Revising the Mpowerment Project: Critical Suggestions to Improve the Effectiveness of One of the Best HIV Prevention Programs- Nicholas Deputy

Over half a million people have died from the acquired immunodeficiency syndrome (AIDS) in the United States since the epidemic began in the early 1980s (2). Homosexuals were often targeted as the cause of the disease, but were also the first activist groups to prevent the disease from spreading (1). The prevention programs that they created were aimed at educating and spreading awareness about the severity of the human immunodeficiency virus (HIV) that causes AIDS (1). These interventions grew to incorporate town and city centers where men who have sex with men (MSM) can go to get HIV testing and to join a support group. These centers also provided the standard information to promote a healthy lifestyle that incorporates safe sex. While these resources are essential to an effective intervention, real progress wasn’t made until the Mpowerment Project and other similar programs were put into place in the 1990s (9). This program has had a lot of success in reducing the numbers of new HIV cases diagnosed by using a diffusion of innovations model (22). Using this technique, the Mpowerment Project attempts to change social norms through social outreach events and education on HIV prevention (9). Informal outreach goals are also incorporated into this program, which include casual conversations about safe sex among friends and acquaintances in order to promote safe sex as a norm (8,9). Community centers were also established, as in traditional interventions, to form a community where young MSM can congregate for social, educational, and recreational events (9).
While the Mpowerment Project and other similar programs have had a lot of success, the incidence of HIV and AIDS has been increasing in the past several years (1,3). Between 2001 and 2005, there has been a 13% increase in new cases, which is thought to be due to unsafe sex practices in MSM (7). Many of these cases have been found to be in young MSM, which indicates a failure of the Mpowerment Program to create an effective prevention program (3,7). This failure revolves around the perceived threat of HIV and AIDS by young MSM, social considerations for the target population, and who is specifically apart of the target population.
Many young MSM currently do not feel an immediate threat from HIV or AIDS (5). These men have grown up in a time where HIV has had a treatment available, and so they are unaware of how severe the disease can be (5,6). The Mpowerment Project does educate about HIV, but it doesn’t put the risks in terms of what young men value most. Young MSM in present day are also faced with more social stigmas than older MSM have not had to face. Stigmas such as homophobia and family acceptance pressure young MSM to be accepted by the general population. The pressure that these stigmas place on young MSM can often cause them to ignore safer sex practices in order to maintain discretion (13). The Mpowerment Project works to create a small safe community for MSM, but doesn’t attempt to change the social stigma that is present outside of that community. The Mpowerment Project also does not include minoritiy MSM in its target population, who are thought to be those most at risk of having unsafe sex (7). Despite the initial strength of the Mpowerment Project, its several failures could be corrected by putting a more proximal frame on HIV, by addressing social stigmas outside of its own community, and by working to include minorities who are at most risk.

The Importance of a Frame
For any public health intervention, a frame is created regardless of whether public health officials consciously spent time creating one. A frame is described as a conceptual base that is used by the mind to help understand a notion (11). Anytime a word, image, event or anything else is perceived by the mind, it begins to create a frame so it can understand the perception and what it is referring to (17). In public health, framing is used to create context around an issue in order to make the intervention more appealing. For example, creating an underlying deception frame around smoking can make teenagers feel that smoking companies are deceiving them with advertisements. This underlying feeling will then cause teenagers to stop or not try smoking because they don’t want to be deceived (23). This kind of customized frame has been proven to make selling a product (public health, in this case) more effective (7,12).
AIDS in itself already has a frame associated with it, one that does not imply an immediate threat or convey the severity of the life threatening disease. The Mpowerment Project does not attempt to alter this frame or stress the threat associated with HIV. If the Mpowerment Project, in addition to attempting to normalize safe sex practices, adjusted the frame and made HIV seem more like a tangible threat, it would create a powerful message. This message would then discourage young MSM from engaging in unsafe sexual practices and make the Mpowerment Project more effective in reducing the incidence of HIV.
The impression that most young MSM have about HIV is that, while it is ultimately a deadly disease, most people are not affected by it (5,7). The advent of HAART, highly active antiretroviral dug treatment, has caused many young MSM to believe that HIV and AIDS is now a treatable disease (5, 6). Because of this misconception, they do not realize the importance of safe sex practices and sometimes decide to forego them (6,7). In order to counter this belief, the Mpowerment Project needs to reframe the issue in order to make it seem more relevant. Reframing issues are particularly effective when they involve an emotional aspect and such a frame could be created that depicts the harsh side effects of HIV/AIDS therapy (19). An example of this kind of frame could include images of young MSM having to take multiple medications a day, or the side effects of aggressive treatments. Another approach could include images of popular gay figures who have died from HIV and AIDS in order to remind young MSM that there is no cure for this virus. A new frame of this issue that incorporates the severe risks and images of popular loved ones who did not survive HIV and AIDS would discourage unsafe sexual activity. Including this new frame in the Mpowerment Project would make it a more effective intervention among young MSM.



The Impact of Social Stigma
The Mpowerment Project encourages the creation of a community within the program to create a sense of connection and belonging among young MSM(9). While this community is set up to provide a place that allows young MSM to be at ease with one another, the project does not address social factors that occur outside of this community. These social factors, which center around social stigmas, do not directly increase the risk of spreading HIV or AIDS, but cause young men at risk to not receive the intervention they need (14). Having to face these social stigmas is one of the largest challenges that MSM have to deal with, and this more distal, but equally important factor is not addressed by the Mpowerment Project (13). Several studies prove that the impact that social stigmas have on MSM hinder an individual’s participation in HIV/AIDS interventions, and thus increases their risk (13,14,15,20). Additionally, findings indicate dealing with stigma might lead to depression, poor self-esteem and in some cases cause a direct increase in risky behaviors (13). The Mpowerment Project does not address this issue, and thus does not address an important factor that contributes to an increase in HIV incidence.
Two of the most common stigmas that MSM must face are homophobia and family acceptance. Homophobia particularly affects MSM because an individual who knows that his community is afraid of him is in turn frightened of his community. Having a homophobic community can cause an individual to fear for his own safety and in order to any danger to himself from his community, he may hide the fact that he is a MSM. Hiding his sexuality makes it particularly difficult to then attend gay targeted outreach projects where the Mpowerment Project is working. This ultimately results in a MSM not receiving the intervention because of his community, and therefore puts him, and others in his situation at a higher risk of engaging in unsafe sexual practices. The family acceptance stigma is similar to that of homophobia. Most MSM believe that their family will not accept them if they admit to their sexual practices, and so they hide them. This prevents them from being able to be targeted by the Mpowerment Project, and therefore puts at higher chance of practicing unsafe sex.
In order to reduce the impact of these stigmas, the Mpowerment Project needs to not only target the homosexual community, but the whole community. Their campaign to raise awareness and normalize condom use should also attempt to encourage the acceptance of homosexuals. Once this is accomplished, individuals will be able to attend the interventions and begin changing their behavior. Through this addition to the Mpowerment Project, the program will increase its effectiveness and be able to decrease the incidence of HIV in young MSM.

Appropriate Targeting: Focusing on Minorities.
The Mpowerment Project has shown to have great success in all of the young MSM who were involved with it. Unfortunately, most of the participants involved were Caucasian (75% or more) and so minorities were not well represented (16). This disregard for minorities limits the Mpowerment Project’s ability to effectively change social norms in all young MSM. This neglect causes a large disparity between Caucasian young MSM and African American young MSM. In fact, it has been reported that approximately 3% of Caucasian young MSM are HIV positive, compared to approximately 14.1% of African Americans (14). This disparity could be treated if the Mpowerment Project targeted all young MSM, including minorities in its attempt to decrease HIV and AIDS incidence.
In order to effectively target these minority groups, considerations that affect non-minority MSM groups have to be considered, such as minority-specific stigmas, and different bar and club habits and locations. African American MSM have their own set of stigmas that impact their involvement. These stigmas are similar to those faced by the general majority, but are often more severe (20). Homophobia and sexual discussion in particular hold a stronger stigma in minority groups. As stated before, homophobia causes individuals to hide their sexuality, and therefore makes them unable to be apart of the Mpowerment Project. Because sexual discussion is also a strong stigma, there is even pressure in communities that are more accepting of homosexuality. In this kind of situation, no one talks about sexual activity, and so the major method of the Mpowerment Project is defeated because safe sex messages cannot spread.
In order to properly target minority groups, more research has to be done to investigate where minority MSM convene. These locations may not be similar to where majority MSM interventions can take place, such as in popular “main-stream” bars or clubs. When attempting to perform outreach in such a minority location, care has to be taken to not offend any of the different subculture. In order to make this transition easier, specifically recruiting minority persons could help to locate and understand potential minority outreach locations. By slowly accumulating minority MSM, attempts can be made to change the stigmas associated with being a MSM, as in the majority group. Doing this will make it easier for minority MSM, who are often the most in need of intervention, to participate in the Mpowerment Project and reduce the spread of HIV.

Conclusions
The goal of the Mpowerment Project is to reduce the transmission of HIV within the young MSM population by attempting to change social norms. This intervention has been very effective but has failed to consider changing trends in the MSM population that have begun to hinder the effectiveness of the program. Similar intervention programs have been criticized in the past for not altering techniques to accommodate new changes in culture (21). An intervention that does not recognize these changes and adapt to them slowly becomes ineffective. If the Mpowerment Project continues without adapting to these new trends it too will become ineffective and will not achieve its mission to decrease HIV incidence.
Adjusting current frames around HIV and AIDS, addressing stigmas, and beginning to target minority groups are all critiques that can be used to improve the Mpowerment Program. The use of framing theory has been proven to be effective in public health interventions as well as consumer marketing campaigns (11,18). Readjusting the frame around HIV will cause more young MSM to recognize the severity of HIV that was common during the beginning of the epidemic. Addressing stigmas will target a more distal cause of unsafe sex in the MSM community: it will allow MSM to feel comfortable with their sexuality and make them easier to target through the Mpowerment Project. Targeting minorities is also essential so that the subgroup most at risk will get the attention it needs to combat the high rates of unsafe sexual practices. Incorporating these suggested strategies will address the new concern about the increase in HIV incidence in young people. These new strategies provide a fresh look at the intervention that has been very successful so far, and will allow it to continue to be successful in the future.

