Norman Hearst

Results of a model AIDS prevention program for high school students in the Philippines

The objectives were to describe the sexual practices of high school students; to describe the process of development of a school-based AIDS prevention program; and to evaluate the effect of this program on students AIDS-related knowledge attitudes and AIDS-preventive behaviors by means of self-administered questionnaires. A cluster-randomized controlled trial with pretest/post-test evaluation was conducted in 4 demographically similar public high schools in a semi-urban district of Metro Manila the Philippines. Of 845 high school students who participated in the baseline survey 804 (95%) completed a postintervention questionnaire. An AIDS prevention program was developed by public high school teachers together with local AIDS experts social scientists and health educators to provide students with accurate information about AIDS dispel misconceptions about casual contagion to foster positive attitudes towards people with AIDS and to develop skills aimed at assessing intended behavior. At baseline 80 (11%) of 804 students reported ever having had sexual intercourse (mean age 14 years). 66 were male and 14 were female (p < 0.001). Among these condom use was low (24%). Reasons for failure to use condoms were: use of other method (26%) and loss of sensitivity (25%). After implementation of the AIDS prevention program the intervention group was more likely to answer correctly that HIV cannot be transmitted by mosquito bites (p < 0.01) through a cough or sneeze (p < 0.01) or by shaking hands with an infected person (p < 0.01). Students who had attended the AIDS education program were less likely to avoid people with AIDS and were more compassionate toward them (p = 0.01). Changes in knowledge about modes of HIV transmission were associated with improvements in preventive knowledge (p < 0.001). While there was no statistically significant overall effect on intended preventive behavior the program appeared to delay the students intended onset of sexual activity. The program was successful in increasing AIDS-related knowledge and improving attitudes toward people with AIDS.

Reassessing HIV prevention

The largest investments in AIDS prevention targeted to the general population are being made in interventions where the evidence for large-scale impact is uncertain.

Delayed effects of the military draft on mortality: a randomized natural experiment

To study the effect of military service during the Vietnam era on subsequent mortality, we analyzed a randomized natural experiment, the military draft lottery of 1970 to 1972. Between 1974 and 1983, there were 14,145 deaths among California and Pennsylvania men whose dates of birth were in the years for which the draft lottery was held. The group of men with birth dates that made them eligible for the draft had a higher mortality rate than the group with birth dates that exempted them from the draft: suicide was increased by 13 percent (P = 0.005 by two-tailed test), death from motor-vehicle accidents by 8 percent (P = 0.03), and total mortality by 4 percent (P = 0.03). Only 26 percent of the men who were eligible for the draft actually entered the military. If military service (rather than draft eligibility) was the actual risk factor, suicide and death from motor-vehicle accidents would have to have been increased by 86 percent and 53 percent among men who served in the military, to produce the increased risk that we observed among all draft-eligible men. A separate analysis that compared the causes of death in veterans and nonveterans yielded similar estimates: veterans were 65 percent and 49 percent more likely to die from suicide and motor-vehicle accidents, respectively. We conclude that the most likely explanation for these findings is that military service during the Vietnam War caused an increase in subsequent deaths from suicide and motor-vehicle accidents.

High-risk sexual behavior and condom use among gay and bisexual African-American men.

OBJECTIVES Little is known about the human immunodeficiency virus (HIV) high-risk sexual practices of gay and bisexual African-American men. These data are needed so that better interventions can be developed and implemented in this population. METHODS The frequency and correlates of unprotected anal intercourse were examined among 250 gay and bisexual African-American men in the San Francisco Bay Area. The cohort was recruited in 1990 from bars, bathhouses, and erotic bookstores, and through African-American gay organizations, street outreach, advertisements in gay mainstream and African-American newspapers, health clinics, and personal referral from other participants. RESULTS More than 50% of the men in our sample reported having unprotected anal intercourse in the past 6 months, a considerably higher percentage than that among gay White men in San Francisco through 1988 and 1989. Men who practiced unprotected anal intercourse were more likely to be poor, to have been paid for sex, or to have used injection drugs; to have a higher perceived risk of HIV infection; and to report less social support for concerns about risky sexual behavior. Condom norms, condom efficacy, and negative expectations about using condoms predicted these mens failure to use them. CONCLUSION In the second decade of the acquired immunodeficiency syndrome epidemic, risk reduction programs are still needed for gay and bisexual African-American men.

Evaluation of an HIV risk reduction intervention among African-American homosexual and bisexual men

ObjectiveTo provide the first data which evaluates an HIV risk reduction intervention designed to reduce HIV high-risk sexual behavior in African-American homosexual and bisexual men. SubjectsParticipants (n = 318) were recruited from bars, bathhouses, and erotic bookstores, and through homosexual African-American organizations, street outreach, media advertisements, and personal referrals of individuals aware of the study. MethodsParticipants were randomized into a single or triple session experimental group or a wait-list control group. Both experimental interventions included AIDS risk education, cognitive-behavioral self-management training, assertion training, and attempts to develop self-identity and social support. Data collection involved assessments of self-reported changes in sexual behavior at 12− and 18-month follow-up. ResultsParticipants in the triple session intervention greatly reduced their frequency of unprotected anal intercourse (from 46 to 20%) at the 12-month follow-up evaluation and (from 45% to 20%) at the 18-month follow-up evaluation. However, levels of risky behavior for the control group remained constant (from 26 to 23% and from 24 to 18%) at 12− and 18-month follow-up evaluations, respectively. In addition, levels of risky behavior for the single session intervention decreased only slightly (from 47 to 38% and from 50 to 38%) at the 12− and 18-month follow-up evaluations, respectively. ConclusionsResults were interpreted to demonstrate the superiority of a triple session over a single session intervention in reducing risky sexual behavior in this cohort.

