that condom use is a behavioral skill that includes interaction with one’s partner, and in the case of women in heterosexual relationships as well as men who are the receptive partner during anal intercourse, use of male condoms can require techniques for putting condoms on partners as well as discussing and persuading partners to use condoms.
3.1.3 Sexual Communication Skills. Sexual negotiation, sexual assertiveness, refusal of high-risk sex, and nonverbal communication are the most common types of communication skills included in HIV risk reduction interventions. Increasing skills for resisting partner coercion to engage in sexual intercourse without condoms, and increasing comfort discussing safer sex with partners in advance of sexual activity occur through instruction, modeling, and practice in communicating sexual decisions and discussing individual limits on behavior. Role playing situations allows for experience in what it may be like to talk with partners about risk and risk reduction. Modeling eﬀective responses, practice, and guided feedback again form the core for the skills training model. Individuals learn techniques to communicate feelings and sexual behavior limits through practice sessions conducted to increase proﬁciency in communication skills and comfort in discussing sexual alternatives with partners.
4. Levels Of Sexual Risk Reduction Interventions
HIV risk reduction intervention elements that include risk education, risk sensitization, and behavioral and communication skills building are found in all eﬀective HIV risk reduction interventions delivered to individuals, groups, and communities. The most common HIV prevention activities occur in face-to-face counseling sessions, usually in conjunction with HIV antibody testing. Risk reduction counseling can be eﬀective when it includes information, motivation, and skills building components, even when delivered in as short a time as 20 minutes (Kamb et al. 1998). However, there is now compelling evidence that HIV testing delivered with information-based counseling that does not include behavioral skills building components is ineﬀective at reducing HIV risks (Weinhardt et al. 1999).
Workshops delivered to small groups of individuals, typically 6 to 12 persons, that include information, motivation, and skills building activities have been shown eﬀective in rigorously controlled studies with men who have sex with men, heterosexual men, women, and adolescents (Kalichman 1998). Finally, HIV prevention eﬀorts delivered at the community level have also been shown eﬀective when they include information, motivation, and behavioral skills. For example, peers and natural opinion leaders trained in skills for disseminating information and motivational messages can successfully change patterns of risk behaviors for entire populations (Kelly et al. 1997). Thus, sexual risks for HIV infection can be eﬀectively reduced when they provide information, risk sensitization, and behavioral skills building opportunities in highly interactive formats.
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- Mann J, Tarantola D J 1996 AIDS in the World II. Oxford University Press, New York
- National Academy of Sciences 1995 Preventing HIV Transmission: The Role of Sterile Needles and Bleach. National Academy Press, Washington, DC
- NIH Panel 1997 National Institutes of Health Consensus Development Statement on Interventions to Prevent HIV Risk Behaviors. NIH Oﬃce of Medical Applications Research, Bethesda, MD
- Weinhardt L, Carey M P, Johnson B, Bickman N 1999 Eﬀects of HIV counseling and testing on sexual risk behavior: A meta-analytic review of the published research, 1985–97. American Journal of Public Health 89: 1397–1405