Reference:
1.) Wolitski, et al. Evolution of HIV/AIDS Prevention Programs --- United States, 1981—2006. Morbidity and Mortality Weekly Report June 2, 2006 / 55(21);597-603
2.) Centers for Disease Control and Prevention. HIV AIDS Basic Statistics. Division of HIV/AIDS Prevention. National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention http://www.cdc.gov/hiv/topics/surveillance/basic.htm
3.) No Author. “H.I.V. Rises Among Young Gay Men” The New York Times. Jan 14, 2007 http://www.nytimes.com/2008/01/14/opinion/14mon2.html?_r=2&oref=slogin&oref=slogin
4.) Crepaz, et al. Highly Active Antiretroviral Therapy and Sexual Risk Behavior. Journal of American Medical Association. 2004;292:224-236
5.) Chen, et al. Continuing Increases in Sexual Risk Behavior and Sexually Transmitted Diseases Among Men Who Have Sex with Men: San Francisco, Calif. 19990-2001. American Journal of Public Health. September 2002, Vol 92, No. 9. 1387-1388
6.) Katz, et al. Impact of Highly Active Antiretroviral Treatment on HIV Seroincidence Among Men Who Have Sex With Men: San Francisco. American Journal of Public Health. March 2002, Vol 92, No. 3. 388-394
7.) Jaffe H, et al. The Reemerging HIV/AIDS Epidemic in Men Who Have Sex With Men. Journal of American Medical Association. 2007; 298(20): 2412-2414
8.) Center for AIDS Prevention Studies, University of California, SanFranciscoThe Mpowerment Project. San Francisco, CA. http://www.mpowerment.org/
9.) Hays, et al. The Mpowerment Project: Community Building With Young Gay and Bisexual Men to Prevent HIV. American Journal of Community Psychology. June 2003, Vol 31, Nos 3/4
10.) Coppola, et al. Preventing without stigmatizing: The complex stakes of information on AIDS. Patient Education and Counseling. Volume 67, Issue 3, August 2007, Pages 255-260
11.) Chua, K. Introduction to Framing. American Medical Student Association Website. February 10, 2006. http://www.amsa.org/uhc/FramingIntro.pdf
12.) Bakker AB. Persuasive Communication About AIDS Prevention: Need for Cognition Determines the Impact of Message Format. AIDS Education Prevention. 1999 Apr;11(2):150-62.
13.) Preston DB et al. The Relationship of Stigma to the Sexual Risk Behavior of Rural MSM. AIDS Education Prevention. 2007 Jun;19(3):218-30
14.) Frost DM, et al. Stigma, Concealment, and Symptoms of Depression as Explanations for STI Among Gay Men. Journal of Health Psychology. 2007 Jul;12(4):636-40
15.) Harawa NT, et al. Perceptions Toward Condom Use, Sexual Activity and HIV Disclosure Among HIV Positive African American Men Who Have Sex With Men, Implications for Heterosexual Transmission. Journal of Urban Health. 2006 Jul;83(4):682-94
16.) Kegeles SM, et al. Mobilizing Young Gay and Bisexual Men for HIV Prevention- A Two Community Study. AIDS. 1999 Sep 10;13(13):1753-62
17.) Valleroy, et al. HIV Prevalence and Associated Risks in Young Men who Have Sex. Journal of American Medical Association. 2000;284:198-204.
18.) Dorfman, et al. More Than a Message: Framing Public Health Advocacy to Change Corporate Practices. Health Education and Behavior. June 2005; Vol. 32(3): 320-336
19.) Professor Siegel
20.) Choi, et al. HIV Prevention Among Asian and Pacific Islander aMerican Men Who have Sex with Men: A critical Review of Theoretical Models and Directions for Future Research. AIDS Education Prevention 1998, Supplement A, 19-30.
21.) Stall, R. How to Lose the Fight Against AIDS Among Men. BMJ 1994 Sep 17;309(6956):685-6
22.) Centers for Disease Control and Prevention. The Mpowerment Project: A Community-Level HIV Prevention Intervention for Young Gay Men. Division of HIV/AIDS Prevention. National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention
http://www.cdc.gov/hiv/topics/prev_prog/rep/packages/mpower.htm
23,) Tengs, TO et al. The Cost Effectiveness of Intensive National School Based Anti-Tobacco Education: Results from the Tobacco Policy Model. Preventative Medicine. 2001 Dec; 33(6): 558-570.

HIV/AIDS Prevention Efforts Have Failed African-American Men – Megan Coffman

African-American men in the U.S. are at a greater risk of being infected with HIV/AIDS than other portions of the population because prevention efforts do not address the specific risks present in this community. African-Americans make up approximately twelve percent of the U.S. population; however, they represent nearly fifty percent of known AIDS cases and AIDS is the fourth leading cause of death among African-American men (1). The Centers for Disease Control and Prevention (CDC) estimates that almost 500,000 African-Americans are infected with HIV, which is almost 2% of the African-American population (1). This is nearly eight times the infection rate of Caucasians in the United States (2).
HIV/AIDS prevention efforts must be more directly targeted towards the African-American male community and conducted in a culturally appropriate manner. Since the HIV/AIDS epidemic first emerged a quarter century ago, the focus of HIV prevention has focused on white gay men. Not enough focus has been put on the specific needs of the African-American male community, and as a result, this population has been especially hard hit. The HIV/AIDS epidemic should be framed as a public health crisis that affects all communities, but that has a disproportionate impact on the African-American community. Public health and government officials must work together to reduce HIV/AIDS infections in African-American men and to inform all levels of government about the impact HIV/AIDS is having on it and the nation as a whole. The United States cannot effectively tackle the HIV/AIDS epidemic without dramatically reducing the number of HIV/AIDS infections in African-American men.

A Message that Resonates
Current prevention messages fail to promote a healthy, self-sufficient and HIV negative lifestyle as a realistic option for African-American men. The failure to represent African-American men in this manner is just one of the reasons HIV prevention messages have not gotten through to African-American men. Recently, there are have been efforts to reach African-American men through public health campaigns via local public health agencies and television companies. Some of these ads are smart, creative, and inspiring, but they have not been effective in reducing the number of African-American males with HIV nationwide. They lack essential elements of Communications Theory that would insure their message would be heard. Communications theory is quite simple: a sender packages a message, the message is sent to the recipient, and the recipient analyzes or distills the message. At present HIV/AIDS prevention efforts have not been packaged in a way African-American men want to analyze or decode.
The Rap-It-Up campaign is one of the most recognized HIV/AIDS prevention campaigns directed at African-Americans. The Kaiser Family Foundation and BET (Black Entertainment Television) are co-sponsors of the national Rap-it-Up campaign. According to Kaiser, the Rap-It-Up campaign is directed at all African-Americans of all age groups (3). However, many of the Rap-it-Up ads feature young, straight African-Americans. Some ads feature young men in school or hanging out with friends in the community. Others include young women texting one another about getting tested or heterosexual couples in a relationship discussing sexually transmitted infections and condom use. This leaves several particularly at-risk groups of African-American men unrepresented in prevention materials. None of the ads address men that have sex with men, men who have sex with multiple partners, or men over thirty. The campaign fails to reach all members of the African-American community because the message is only meant for a specific audience and does not resonate with the entire population. Being able to decode the messages that are being shared by any sender is a key element of Communications Theory. (4) If messages are not accessible to a variety of sub-groups within the African-American male population only small portion of the recipients will identify with the message.
Not only are the TV ads not representative of the broad spectrum of African-American men, they can be simply offensive. One Rap-It-Up print ad tells readers “Making smart decisions is easier than you might think”(5). As if making a smart decision is not an easy task. This message implies that African-American do not typically make smart decisions.
Another ad asks the audience to “Assume that everyone is positive” (5). Messaging like this may lead to negative assumptions about themselves and their communities and leaves them without hope that they are negative. If one assumes that everyone is positive, why bother trying to protect one self because if they are not already infected now, they will be soon. If one just assumes that their partner is positive, then they may not make an effort to have a healthy discussion about pregnancy, preventing other sexually transmitted infections, or the status of their relationship with their partner.
When Kaiser surveyed a small group of African-Americans over 18, the respondents listed HIV/AIDS as the most urgent health issue facing the country today. However, when they asked members of the survey group if they had ever discussed HIV/AIDS with any partner, nearly 40 percent responded no (6). This demonstrates a serious failure of these campaigns and illustrates why they have not been successful in sufficiently reducing the number of new infections within the African-American community.
The federal governments’ attempts to address HIV/AIDS in African-American men do not even try to tailor the message to African-American men. The CDC uses the same message to address HIV/AIDS among African-Americans as they with other demographics. Prevention advice listed on the CDC website for African-Americans includes: “Don’t have sex when you are taking drugs or drinking alcohol”, “Use only clean needles and syringes” when injecting drugs, and “Abstain from sex until you are in a relationship with only one person (7)”. These messages are exactly the same for other demographics and make no effort to incorporate African- American culture or beliefs in the message. Not to mention, these messages infer that message recipients are not leading a healthy lifestyle.
In addition to its generic messaging, the CDC is late in addressing the challenges facing men who have sex with men, but do not consider themselves gay. African-American men have been especially hard hit by the lack of prevention efforts directed towards men who have sex with men. There are increased cultural barriers facing men who have sex with men in the African- American community based on faith, family expectations, and tradition (8). The CDC addresses this specific group of men as particularly at risk, but does not present any specific ways in which to prevent HIV within this demographic (7).

The Right Frame
Early in the history of the epidemic, public health officials and political leaders framed the AIDS epidemic as a disease that only affected gay white men, and have failed to frame the HIV/AIDS epidemic as a threat to African-American men. Successful use of Framing Theory involves the ability of invested individuals to frame an issue in a specific way. Based on how the issue is framed determines how people will respond to the issue. Simplified: it is all in the presentation (9). Unfortunately, this mis-framing of HIV/AIDS as a disease of gay white men led other communities, especially African-Americans, to believe they were not at risk of HIV/AIDS infection and therefore did not need to take the necessary precautions. This association between HIV/AIDS and homosexuality hit the African-American community especially hard. The impact has been two-fold. Heterosexual men do not see HIV/AIDS as a risk, and therefore are not taking the necessary precautions to stop the spread of HIV.
The other component relates to widespread negative attitudes towards homosexuality within African-American communities (10), which see homosexuality as a taboo subject. It goes against gender role expectations, definitions of masculinity, community norms relating to sexuality, and is perceived as sinful and unnatural. Because of these community expectations, African-American men are less likely than Caucasian men to identify as being gay. Fear of being labeled gay prevents some heterosexual men from discussing condom use. This is because they are concerned that their female partner will think they are gay or bi-sexual, that they are having sex outside of the relationship, or that they have a sexually transmitted infection. This social stigma contributes to low rates of participation in HIV prevention services by gay, bi-sexual and straight men of color (10). All of these fears and expectations negatively impact the African-American community in their efforts to prevent the spread of HIV. If the HIV/AIDS crisis had been framed in a way that affected all people, African-American men would not be paying such a heavy price now.