Injecting drug use and HIV infection in southwest China.

Objectives:To determine the prevalence of drug injection among drug users, the seroprevalence of HIV and risk factors for HIV infection among injecting drug users (IDU), and to determine heterosexual transmission of HIV among IDU and their spouses in southwest China. Methods:Using a cross-sectional design, we conducted an HIV seroprevalence and behavioral survey in three rural counties of Yunnan province, Ruili, Longchuan and Luxi in southwest China, bordering Myanmar (Burma). A total of 860 drug users were recruited in randomly selected communities at the three study sites (response rate, 97%). In addition, a random sample of 62 wives of HIV-infected IDU were assembled from 460 known HIV-positive IDU in Ruili and Longchuan (response rate, 81%). Results:In the sample of 860 drug users, 33% reported injecting drugs. Among the 282 subjects who injected drugs, 82% began intravenous drug use after 1988; 64% injected drugs at least once every day. All subjects shared needles but none cleaned the injection equipment with alcohol or bleach. Overall, 49% tested HIV-positive. HIV seropositivity was independently correlated with a longer history of drug injecting, daily injecting, frequent needle-sharing, being younger, and living in Ruili county. Among the 62 wives of HIV-positive IDU, none used condoms during sex and 10% tested HIV-positive. Conclusions:We conclude that the introduction of HIV into drug-using communities and the rapid increase in heroin injecting in this population appear to have triggered an explosive HIV epidemic among IDU in southwest China. We recommend that AIDS prevention efforts should begin immediately and focus on discouraging the shift from opium smoking to heroin injecting, needle-sharing, and unprotected sex among drug users and their partners.

The time has come for common ground on preventing sexual transmission of HIV.

The HIV/AIDS pandemic is an urgent health and growing humanitarian crisis especially in the high-prevalence regions of sub-Saharan Africa where most new infections continue to occur. On World AIDS Day (Dec 1) two decades after the discovery of the virus that causes AIDS and after many millions of deaths we believe it is critical to reach consensus on a sound public-health approach to the prevention of sexually transmitted HIV. Although transmission from injecting drug use is a serious and increasing problem in some regions here we focus on sexual transmission which continues to account for most infections globally. Sexual behaviour is influenced by many factors not always under an individual’s control including gender norms and social and economic conditions. However the public-health community has an obligation to offer people the most accurate information available on how to avoid HIV and to encourage changes in societal norms to reduce the spread of the virus. Although prevention should encompass multiple integrated elements including links to expanded treatment access changing or maintaining of behaviours aimed at risk avoidance and risk reduction must remain the cornerstone of HIV prevention. We call for an end to polarising debate and urge the international community to unite around an inclusive evidence-based approach to slow the spread of sexually transmitted HIV on the basis of the following key principles. (excerpt)

Multiple Heterosexual Partners and Condom Use Among Hispanics and Non-Hispanic Whites

A telephone survey of 1,592 Hispanic and 629 non-Hispanic white men and women aged 18-49, randomly selected from nine states in the northeastern and southwestern United States, found that married Hispanic men are more likely to have had two or more heterosexual partners in the previous 12 months than are married non-Hispanic men (18% and 9%, respectively). A large proportion of unmarried men (60% of Hispanics and 54% of non-Hispanic whites) report having had more than one partner in the past 12 months. After adjusting for other variables, the odds of having multiple partners are 2.5 times higher among Hispanic men aged 18-24 than among those aged 41-49 and 1.8 times higher among those who live in the Northeast than among those in the Southwest. Highly acculturated Hispanic men are less likely to have multiple partners than are less acculturated men. Among Hispanic women, those who are moderately or highly acculturated are more likely to have multiple partners (odds ratios of 4.9 and 8.4, respectively) than are less acculturated women. About half of men and women with multiple partners report always using condoms with secondary heterosexual partners.

Factors associated with condom use in a high-risk heterosexual population.

The use of condoms has been advocated as a means of preventing the transmission of the human immunodeficiency virus and other sexually transmitted agents. To better understand factors that may influence condom use, 300 heterosexuals were enrolled in a cross-sectional study of patients attending San Franciscos only public sexually transmitted disease clinic. Interviewer-administered questionnaires were conducted. Condom use at last sexual intercourse was examined by logistic regression analysis. Men who used drugs or alcohol at last intercourse and whose partners did not want to use condoms were less likely to have used them; women who were black or Hispanic, who reported difficulty getting their partners to use condoms, or who reported that condoms decrease sexual pleasure also were less likely to have used them. Efforts to increase condom use in this population should target minorities, assist women to negotiate their use, emphasize the dangers of using alcohol and other drugs with sex, and address the perception that condoms interfere with sexual pleasure.

Determinants of survival in adult Brazilian AIDS patients 1982-1989.

ConclusionsThese results tend to confirm the predictors of AIDS survival previously reported from developed countries and to document the poor survival of AIDS patients in the developing world.