AIDS Programs Failing Groups at Highest Risk

There is growing evidence that prevention programs aimed at stopping the spread of the AIDS virus are failing to influence many of those at highest risk, and experts say the reasons include a lack of imaginative approaches and a kind of societal failure of nerve.

At a time when the course of the epidemic is shifting toward drug users, women, adolescents and younger gay men, experts say the reluctance to design explicit prevention programs specifically for those groups has left the next generation dangerously vulnerable to infection. In interviews and presentations last week, prevention specialists discussed the way that public policies and private attitudes have contributed to the failure to unravel ingrained patterns of sexual behavior and drug use among certain groups.

“There’s been an American tradition of not talking about sex in explicit detail . . . and of providing very inadequate health care for people with substance-abuse problems,” said Don C. Des Jarlais of Mt. Sinai School of Medicine in New York City. “AIDS has upped the ante for those traditions.”

It has been known for seven years that the human immunodeficiency virus (HIV) is spread through sex and through the exchange of blood by injection. Nevertheless, 40,000 to 80,000 Americans are still becoming infected each year with the lethal virus, federal estimates suggest.

In the absence of the ability to vaccinate people against the virus, health officials and social-service groups have put their faith in education and prevention--an array of programs that includes counseling and testing, public-service campaigns, school programs, street outreach and promotion of condoms.

In some cases, prevention has been successful: The rate of new infections among older gay men in large cities has plummeted. That is evidence, experts say, that it is indeed possible to change that most mysterious and instinctive form of behavior, human sexuality.

But research presented here at the Sixth International Conference on AIDS offered ominous proof that, in other areas, prevention is failing, and that many women, teen-agers and drug users continue to engage in unsafe forms of sex and drug use and are being infected at rising rates.

For example, despite evidence that more and more intravenous drug users in San Francisco say they avoid sharing or using dirty syringes, a federal study found little change in other cities. And everywhere, researchers have found high rates of unprotected sex among drug users and their partners.

Similarly, researchers reported scant use of condoms among teen-agers and women of child-bearing age. And a study of young gay men in medium-sized West Coast cities found that 43% had practiced unprotected anal intercourse, one of the riskiest forms of sex, in the previous six months.

“What it says is new people are entering this pool and they are considering themselves invulnerable,” said Thomas J. Coates of the Center for AIDS Prevention Studies at UC San Francisco. Coates and others criticized existing prevention efforts as insufficiently explicit or intensive.

One difficulty is that the epidemic is not monolithic, said Dr. Alan Hinman of the U.S. Centers for Disease Control. It is many epidemics spreading differently in different groups, each group having “unique social and psychological characteristics . . . and patterns and standards of behavior.”

For example, white and minority drug users often behave differently. Some use different methods of injection, some share syringes with strangers instead of friends. Prevention programs therefore must address different types of risk; some alternatives will appeal to some groups and not to others.

Similarly, the sexual relationships of white and minority women are often different. A woman’s role in a relationship will determine how she can negotiate safer sex. Young gay men may not identify with older gay men and therefore may not respond to messages tailored to older men.

But the problem is not simply the complexity of the epidemic and the inscrutable subtleties of behavior, researchers said. They also blamed societal wishful thinking--the belief that it is enough to tell people how the virus is spread without giving them accessible tools to avoid it.

The researchers contended that it is unrealistic to ask many teen-agers to simply avoid sex; they need to learn communication skills required to negotiate safe sex. As Coates puts it, you don’t teach a teen-ager to drive by telling him how a car engine works; you put him in a car and show him.

Intravenous drug users, too, are often denied the tools to avoid infection, researchers said. Public policies restricting access to addiction treatment programs and sterile syringes have left many users with information about AIDS risk but without realistic and immediate ways of avoiding it.

“Policies that impair condom or bleach distribution because they might lead to increases in sexual activity or drug use ignore the data,” Coates said in a speech at the conference. “There are no data to support the adverse effects of these programs.”

“Prevention has to be a lot more than information,” said Robert Battjes, of the National Institute on Drug Abuse, in an interview. “To bring about behavior change requires a great deal of intense effort. . . . We’ve got to be in there intervening over and over again.”

Ultimately, behavioral scientists agree that widespread behavior change is impossible without changing social and community norms--not unlike the way public-health campaigns against smoking over the last two decades have changed the image of cigarettes from glamorous to anti-social.

For that reason, they called for education and prevention programs that change the way people feel about high-risk behavior--for example, by making safer sex seem not a poor substitute for the real thing but erotic, normal and perhaps even patriotic.

They pointed to the San Francisco AIDS Foundation’s controversial bus-shelter poster showing a young, gay couple--smiling, naked, holding up a condom and draped in the flag. Above them, the slogan reads, “Life, liberty and the pursuit of happiness.”

Related STORIES: A3, A24