Setting the Record Straight
The media, public health officials and political leaders have failed to identify HIV/AIDS among African-American men as a crucial part of public health efforts. The responsibility to raise this issue falls squarely on political leaders, public health officials, and the media. Without their concern and influence African-American men will continue to be infected with HIV at rate 8 times that of their Caucasian counterparts. The United States has made fighting HIV/AIDS in the developing world a priority, and now it must do the same at home. President Bush hopes to spend $30 billion on fighting HIV/AIDS in Africa over the next five years. The president should be commended for these efforts abroad, but he and other leaders are missing the crisis right here at home (11).
All over the country individuals are trying to spread the word of the crisis with in the African-American community. Paula Silvestone, the Executive Director of AIDS Rochester, believes that “We need people on the streets, mass media campaigns, black leaders, black ministers who step up to the plate and talk about this (12).” Her call is being echoed in communities across America. Members of the National Medical Association, a professional association of African-American physicians, have called on the President to take action now to create a national plan to prevent HIV/AIDS in the United States before the crisis spirals further out of control (13). Unfortunately, the public health community and government officials have failed to heed this call and exert their influence to utilize agenda setting theory in informing and educating the public on this health crisis. The application of agenda-setting theory influences mass-news media to determine what stories will be told or what information the media will share (4). As of yet the media has not deemed the HIV/AIDS crisis in African-American men as important and relevant to the public as a whole. Failure to appropriately influence the media on the severity if HIV/AIDS in African-American men being especially hard.
In addition to raising the issue of HIV/AIDS prevention, the public health community must address the fear and skepticism that many African-American men feel towards the U.S. government and pubic health clinics. Misconceptions about the epidemic and a general mistrust of the public heath and political establishment contribute to the lack of effective communication and testing efforts. Common myths about HIV among the African-American community include: a cure exists, but the government refuses to share it with the poor; like syphilis, HIV was engineered in a lab and is part of a larger strategy to kill African-Americans and destabilize the community. Those that believe strongly in the HIV/AIDS conspiracy theories are less likely to utilize condoms consistently (14). African-American men continue to be reluctant to have their blood drawn and tested in public clinics for fear of being exploited (14). Until the public health community can frame their efforts as a way of helping African-American men instead of exploiting them they will continue to see limited progress in HIV/AIDS prevention efforts (15).
Public health practitioners and local leaders have failed to gain a better understanding of how the HIV/AIDS epidemic is affecting their community. More often than not, the solutions are within the community, but they need some of the resources to support their ideas. A number of common community solutions that have proven successful in other contexts, but that local leaders have still failed to utilize, include partnering with schools, clubs, sports teams, churches and mosques, community organizers, and radio stations at the local level to incorporate community driven efforts (14); encouraging community members to write Op-ed pieces in the paper or on-line, contact local news outlets, and tell their own story regarding the need for more resources in the fight against HIV/AIDS; putting pressure on elected officials.

Bringing the Message Home
Creating effective HIV/AIDS prevention outreach campaigns, appropriately framing the HIV/AIDS crisis in America, and setting the agenda on a local, state, and national level will help to reduce the number of African-Americans infected with HIV/AIDS. The failure to do so has led to an HIV/AIDS crisis among African-American men. Going forward, more HIV prevention messaging must be utilized that resonates with all members of the African-American male community, and does not stigmatize men who have sex with men, utilize drugs, have been imprisoned, or feel like an outsider. African-American men must be represented as being healthy, self-sufficient, and HIV-negative in order for prevention efforts to be effective going forward. It is important that public health practitioners recognize some of these barriers to change within the African-American community and frame their message appropriately. Public health advocates must remember to consider their target audience and how they present their case has an impact of how their audience will respond. Who do they want to make a change? What is the desired outcome of the message? How will individuals benefit from the change? What is needed to convince members of the community that they will benefit? How will the message be dispersed (16)?



References
1.“Fact Sheet: Black Americans and HIV/AIDS” Kaiser Family Foundation. March 2008. http://www.kff.org/hivaids/upload/3029_08.pdf
2. “Out of Control: AIDS in Black America.” ABC news.com. August 23, 2006. http://abcnews.go.com/Primetime/story?id=2346857&page=1
http://www.cdc.gov/hiv/topics/aa/protection.htm
3. Kaiser Family Foundation website: Entertainment media Partnership. Rap-It-Up. http://www.kff.org/entpartnerships/bet/
4. Edberg, Mark. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Boston. Jones and Bartlett. 2007.
5. Kaiser Family Foundation: Entertainment Partnerships Site. 2007. Kaiser Family Foundation. 15 April 2008. http://www.kff.org/entpartnerships/bet/psas.cfm
6. “Assessing Public Education Programming on HIV/AIDS: National Survey of African Americans.” March 2004. http://www.kff.org/entmedia/upload/Assessing-Public-Education-Programming-on-HIV-AIDS-A-National-Survey-of-African-Americans.pdf
7. “What can African-Americans Do?” Centers for Disease Control and Prevention. March 8, 2007.
8. Bogart, Laura and Sheryl Thorburn, “Relationship of African Americans’ Sociodemographic Characteristics to Belief in Conspiracies about HIV/AIDS and Birth Control” Journal of the National Medical Association. Vol 98, NO 7 July 2006.
9. Siegel, Michael. Social & Behavioral Sciences in Public Health. School of Public Health, Boston University. Boston, MA. 14 February 2008.
10. Brooks, Ronald A., PhD., and Mark A. Etzel, M.P.P., Ernesto Hinjos, M.P.H., Charles Henry, and Mario Perez. “Preventing HIV Among Latino and African American Gay and Bisexual Men in a Context of HIV- Related Stigma, Discrimination, and Homophobia: Perspectives of Providers.” AIDS Patient Care and STDs. Volume 19, Number 11, 2005.
11. Bolton, Warren. “Blacks silent as HIV/AIDS attack through their communities.” The State, Columbia, S.C. 6 March 2008.
12. Wang, Justina. “Lack of voice gives life to persistent killer.” Rochester Democrat and Chronicle, Rochester, N.Y. 1 April 2008.
13. Adams, Nelson L., and Mohammad N. Akhter. “Op-Ed: Fight AIDS here at home.” Appeal- Democrat, Marysville, CA. 1 March 2008
14. King, William. “Examining African Americans’ Mistrust of the Health care System: Expanding the Research Question.” Public Health Reports. Volume 118, July-August 2003.
15. Healthy People 2010. U.S. Department of Health and Human Services. 15 April 2008. http://www.healthypeople.gov/default.htm
16. Siegel, Michael and Lynne Doner. Marketing Public Health. Sudbury: Jones and Barlett, 2004.

Needle Exchange Programs: An Unrealistic Approach to Decreasing Rates of HIV/AIDS – Elyssa Pesin

The HIV/AIDS Epidemic
Human Immunodeficiency Virus (HIV), the virus that causes AIDS, attacks the immune system, leaving the body vulnerable to a variety of life-threatening infections and cancers [1]. This devastating disease is the focus of many public health interventions in the United States, especially among intravenous drug users (IDUs), a recognized risk group. Nevertheless, current efforts are inadequate to address the complex risks associated with injection drug use, particularly among disadvantaged populations [2]. The nature of intravenous drug use, specifically the process of preparing and injecting drugs, is conducive to the spread of HIV. As the CDC reports, “many opportunities for contamination with and transmission of HIV or other blood-borne viruses” exist among IDUs, due to the mechanics of drug injection [3].

Introduction: A Public Health Intervention
Needle Exchange Programs (NEPs), in which IDUs exchange dirty needles for clean replacement needles, are intended to be a critical strategy for containing the spread of HIV and other blood-borne diseases within this population. However, issues relating to social and behavioral sciences, differences in socioeconomic stratum and sociopolitical issues contribute to the failure of implementation in the United States. Contrary to the 1980’s United States Drug Campaign known as the “war on drugs,” using the slogan “Just say no,” the NEPs’ ideology is based on “Just say yes,” as these programs prioritize HIV/AIDS prevention over reducing drug use.
In a social and behavioral context, the Health Belief Model (HBM) was developed to explain health-related behavior at the individual, decision-maker level. The focus of this model is preventative health behavior of individuals, assuming that human behavior is determined by an objective, logical thought process. HBM includes four concepts: “perceived susceptibility,” “perceived severity,” “perceived barriers to taking that action,” and “perceived benefits of an action” [4]. With regard to NEPs, the former three concepts are skewed and lead to NEP failures. First, instead of realizing that the perceived susceptibility of drug use is the chance IDUs will overdose, develop neurological problems, or acquire multiple chronic and acute illnesses, the perceived susceptibility is the realization that IDUs could only contract HIV/AIDS through dirty needles. Second, IDUs overlook the perceived severity, that is, how severe the effects of transmitted diseases might be, as they continue to use drugs and reject other ways blood borne diseases are transmitted - through sexual contact [5]. Lastly, the perceived barriers and costs of emotionally and financially supporting drug use are overlooked by NEP creators and supports. Interestingly, NEPs use an HBM limitation to their advantage – that is, if drug users have the intent to do a particular behavior, they will do it. Thus, NEPs are structured around the susceptibility to HIV/AIDS and the perceived benefits of preventing the transmission of the disease through shared needles.
By expecting drug-users to seek out these programs on their own using undersupplied and underprovided distribution methods and providing limited geographic locations, needle exchange programs fail to decrease HIV/AIDS through shared needles within the IDU population. More specifically, failures of NEPs can be seen in their inability to reach many drug users due to geographic disparities, broad target populations, and limited distribution strategies.

Reason for Failure #1 – Geographic Disparities
Failures of NEPs are attributed to several different models of social and behavioral science. First, the Stages-of-Change model applies to IDUs who utilize NEPs, who realize they engaged in drug use, who contemplated the risks of intravenous use, and who decided to address those risks by participating in a needle exchange program. Nevertheless, the “action” and “maintenance” stages of change in NEPs, where individuals begin to engage in a new behavior and attempt keep that pattern going or sustain the new behavior respectively, is flawed [6]. This relates to an IDUs use of NEPs, as research shows there are inconsistencies in location, equal distribution of supplies, and accessibility [7]. As a result, IDUs are not able to engage in and maintain this new behavior consistently. Herein lies the first problem: NEP geographic disparities.
Geographic disparities in access to NEPs present clear difficulties to program utilization. Indeed, NEP locations do not always correspond to a demand for such a program in the area. In 1999, a study reported the existence of NEPs in 81 cities and 31 states as well as the District of Columbia. The study concluded that many of these programs were heavily concentrated in four states: California, New York, Washington, and New Mexico. Yet, data suggest that New Jersey – a state with high demand for NEPs –disproportionately lacks in access to these programs [8]. As Barbara Tempalski reports, “injection drug use is the most frequent reported risk behavior among HIV-positive individuals” in New Jersey, and in Jersey City, Newark, and Bergen-Passaic have some of the highest rates of IDU related AIDS in the country [9].
Even within existing NEPs, inequalities in supplies inhibit the efficacy of these programs; twelve of the largest programs, for example, receive 62 percent of available syringes, leaving other NEPs without adequate supplies [10]. The unequal distribution of NEPs and NEP-related resources do not address disparities in HIV prevalence among socially disadvantaged groups or the geographical distribution of IDUs.
One last social and behavioral theory can be attributed to the first reason for NEP failure. The last several stages of the Diffusion of Innovations (DOI) theory are interrupted, as the NEP geographic and inventory shortages prohibit the success, wider implementation, and unrestrained use of this public health intervention. Within the DOI theory, the “adoption process,” is affected by insufficient locations, supplies, and geographic representation, prohibiting the “uptake” of the behavior by IDUs. According to this principle, “uptake” requires movement through knowledge of NEPs, persuasion or attitude development (about adopting behavior), decision (to adopt behavior), implementation, and confirmation, and none of these steps can occur, as NEPs fail to be equally accessible or sufficiently equipped [11].

Reason for Failure #2 – Broad Focus
Two additional social and behavioral principles can be applied to a second reason for NEP failure. On one hand, the success of NEPs relies largely on selecting a target population, where IDUs among different socioeconomic strata are the targets. The widespread use of the intervention relies on these social groups or networks to communicate the benefits of the program. On the other hand, failure to account for the “political economy,” which has an important bearing on why and how people do what they do, and consequently, how people change what they do, affects the efficacy of NEPs [12]. Both political economy and behavior are factors that must be addressed when assessing the inadequate and very broad focus of NEP interventions as it contributes to the crisis of HIV/AIDS in poor, urban communities. Because HIV/AIDS has such a disproportionate effect on poor, minority, and urban communities, NEPs are suffering because they frame HIV/AIDS as just a health problem, rather than the product of a larger set of social relationships, particularly relationships of socioeconomic structure, class, ethnicity, and gender [13]. Consequently, the NEP failure is rooted in its very broad focus, as they do not take into account the aforesaid larger set of social and political relationships.
Despite drug regulation, illegal drug use continues among the underserved and the needs of those who seek prevention or treatment have not been met. As Dr. Adewale Troutman states in his on-line tutorial Creating Health Equity Through Social Justice, “the existence of social injustice typified by the continued growth of the gap between the have and the have-nots, lack of access to services and care, preventive and curative is unethical and immoral” [14]. This inequality is ever-present among IDUs. According to Richard Hofricter, although overall life expectancy has increased and mortality rates have decreased in the twentieth century, “an increasing level of inequality in the health status and mortality of those with less material resources in relation to their social class, particularly in ‘communities of color’ persists” [15]. Moreover, disadvantaged groups do not benefit equally from advances in HIV and AIDS intervention, treatment and prevention.
While the HIV/AIDS epidemic has had a disproportionate impact on certain populations, particularly racial and gender minorities, NEPs do not effectively narrow their focus among these groups. Within the IDU population, disadvantaged groups are especially vulnerable to HIV infection. In certain racial and ethnic groups, half of the deaths due to HIV in both African American and Latino populations can be attributed to injections with contaminated needles. Furthermore, African American IDUs are 5 times as likely, and Latinos are 1.5 times as likely as white IDUs to develop AIDS [16]. These statistics highlight the limitations in the breadth of NEP, as programs do not have specific strategic plans to reach each group.
The African American experience portrays an obstacle that NEPs do not address or overcome with regard to ethnicity. African Americans are increasingly vulnerable to the transmission of HIV/AIDS. With this, another social and behavioral principle accounts for the larger HIV/AIDS cases in this group: the Social/Environmental Context, and more specifically within this context, the Historical Context. Historically, African American communities have greatly opposed NEPs as a consequence of their distrust of the government and medical trials in general. According to Stephen Thomas, African Americans’ adverse response to NEPs is connected to the “persistent neglect of the drug abuse epidemic, mistrust of public health authorities, and fear that the broader society may consider large segments of the black population expendable consumers of scarce human and economic resources” [17]. Many of these opponents worry that needle exchange programs will ultimately lead to Tuskegee-like abuse of research subjects [18]. Within many African American communities, NEP initiatives are held in high suspicion due to historic exploitation and discrimination [19]. With these factors, one can observe that throughout various segments of the American public, NEPs prove controversial. This Social/Environmental Context is relevant, as the Tuskegee-mentality is shared across this group, contributing to an African American experience made up of historical influence and personal experience interacting with the environment that inhibits this group from utilizing NEPs [20]. The failure of NEPs in this group is rooted in the history of the African American experience for which NEPs do not account.

Reason for Failure #3 – Methods of Distribution and Legal Implications
A third reason for the failure of NEPs lies in their distribution strategies, which are neither private nor anonymous. When using NEPs, IDUs must make themselves publicly available to the needle “exchanger” and must make behavioral changes through regular needle exchanges. For this reason, there is a great deal of social and personal responsibility, motivation and social and personal acceptance of help. The two primary methods of delivery are fixed NEPs located in pharmacies or health and community centers and NEP vans that drive through areas with known groups of IDUs [21][22]. Both of these methods of delivering exchange services require IDUs to seek out needle-exchange programs, which deter many from utilizing them. For this reason, drug-users typically refrain from using NEPs, consequently transmitting disease.
Many states have opted to utilize pharmacies in addition to local community centers to allow IDUs to obtain sterile syringes if businesses choose to participate. Nevertheless, while the pharmacy model has been shown to dramatically reduce the risk associated with IDU, not all geographic areas have benefited from these programs. For example, in New York, it is legal for pharmacies and other organizations to register and to provide up to ten syringes to individuals over the age of eighteen without prescriptions [23]. However, many pharmacists have refrained from participating in such services due to personal beliefs of fear that the presence of IDUs are detrimental to their businesses [24]. Moreover, the exchange of syringes in this model is not necessarily free, so many IDUs are unwilling or unable to participate [25]. For this reason, implementation of the pharmacy exchange model has been piecemeal and inadequate, contributing to the failure of NEPs in pharmacies.
Mobile exchange services are the second method of distribution which intend to reach more drug users. These mobile programs, which have predetermined van routes, are interventions for including hard-to-reach individuals and those who do not typically access mainstream services. For instance, an analysis of a 1997 Baltimore program revealed that mobile services attracted twice as many high-frequency injectors as pharmacy programs [26]. Furthermore, a study of the Vancouver program, which consisted of a variety of different facilities, reported that 65 percent of participants obtained some of their needles from the van and 17 percent used the van as their main needle source. Typically, users of this mobile exchange injected more frequently, were younger, more likely to engage in prostitution, and less likely to enroll in a drug treatment plan [27].
The mobile exchange model, whose intention is to reach those who are unable to access participating pharmacies, has several limitations [28]. First, the mobile programs offer fewer opportunities for counseling and other educational service, as the mobile programs do not afford lengthy time intervals during which the staff and clients can interact. Second, in the case of the San Diego, California NEP, IDUs refrained from visiting this site because legislation fails to protect IDUs from state laws prohibiting the transport of drug paraphernalia. In fact, reports confirm that law enforcement officers wait outside NEPs and arrest individuals suspected of carrying syringes [29]. Two social and behavioral theories, the Social Cognitive Theory and more specifically the Social/Environmental Context applies to the existing laws pertaining to drug paraphernalia in each state [30]. Drug paraphernalia laws, which exist in all states except Alaska, hinder the sale, distribution, purchase, and possession of syringes. In fact, 20 states have drug paraphernalia laws that are used against IDUs who possess a syringe [31]. Additionally, pharmacies may implement their own requirements and regulations that inhibit access [32]. The fear that this regulatory environment and existingpolicies instill in IDUs prevents them from accessing either method of distribution, even though the presence of these programs is acceptable. A third theory known as Political-Economic Space - a space that is governed by a specific political system, with regulations, values, and procedures –applies to the existing regulations and laws that affect health [33]. In this framework, many states, even those that support NEPs, continue to restrict the sale of syringes to pharmacies and require IDUs to have a prescription, provide valid identification, or disclose their reasons for purchasing the syringe [34]. This barrier to access is associated with the Political Economy, as NEPs encompass a wide range of theory and history about the links between politics and behavior, and their functions in society [35]. While NEPs focus on reducing disease transmission through sharing needles among IDUs, NEPs have failed to address the legal implications of the program such that the legal framework and Political Economy deter users for fear of identification and police harassment.
The lack of anonymity in these two methods of distribution makes IDUs vulnerable to the ever-present legal and regulatory barriers to access and to possess sterile syringes. Barriers include: drug paraphernalia laws, syringe prescription laws (both of which place restrictions on syringe exchange programs), pharmacy regulations and practice guidelines, fear of identification and police harassment - presenting obstacles to participation and decreased disease transmission. Further, the fear instilled in IDUs is largely derived from a Social Cognitive Theory known as Reciprocal Determinism, in which a person acts based on individual factors and social environment cues, receiving a response from that environment, and adjusting behavior accordingly [36]. In this fashion, IDUs act based on their personal responsibility and motivation to use NEPs, but ultimately react to the negative “cues,” that is regulation and punishment for attempting to use this intervention. Lastly, the concept of Self-Efficacy applies, as IDUs’ past experiences with NEPs will affect whether they are motivated to use this intervention. IDUs with low Self-Efficacy regarding NEP use may feel more hesitation, and when they actually use the program, may be reluctant to use it for fear of being punished. Once IDUs feel comfortable and confident in their chosen NEPs, this sense of Self-Efficacy may help the IDU continue this intervention and spread the word about NEPs in their networks [37].

Conclusion
NEP programs, meant to decrease HIV/AIDS transmission, are unsuccessful not only structurally, but also for reasons surrounding social and behavioral sciences, socioeconomic strata, and sociopolitical issues. More specifically, NEPs fail to address their geographic disparities, political patterns, and relationships of ethnicity that contribute to the efficacy of this intervention. This intervention fails to identify groups of IDUs on which to focus their strategies, as the target population is much too large to see positive results, that is, a decrease in HIV/AIDS transmission. After this assessment, it is clear that HIV/AIDS affects a wide-ranging population of potential NEP users who, in one form or another experience barriers to access.

References
1. Centers for Disease Control and Prevention. Prevention Among Injection Drug Users. US Department of Health and Human Services, January 2007. http://www.cdc.gov/idu/default.htm. Date accessed: 27 Mar 2008
2. Ibid.
3. Ibid.
4. Rosenstock, Irwin M. Ph.D. Historical Origins of the Health Belief Model. Health Education Monographs 2 (4): 328-335, 1974.
5. Centers for Disease Control. op.cit.
6. Prochaska JO, Reding CA, Evers KE. The transtheoretical model and stages of change. In: Glanz K, Rimer BK, Lewis FM, eds. Health Behavior and Health Education, 3rd ed. San Francisco, CA: John Wiley & Sons; 2002.
7. Centers for Disease Control and Prevention. Epidemiology of HIV/AIDS—Unites States, 1981- 2005. Morbidity and Mortality Weekly, 55(21):589–592, June 2006.
8. Robert E. Fullilove and Mindy Thompson Fullilove. HIV/AIDS in the African American Community: The Legacy of Urban Abandonment.
9. B. Tempalski, P.L. Flom, S.R. Friedman, D.C. Des Jarlais, J.J. Friedman, C. McKnight, and R. Friedman. Social and Political Factors Predicting the Presence of Syringe Exchange Programs in 96 US Metropolitan Areas. American Journal of Public Health, 97(3):437, 2007.
10. M.P. Singh, C.A. McKnight, D. Paone, S. Titus, D.C. Des Jarlais, M. Krim, D. Purchase, J. Rustad, and A. Solberg. Update: Syringe Exchange Programs–United States, 1998. Morbidity and Mortality Weekly Report, May, 18:384–87, 2001.
11. Rogers EM. Diffusion of Innovations, 4th ed. New York: Free Press; 1995.
12. Edberg, Mark, Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett, 2007, 72.
13. Bandura A. Social Learning Theory. Englewood Cliffs, NJ: Prentice Hall;
1977.
14. Adewale Troutman. Creating Health Equity Through Social Justice. Satellite broadcast originally aired February 20, 2003.
15. R. Hofrichter. Health and Social Justice: Politics, Ideology, and Inequity in the Distribution of Disease. Jossey-Bass, 2003.
16. Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report. US Department of Health and Human Services, 2004.
17. S.B. Thomas and S.C. Quinn. The Burdens of Race and History on Black Americans’ Attitudes toward Needle Exchange Policy to Prevent HIV Disease. Journal of Public Health Policy, 14(3):320–347, 1993.
18. Ibid., p337
19. Ibid., p343
20. Edberg, Mark, Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett, 2007, 52.
21. Institute of Medicine of the National Academies. Preventing HIV Infection among Injecting Drug Users in High Risk Countries: An Assessment of the Evidence. The National Academies Press, 2006.
22. Riley E.D., M. Safaeian, S.A. Strathdee, M.A. Marx, S. Huettner, P. Beilenson, and D. Vlahov. Comparing New Participants of a Mobile Versus a Pharmacy-Based Needle Exchange Program. JAIDS Journal of Acquired Immune Deficiency Syndromes, 24(1):57–61, 2000.
23. Institute of Medicine of the National Academis. op.cit.
24. Institute of Medicine of the National Academis. op.cit.
25. Institute of Medicine of the National Academis. op.cit.
26. Riley, E.D. op.cit. p59.
27. M.W. Tyndall, J. Bruneau, S. Brogly, P. Sptal, M.V. O’Shaughnessy, and M.T. Schechter. Satellite Needle Distribution Among Injection Drug Users: Policy and Practice in Two Canadian Cities. JAIDS Journal of Acquired Immune Deficiency Syndromes, 31(1):98–105, 2002.
28. Riley, E.D. op.cit. p60.
29. Kaiser Family Foundation. Syringe Exchange and AB 136: The Dynamics of Consideration in Six California Communities, February 2002. Pub 6018.
30. Bandura A. Social Cognitive Theory: an agentic perspective. Ann Rev
Psychol. 2001;52:1-26.
31. T.S. Jones and P.O. Coffin. Preventing Blood-Borne Infections Through Pharmacy Syringe Sales and Safe Community Syringe Disposal. Journal of the American Pharmacists Association, 43:6–9, 2002.
32. Ibid., p 6-9.
33. Edberg, Mark. op. cit. p52.
34. Ibid., p52.
35. Ibid., 72.
36. Bandura A. The Self System in Reciprocal Determinism. Am Psychol. 1978; 33:344-358.
37. Bandura A. Social Learning Theory. op. cit.

“Get Tested” Campaigns Should Get Lost: Many Ads Encouraging HIV/STD Testing in Young Adults Fail to Make the Grade – Monica Morrison

It is estimated that for every four teens that have become sexually active, at least one of them will contract a sexually transmitted disease (STD) every year, amounting to roughly four million cases annually. In fact, people under age 25.4 account for approximately half of all new HIV infections in the United States (1). Public health professionals have begun targeting this group with interventions promoting abstinence, safe-sex practices, and encouraging HIV/STD screening. The public health community has been especially successful in getting the issue onto the national agenda and gaining attention from the media. Such efforts help to raise public awareness around this issue.

Recently, encouraging HIV/STD testing has become a cornerstone of many interventions trying to stop the spread of these diseases. Campaigns created by several public health organizations across the country prompting young people to “Get Tested” can be found in magazines, on the television, on the radio, and in other forms at increasing rates. It has been a great initiative, seeing as many people who transmit HIV or other STDs to their partners do so unknowingly. According to a report given at the National HIV Prevention Conference in 2005, it was estimated that 25% of those infected with HIV are unaware of it (2). However, the ways in which these campaigns aim to encourage testing are, for the most part, based on ineffective models of behavior, and they do not consider all of the factors affecting whether or not a person will choose to be tested. Also, many of these campaigns bombard the audience with facts and statistics to get their attention and to demonstrate why testing is so important. However, by only playing to their targets’ intellect, they fail to generate an emotional response to the subject. These ads may not affect young people as strongly as other campaigns that are not based on the typical health behavior models and help to evoke an emotional connection to the issue.

Right Idea, Wrong Approach
Many ineffective campaigns attempting to encourage young people to be tested for STDs and HIV are based on traditional behavior models, particularly the Health Belief Model. According to the Health Belief Model, behavior is determined by an individual’s weighing of the benefits of doing a behavior, which are influenced by the perceived susceptibility and perceived severity, and the costs of doing a behavior. Consideration of the benefits versus the costs leads to their intentions regarding the behavior, which then directly determines whether or not they will do the behavior (3). This model predicts behavior at the level of the individual and relies on a rational thinking process.

The “Don’t Think. Know.” Campaign developed by the Los Angeles County Department of Public Health is a great example of an ad based on the Health Belief Model. The ads feature a young woman standing confidently by the phrase “I know.” Other phrases surround her including “that hooking up can have a downside,” “that over 35,000 women in the LA County get chlamydia and gonorrhea every year,” and “that it’s important to get tested for chlamydia and gonorrhea.” The ads also urge the audience to “KNOW the facts,” “KNOW about testing” and “KNOW what you can do” (4).

The “Get Real. Get Tested.” Campaign implemented by the North Carolina Department of Health and Human Services is another example. The statewide campaign is designed to educate people about HIV and AIDS and to encourage screening. A press release announcing its implementation explains that “the TV spots give people fast facts about HIV/AIDS and getting tested” (5).

These campaigns, based on the Health Belief Model, count on rational decision making by their audience to influence testing behavior. They rely on the fact that once their targets “know” all about STDs and testing, they will intend to get tested. And as the Health Belief Model states, intention to do a behavior leads directly to doing the behavior. However, this is not always the case because many other factors contribute to this decision (6). A person’s attitudes, beliefs, and emotions about the behavior, their up-bringing, their environment, and social norms are just a few influential factors that are not accounted for by the Health Belief Model and are not considered in these campaigns. Ads such as these are doomed to fail because they use only facts and figures to encourage young people to get tested.

Other Factors to Consider
These campaigns fail to recognize and, therefore, to address other aspects of an individual’s decision-making process such as social and emotional factors. Based on the Health Belief Model, many campaigns, like the previous examples, assume that the costs and benefits are the only factors upon which individuals base their decisions of whether or not to get tested for HIV and STDs (7).

In a 2004 study examining the barriers to screening and utilization of other STD services for young adults, several focus group discussions were conducted consisting of individuals from varying ethnic and social backgrounds with ages ranging from 14 to 24. One deterrent from being tested mentioned frequently was “the feeling of shame” associated with visiting a testing center. Many participants were concerned about being seen entering a testing center and/or about the level of confidentiality that was maintained by the clinic (8). Another study identified the stigma attached to HIV/STD testing to be a primary barrier to testing (9).

Emotions such as fear and anxiety are also factors that play a role in making the decision to get tested. If an individual has never been through the screening process before, their fear of the unknown may outweigh their perceived need to be tested. In some cases, prior knowledge of what the tests entail can also scare young people away. In the first study mentioned previously regarding barriers to testing, “almost all male participants expressed a strong aversion to urethral swabs as a specimen collection” method. For many female participants, the expected fear and anxiety concerning the whole process including the test results themselves was also a deterrent. They stated that it was very important for a clinic or testing center to offer “health education and counseling services at the time of screening or testing” (8).

One campaign that successfully addresses these other factors is the “It’s Your (Sex) Life” campaign co-developed by the Kaiser Family Foundation and MTV (10). The success of the campaign can be attributed to incorporating principles of social expectations theory, which basically states that behavior can be influenced by an individual’s perception of social and cultural norms, and because the mass media depicts these norms they can, therefore, influence an individual’s behavior (11). The campaign’s goal is unique in that it aims to encourage HIV/STD testing among young people not by appealing to their intellect and rationality, but by attempting to change the social and cultural norms surrounding testing, making it more socially acceptable. Short segments airing on MTV News depict their peers being tested for HIV and/or other STDs. One segment follows a young couple as they go to be tested for HIV together and another follows a popular MTV News anchor, Gideon Yago, as he is tested for STDs (12,13).

Not only are these segments recognizing the social factors that go into the decision to get tested by attempting to change the norms associated with the behavior, but they are also acknowledging the emotions that may act as deterrents to being tested. By increasing the social acceptability of being tested for HIV/STDs and normalizing the behavior, the feelings of shame that accompany going to a testing clinic can be diminished. In addition, by following their peers through the entire process of being screened for HIV and STDs, from the pre-test consultation, to the test itself, and then to the results and post-test consultation, feelings of fear and anxiety are subdued and the target audience now knows exactly what they can expect when getting tested.

Forming An Emotional Connection
By only connecting with their targets on a facts and statistics basis, most of these campaigns fail to generate an emotional response from the audience to the issue, and as a result, they may not affect young people as strongly. In order for young people to realize the importance of being tested, they have to care about it. They need to feel how this issue affects them on a personal basis. For example, telling them that this particular number of people contracts an STD every year or that the rate of infection is increasing this much every day will not affect them as strongly as finding out that their best friend is HIV positive or that their significant other has an STD. The strength of the influence that a testing campaign has on its audience depends on the way in which the issue is framed. Framing theory explains that the same message can be perceived several different ways when it is presented from different perspectives and/or using varying approaches to the subject. Basically, “it’s not what you say; it’s how you say it” (14). Campaigns trying to frame testing in a way that will evoke an emotional connection from the target audience to the issue will be more successful than those that do not.

The “It’s Your (Sex) Life” campaign mentioned previously is a great example of a campaign that effectively uses framing theory to generate an emotional connection in young people to HIV/STD testing. One segment shows the day-to-day lives of real young people who are HIV-positive, and that these people could be your neighbor, your best friend, your classmate, etc (10). This helps to drive home that anyone can be affected by HIV, whether directly by being infected by the virus or indirectly by just knowing someone who has. The way that testing is framed in these ads makes young people care about it and brings the issue down to a personal level, where facts and figures alone cannot.

Recent research conducted by the Kaiser Family Foundation to determine the effects of the campaign have shown that it has been successful in increasing HIV/STD testing among young people. In a report summarizing this research it was stated that “65% of those ages 16-24 who have seen the ads say that they are much more likely to be tested for HIV and other STDs. [And] 24% of those ages 16-24 who have seen the ads said that they have been tested for HIV or other STDs as a result of the campaign” (1).

Implications
In order to be successful in future endeavors attempting to encourage HIV/STD testing behavior in young people, we must move away from using the traditional behavioral models, like the Health Belief Model, and towards using alternative models, such as framing theory and social expectations theory. One main advantage that these models have over the traditional Health Belief Model is that they do not focus on changing behavior at the individual level but rather at the group level. This alone is a major factor in the success of those ads that have been based on the alternative models. Changing the behavior of the group is a much more powerful strategy than targeting only individuals.

Social expectations theory, specifically, should be the foundation of these campaigns. With an issue such as HIV/STD testing, reason and rationality are not the major players in making the decision to be tested. Because there is an undesirable stigma attached to testing and to the people who are seen at testing centers, this behavior is not the social norm yet. This is one of the major barriers for young people to testing. With the use of Social expectations theory, campaigns can help to normalize this practice and make it more socially acceptable. In doing so, it will help to lessen any feelings of shame or embarrassment that testing may produce, thereby eliminating a barrier to testing. In addition, by normalizing testing behavior, feelings of fear and anxiety concerning the test itself will not diminish altogether, but they may be dominated by the perceived need to be tested. For example, women do not necessarily look forward to annual visits to their gynecologist to be screened for cervical cancer, nor do people joyfully anticipate getting vaccinations, but these services, as being considered part of a normal healthcare regimen, are viewed as necessary evils. An individual’s fear and anxiety regarding these prevention procedures do not overshadow their perceived need to be tested and lead them to avoid the situation altogether, as they do in the case of HIV/STD testing.

In Conclusion
Public health professionals can continuously push sobering facts and figures onto young people, but until the social norms surrounding HIV/STD testing are changed, and it can be viewed as part of routine health care, their messages will do little to change testing behavior. In order to create successful and effective campaigns to encourage testing, we have to abandon the typical strategies that have been used thus far. These new campaigns should show young people that their peers are getting tested, they should address emotions that play a role in the decision-making process, and they should engage the audience on an emotional and personal level before thrusting facts and statistics at them.

REFERENCES
1. Henry J. Kaiser Family Foundation. Reaching the MTV Generation: Recent Research on the Impact of the Kaiser Family Foundation/MTV Public Education Campaign on Sexual Health. Menlo Park, CA: Henry J. Kaiser Family Foundation, 2003.
2. Glynn MK, Rhodes P. Estimated HIV Prevalence in the United States at the end of 2003. Atlanta, GA: Presentation, National HIV Prevention Conference, 2005.
3. Edberg M. Individual health behavior theories (pp. 35-49). In: Edberg M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007.
4. County of Los Angeles Department of Public Health. Don’t Think. Know. Los Angeles, CA: County of Los Angeles Department of Public Health. http://www.dontthinkknow.org.
5. North Carolina Department of Health and Human Services. “Get Real. Get Tested.” Campaign Comes to Charlotte Feb. 28. Raleigh, NC: North Carolina Department of Health and Human Services, 2007.
6. Salazar MK. Comparison of four behavioral theories: a literature review. AAOHN Journal 1991; 39:128-135.
7. Choi K, Yep GA, Kumekawa E. HIV prevention among Asian and Pacific Islander American men who have sex with men: a critical review of theoretical models and directions for future research. AIDS Education and Prevention 1998; 10, Supplement A:19-30.
8. Tilson EC, Sanchez V, Ford CL, et al. Barriers to asymptomatic screening and other STD services for adolescents and young adults: focus group discussions. BMC Public Health 2004; 4:21. http://www.biomedcentral.com/1471-2458/4/21
9. Fortenberry JD, McFarlane M, Bleakley A, et al. Relationships of stigma and shame to gonorrhea and HIV screening. American Journal of Public Health 2002; 92:378-381.
10. Think MTV. It’s Your (Sex) Life. Viacom International Inc., 2007. http://think.mtv.com/Campaigns/iysl/.
11. DeFleur ML, Ball-Rokeach SJ. Socialization and theories of indirect influence (pp. 203-227). In: DeFleur ML, Ball-Rokeach SJ. Theories of Mass Communication, Fifth Edition. White Plains, NY: Longman Inc., 1989.
12. MTV News. ‘Didn’t Even Feel It’: Getting an HIV Test. Viacom International Inc., 2007. http://think.mtv.com/044FDFFFF0098989A001700989896/.
13. MTV News. Gideon Yago Gets Tested for STDs. Viacom International Inc., 2007. http://think.mtv.com/044FDFFFF0098989A0017009898B5/.
14. Scheufele DA, Tewksbury D. Framing, agenda setting, and priming: the evolution of three media effects models. Journal of Communication 2007; 57:9-20.

Our Government’s Failure to Adopt A Policy For Needle Exchange Programs Rooted in Social Theories For IDUs – Aude Wilhelm

History of the government vs. NEPs
In the late 1970’s and 80’s, local community members, injection drug users and health care workers began Needle Exchange Programs (NEPs) to meet the growing concern of injection drug users (IDUs) about the rising rates of HIV [1]. NEPs provided IDUs with sterile syringes in exchange for their used ones. Aside from reducing the chance of HIV transmission among IDUs, these programs also provided HIV education for a previously hard to reach population. Despite the growing support of public health authorities, federal opposition created a long uphill battle for NEPs across the country to acquire state and national funding. In the conservative politician’s eye, supporting NEPs was giving the nod to drug dealers/users to maintain their habits and could even increase the amount of drug use among IDUs due to the extra available needles. Moreover, NEPs clashed with both paraphernalia state laws (which make the manufacture, possession, or distribution of drug paraphernalia a misdemeanor or felony offense: observed in 46 states) and prescription laws (which require a physician's prescription in order to purchase a syringe: observed in 10 states and the District of Columbia) [2]. As a result, many NEP programs started out as illegal, underground programs, with only some receiving funding from local organizations, leaving many to struggle financially. For these reasons, NEPs had little initial political support and directly clashed with the federal government’s non-tolerance policy of all drug-related behaviors.

Over the next 20 years, the effectiveness of NEP programs at reducing HIV rates became undeniable and the rates of HIV among IDUs impossible to ignore. Of the three known methods of HIV transmission (sexual contact, blood contact, and mother-to-child-transmission), all three can stem from drug injection behavior. According to a CDC 1993 surveillance report, “by early 1993, 253,448 people in the US had been diagnosed with AIDS. Of these, 73,311 (29%) were IDUs, 8,481 (3%) were people with heterosexual contact with an IDU, and 2,420 (1%) were children born to IDUs and their sex partners” [3]. Due to these alarming numbers, the number of NEP programs nationwide shot up over the last two decades. As of November 2006, more than 190 NEPs were in operation across 36 states, the District of Columbia, Puerto Rico, and on American Indian lands, with over half operating on private funding [4].

A 2005 study (done by the Association for Public Policy and Management on Drug Use Forecasting data from 24 large US cities) looked at the effect of NEPs on adult male arrestees’ IDU behavior living in 9 of those cities. They reported that the presence of an NEP in a city is associated with a 13% decline in drug injection and 20% decline in needle sharing among drug injectors [5]. Moreover, a 1993 CDC report on the health impact of NEPS stated that these programs show no evidence of increased drug use by NEP clients or of having an effect on injection behaviors at the community level [6]. As it stands today, NEPs are now accepted as essential components of HIV and hepatitis C prevention in many parts of the world, the US being a major exception.

The proven efficacy of NEP programs is slowly changing the no-federal-funding-of-NEPs trend, but the change is slow. In December 2007, Congress finally lifted a 9-year federal-funding ban of all NEPs in the District of Columbia but conservative politicians are already looking for a way to repeal this motion. Also, 5 studies on NEPs are currently being federally funded to synthesize existing information on NEP effectiveness [6].

The issue: lack of incorporation of social theories
Despite the perceived legal and moral paradox of giving addicts syringes to use illicit drugs, the government’s policy of not providing federal funding to NEP programs is shortsighted and costing lives. NEPs are believed to be particularly effective at reducing HIV transmission rates because they not only provide sterile syringes but also employ social theory techniques such as self-efficacy, harm reduction and the use of social networks among IDUs to reach out to a larger population of IDUs and engages them to consider changing their behavior. Social theories in public health can clearly delineate that a non-tolerance, “prohibition” strategy will not prevent needle sharing among IDUs. Moreover, a prohibition strategy is a power/coercive behavioral change strategy, a type of strategy that often doesn’t work in public health [7]. In the end, the government’s ineffective non-tolerance policy fails to incorporate these powerful social theories and ultimately impedes the prevention efforts of NEPs.

Self-Efficacy
Many IDUs perceive themselves as unable to quit their habit. The ‘irrationality’ of their choice to continue engaging in this high-risk behavior is partly due to their physical addiction but also because they feel that they lack the willpower/are physically unable to change their behavior, despite any intention to do so. Critics of conventional rationality-based social theories have clearly shown that intention to change a behavior does not guarantee that the behavior will change. Just because an IDU wants to stop injecting drugs does not mean he will do so and one reason for this is self-efficacy. The theory of Self Efficacy states: “it is the perceived capabilities rather than the actual that often influence behavior” [8]. An IDU may not feel strong enough as an individual to quit the behavior, emphasizing the fact that changing a behavior is based on a complex combination of social, behavioral, and cultural factors [9].

This is as an important consideration in explaining why prohibiting access of clean needles to drug addicts won’t affect their drug-using behavior. Ultimately, most drug addicts are more interested in their continuing drug use than whether or not they are using clean or dirty needles. Incorporating some re-educative techniques (through treatment therapy, for example) to heighten one’s sense of self-efficacy is a better strategy than prohibition. Some NEPs do this by requiring IDUs to undergo some form of treatment to access clean needles, but many will focus on keeping IDU habits HIV-transmission-free. As a result, they are able to reach out to a large IDU population and create an effective prevention strategy. The government’s power/coercive approach doesn’t help drug users to believe that they can discontinue their drug use because there is no skill building or education involved. The failure to incorporate self-efficacy in their strategy is one of the reasons for their ineffectiveness at decreasing the number of IDUs in our nation and only impedes the HIV prevention efforts of NEPs.

Harm reduction
As previously mentioned and reiterated by Des Jarlais in his 1993 review of public health: “NEPs acknowledge that many IDUs, including some in drug treatment programs, continue to inject drugs and share injection equipment. They therefore seek to reduce the harm associated with these practices, a philosophy sometimes referred to as harm reduction or harm minimization” [10]. Harm reduction’s message is: we don’t judge your behavior but care about your health. This strategy involves IDUs by having them be the ones to decide whether to access the NEP programs for clean syringes and not judging them. This social approach has led to other successful public health interventions such as Florida’s truth campaign. Their amazing results at reducing smoking rates among teenagers statewide (resulting in a 7.4% decrease in middle school kids and 4.8% decrease in high school kids) were largely attributed to youth involvement. This was done by organizing focus groups to ask kids directly what factors get them to start smoking and using a non-judging tone when interacting with the kids. Since teenage kids do not want to be told what to do, the truth campaign released large-scale advertisements just giving the facts about long-term smoking and highlighted the manipulative strategies used by tobacco companies to conceal such facts. Based on this, the kids then were left to make their own decision, but were not judged for them [11]. NEPs do this by having IDUs come to them with their dirty needles and giving them the facts on dangers of injection drug use. They then let IDUs decide if want to change their behavior or not. The general public, leaders in public health, and even some conservative politicians now accept NEP’s use of harm reduction as a reasonable prevention strategy [1].

Based on the success of the truth campaign and the effectiveness of NEPs at reducing HIV rates among IDUs, it is clear that harm reduction is a much more effective strategy than a non-tolerance policy message. Moreover, the non-judgmental approach attracts greater numbers of IDUs, making NEPs extremely competitive in decreasing black market demand by providing clean needles free of charge. Our government fails to incorporate harm reduction into its strategy to eliminate drug injection behavior in our nation. Instead, they chose to decrease HIV transmission rates by being intolerant to IDUs and refusing to financially support NEPs. Having the government label NEP clients as “responsible” and “irresponsible” is at odds with the nonjudgmental harm reduction stance espoused by NEPs. NEPs already have difficulty establishing credibility among IDUs so punitive policies can only impede their reach efforts, reduce NEP attendance, and ultimately reduce HIV prevention [12]. In this case, the government is doing more harm than good.

Social Networks
A third social theory consideration is based around the fact that IDUs tend to inject in known network groups and not with strangers. This concept is best explained by a public health theory known as Social networks theory. This theory states that a main behavior predictor is the social network that an individual belongs to since group factors affect behavior [13]. Indeed the social influence from these IDU social networks encourages needle sharing, resulting in higher HIV transmission rates within these individual IDU social networks [14]. As a result, NEPs serve as an ideal intervention since they use this network influence to reduce rather than encourage syringe sharing. Because of these networks, NEPs provide a unique opportunity to access these particularly high-risk, individual networks in the IDU community. Moreover, the fact that IDUs inject drugs as a group increases the chance that the one accessing the NEP (the provider) will promote safer injection drug use behavior to his/her social network [15]. The concept of safer injection drug practices among IDUs relying on their social network

An article in the journal of urban health reports that at the moment, “only 7% of IDUs have access to and use NEPs, leaving some IDUs to engage in secondary syringe exchange (SSE), where a ‘provider’ obtains syringes at an NEP to distribute to other IDUs (‘recipients’)”[15]. Since SSE is embedded in existing social networks, this provides natural opportunities for peer education on the dangers of injection drug use, which is something that may help change their behavior. This journal article on SSE also indicated that the primary motivation for providers to access NEPs was to help other IDUs, while recipients reported convenience as their primary reason for using SSE.

The government’s no-tolerance policy fails to account for the relationship between IDUs and Peer groups/social networks, which is another missed opportunity for them to employ an effective strategy at reducing HIV transmission. In the mean time, a no-tolerance approach and refusing NEP funding only harms HIV prevention efforts, once again highlighting the shortsightedness of this strategy.

Conclusion
“Substance use plays a major role in the transmission of HIV disease. Clearly, our nation's drug control policies must recognize this inextricable linkage between drugs and HIV disease and be designed to address the two aggressively and simultaneously” [16]. This is a crucial point that has not yet been understood by our government. In order to be truly effective at HIV prevention, the government must work with IDUs and employ these powerful social theories instead of blindly hoping that by prohibiting access to needles and refusing to cooperate with drug users, their behaviors will change. Increasing the sense of self-efficacy of IDUs, using harm reduction and paying attention to IDU social networks serves as a great starting point in creating a new national public health strategy to reduce HIV transmission through sharing of needles. NEPs understand the power of these theories when interacting with IDUs and should be used as a guiding arm by our government to start a new, powerful, re-educative public health initiative that will have a lasting impact on the health of our nation.

REFERENCES
1. Henry J. Kaiser Family Foundation. Needle Exchange: a Brief History; San Francisco, CA: Needle Exchange Program Evaluation Project; 1993.
2. Gostin, L. The interconnected epidemics of drug dependency and AIDS. Harvard Civil Rights-Civil Liberties Law Review. 1991; 26:113-184.
3. Anon. Centers for Disease Control. HIV/AIDS surveillance report. January, 1993.
4. Tempalski, B et al. Social and Political Factors Predicting the Presence of Syringe Exchange Programs in 96 US Metropolitan Areas. AJPH Volume 97(3), March 2007, pp 437-447.
5. DeSimone, J. Needle Exchange Programs and Drug Injection Behavior. Journal of Policy Analysis and Management; 24(3), January 2005, pp 559-577.
6. Centers for Disease Control and Prevention. The Public Health Impact of Needle Exchange Programs in the United States and Abroad Summary, Conclusions and Recommendations; Report by Institute for Health Policy Studies, University of California, San Francisco, CA; 1993.
7. Siegel, M. Education and persuasion versus coercion as public health approaches. The rest of the story: tobacco news analysis and commentary (blog). May 4, 2006. Available at http://tobaccoanalysis.blogspot.com/2006/05/in-my-view-education-and-persuasion.html
8. Bandura, A. (1977). Self efficacy: Toward a unifying theory of behavioral change. Psychological Review. 84, 191-215.
9. Becker, M.H. The Health Belief Model and Personal Health Behavior. Health Education Monographs. Vol. 2 No. 4.
10. Des Jarlais DC, Friedman SR, and Ward TP. Harm reduction: A public health response to the AIDS epidemic among injecting drug users. Annual Review of Public Health. 1993;14:413-450.
11. Hicks, J. The strategy behind Florida’s Truth Campaign. Tobacco Control 2001; 10:3-5.
12. Strike CJ, Myers T, and Millson M. Needle exchange: how the meanings ascribed to needles impact exchange practices and policies. AIDS Education and Prevention, 14(2), 126–137, 2002.
13. Turkat D. Social networks: Theory and practice. Journal of Community Psychology. 8(2), 99 – 109, 2006.
14. Neaigus A et al. Drug injectors' social networks can be risk factors for syringe sharing. Int Conf AIDS. 1996 Jul 7-12; 11: 41 (abstract no. Mo.C.462).
15. Snead, J et al. Secondary syringe exchange among injection drug users. J Urban Health. 2003 Jun;80(2):330-48.
16. National Commission on AIDS, The Twin Epidemics of Substance Use and HIV, 1991.

AIDS Intervention Strategies in India: A Socio-Political Approach Explaining Why They Are Ineffective – Nandini Ravishankar

India, a country with a population of one billion, is experiencing a rapid and extensive spread of AIDS. When HIV infection was discovered in India in 1986, the health authorities set up the National Aids Control Organization (NACO), which was primarily funded by the World Bank and technically supported by the World Health Organization (WHO) (9).

The current AIDS estimate suggests that the national adult HIV prevalence in India is 0.36 percent, amounting to between 2.5 and 3 million people. This number has seen a drop of nearly 50 % from the previous estimate of 5.2 million people living with HIV/AIDS (9). However despite a decrease in the overall number of people afflicted with AIDS, the current numbers are considerably high with most of the affected population losing out on the productive years of their lives. The prevalence rate for men is 0.43% while for women it is 0.29%. Prevalence is also high in the 15-49 age group (88.7% of all infections) indicating that AIDS still threatens the cream of society, those in the prime of their working life (20,23).

However, despite the work being done to tackle the crisis, there are some hurdles that may hamper the progress of the current interventions. Disparities still exist in the effectiveness and applicability of the interventions to vulnerable populations. The strategies adopted by the National AIDS Control Organization (NACO) to mitigate AIDS in India have been ineffective because social and political pressures prevent the right groups from being targeted.

1. Adolescents are not provided with adequate education about HIV/AIDS

Social Learning Theory is based on the tenet that people do not learn behaviors in a vacuum, isolated from external interactions (1). The theory stressed that a large contribution to adopting behaviors stems from observing and then emulating the actions of others within an individual’s community. In Indian society, there is a high level of taboo associated with talking about sex. Much of the information is communicated through a non-verbal channel and there are estimates that about two-thirds of meaning is communicated nonverbally (13). When adolescents see their parents and other elders hesitating to talk about sex, it leads them to believe that sex is something to be embarrassed about and something that is negative in nature. Adolescents may also experience confusion as the message projected in the interventions may not be in line with their core values, the core values being ‘sex is not something to be discussed’. They are less likely to accept interventions that are against their core values and may thus dismiss the information and education provided.

As mentioned earlier, in India it is taboo to talk about sex and it is an even greater taboo for parents to talk about sex with their children. There have been many barriers that have been identified which impede parents from communicating with their children about sex and sexually transmitted diseases (STDs). Studies report that parents often feel inadequately informed, embarrassed and ineffective and have difficulty finding the right place and time for communication (12). Thus parents often do not talk about sex and the adolescent is reprimanded for asking questions about sex. Parental education allows the adolescent to incorporate the idea of sex in a way that is in line with their core values. This would enable the adolescent to be better informed and better adjusted to the concept of sex and sexually transmitted diseases. Parents can also tailor the presentation of information to the life circumstances and social and familial context of the adolescent (12).

In the absence of parental communication, adolescents often turn to other sources to get more information. Recent work has supported the position that peers are often responsible for the onset of risk behaviors in adolescents (25). This work implies that although teens acquire information regarding risk behaviors from parents, teachers and the media, peers may also play a crucial role in a child’s development by shaping his/her normative beliefs and interpretation of information regarding risk activities (24). Becoming a member of a peer group is one of the primary developmental tasks of adolescence (4). Peer groups influence adolescent socialization and identity by allowing young individuals to explore individual interests and uncertainties while retaining a sense of belonging and continuity within a group of friends (8). Although a key aspect of normal adolescent development, there may be costs associated with becoming a member of a group of people. Some have considered peer pressure the ‘price of group membership’ (3), which research has linked to a variety of potential problems including substance abuse, risk-taking behavior and delinquency as well as dating attitudes and sexual behavior. For many young persons, substance use, risk-taking behavior and sexual activity may represent efforts to ‘conform to the norms of the group and to demonstrate commitment and loyalty to other group members’ (15).

Another frequent source of information for adolescents is the media, which influences how adolescents think and is likely to have a great impact on their behavior. The modeling theory is particularly relevant to the study of mass communications because the portrayal or description of social life is a frequent subject in the media. The actors who portray real people in visual, auditory or print media often serve as role models for others to imitate (6). As seen with other behavioral influences, the negative consequences of risk-taking behavior are rarely mentioned in the media in a way that would provide adolescents with important information. In the current scenario, the message that adolescents get is that it is acceptable to indulge in risky sexual behavior without experiencing any negative consequences. This contributes to an increase in sexual risk taking behavior among adolescents as they believe in the ‘feel good’ message being projected without considering the reality of the situation (8).

2. Social Stigma attached to HIV/AIDS

In many Asian countries including India, homosexuality is still a taboo. The social ostracism is also evident from the fact that homosexuality is considered a crime by the Judicial System in India. The statute does not directly state the ban on homosexuality but follows a law that was set by the ruling British Government in 1860. The Indian Penal Code (Section 377) states that: “Whoever voluntarily has carnal intercourse against the order of nature with any man, woman or animal, shall be punished with imprisonment for life, or with imprisonment of either description for a term which may extend to ten years, and shall also be liable to fine”. The punishment for this crime ranges from 10 years to life imprisonment. The word ‘carnal intercourse’ being vague, it has often been used against homosexuality (21). To bring about change in the current status of the HIV/AIDS epidemic in India, drastic changes need to be brought about not only at the societal level but also at the judicial level.

Goffman (1963) defined stigma as any condition, attribute, trait of behavior that symbolically marked off the bearer as ‘culturally unacceptable’ or inferior with consequent feelings of shame, guilt and disgrace (10). There is a high level of stigma that is associated with HIV/AIDS and very often, people do not confess that they have the illness which explains why the heterosexual partner, in most cases the woman is afflicted with the virus as well. The spread of HIV in India has been at its peak in the Western and Southern part of the country (19). Stigma associated with HIV-AIDS negatively impacts people’s decision regarding whether and when to be tested for the virus (26). Stigma therefore is a crucial aspect that needs to be understood in the management of people with HIV/AIDS. Stigma not only exists in the general community but also exists within the homosexual community itself. Results of a study indicated that many HIV-positive gay men perceived a division within the gay community related to HIV/AIDS. Their perceptions that HIV-negative men held stigmatizing attitudes toward HIV-positive men included feelings of sexual rejection and discrimination (5).

Social stigma and ostracism against homosexuality are held not only by society, but by the families as well. Homosexual men often are faced with the difficulty of dealing with the cultural expectations of their parents. They experience parental pressure to get married, have children, carry on the family name and traditions and not bring shame to the family by individual behavior choices and nonconformity (2). As a result of these expectations, many homosexual men choose not to come out of the closet. This prevents them from obtaining and having access to the right preventive information regarding HIV/AIDS. The perceived failure of meeting parental expectations associated with the role of the son, as well as the shameful stigma associated with homosexuality often leads the gay son to hold negative emotions like guilt, shame, low self-esteem, social inhibitions and insecurities (2). Very often, homosexual relations are maintained in secret without the knowledge of the family and in such situations, safe sex and the use of condoms take a backseat as keeping the relationship secret becomes the first priority. Choi et al. (1998) also conducted another study where they found that family obligations and homophobia in the community, along with negative sterotyping, marginalization contributed to low self-esteem and in turn resulted in risk-taking and lapses to unsafe sex (2).

The law criminalizing homosexuality has led to interventions that are designed to tackle HIV/AIDS but have not taken into account the needs of the gay community. Few published research studies have delved into the lives, the minds and the hearts of gay men to understand their feelings, attitudes, experiences and values. As a result, the public health interventions have failed because they have not targeted the core values of one of their target audiences: the gay community (18). One example of a shortcoming evident in the HIV/AIDS intervention programs that stems from a lack of insight into the lives, feelings and experiences of gay men is the virtual disregard for risk reduction as opposed to risk elimination strategies and the reluctance to candidly discuss, rather than merely dismiss as deviant, unsafe sex. As a consequence of the failure of the interventions, a sense of hopelessness and complete lack of control has arisen among gay men (18). Because they do not really believe that they will use a condom each time, many men assume that they are destined to become infected and therefore see no point in using condoms at all (11). This is an important issue to consider when initiating HIV/AIDS interventions. The needs, feelings and attitudes of the gay community must also be included. Thus, to tackle the HIV/AIDS crisis in India, interventions must not only focus on the heterosexual population and youth but must also address the fears and concerns of the gay community.

While it is important to address the individual behavioral factors that contribute to HIV/AIDS, it is also important to contextualize the risk factors, that is, attempt to understand how people come to be exposed to the individually based risk factors to design more effective interventions. By this, interventionsists must use an interpretive framework to understand why people come to be exposed to risk factors and the circumstances that shapes their exposure to the risk factors (14). For example, it is important in the framing of interventions to contextualize the risk factors for HIV/AIDS which would give a better understanding of why some people cannot avoid the risk. In a patriarchal society like India, it is important to understand the reasons why commercial sex workers are unable to get the men to practice safe sex which consequently may lead to an increase in the levels of HIV/AIDS in the sex workers.

3. Political factors impede HIV/AIDS Interventions

In a developing country like India with a population of one billion, there are structural inequalities that come with the treatment of HIV/AIDS. There are often other diseases and illnesses which take precedence over AIDS and the social taboos often play a role in influencing political agenda as well (16). Parker (2002) reported that a range of structural inequalities intersect and combine to shape the HIV/AIDS epidemic. There is an increasing gap between the rich and poor states with regard to public resources available for health, with resultant disparities in health outcomes (16). A major political concern that interventions need to consider and address is the reduction in the role of the central government in health care delivery. With decentralization and privatization being the answer to fill the gap in health care delivery, safety nets for the poor, especially those in the rural areas are being threatened. According to the WHO, India continues to bear the burden of the highest number of tuberculosis patients (7). With TB being an overwhelming burden and the leading cause of death in the country, there is less emphasis and priority given to HIV/AIDS. NACO programs are also supplemented by state level agencies, with great variabilty in terms of emphasis given by each state to the HIV/AIDS crisis. Many states are still in denial about the spread of HIV/AIDS within the state and thus are unwilling to provide money to tackle the crisis (7). Thus in order to address these concerns, more HIV/AIDS interventions need to be conducted at the state level to ensure that all citizens of the country have access to the same level of services and state governments must be required to co-ordinate activities in accordance with NACO. The partisan views of the various political parties must be addressed and modified for any effective change to occur in HIV/AIDS interventions at the political level.

Framing according to Tversky and Kahneman (1981) is ‘focusing the attention of people within a field of meaning’. Framing theory suggests that how something is presented (‘the frame’) influences the choices people make. The agenda setting theory is also closely related to the Framing theory (22). This theory states that agenda setting not only tells individuals what to think of an issue but also how to think about that issue. The agenda setting theory states that in order to get people to pay attention to the information, they have to view it as important and relevant (27). Thus, the moral, core values and principles of the current ruling political party determine how the crisis of AIDS will be tackled. The framing and agenda setting theory explain why conservative political parties would be more likely to promote the thinking that commercial sex workers are the most high risk populations as this is in line with social thinking and is likely to garner them more election votes. Thus by projecting AIDS as an issue among heterosexual individuals, the conservative political parties ignore the presence of AIDS among the homosexual population.

The Health Belief Model (HBM) was developed to explain health-related behavior at the level of the individual decision maker. The Health Belief Model (HBM) proposes that individual health beliefs associated with a disease or medical condition (i.e. perceived vulnerability to HIV/AIDS) determines their likelihood of engaging in preventive health actions (eg: use of condoms to prevent exposure) (17). The interventions developed by NACO also operate on the same rationale. It is believed that as long as individuals are provided with the interventions, they will utilize it based on their health beliefs. However the model and the consequent interventions fail to take into account socio-cultural factors. According to Choi et al., HBM has limited utility in addressing environmental factors affecting HIV risk because they ignore the wider social context within which the individual must circulate such as the family, and any communities of which an individual may be a member (2). Furthermore, the model assumes that all behavior is the result of a cost/benefit analysis, of calculated rational thought following the principle of self-interest. The Health Belief Model views the individual as devoid of emotion even though interacting with the wider social environment may entail situational and emotional difficulties for the individuals that consequently affect HIV risk (2). As seen with the model, there is a tendency for those in power to operate with an ‘inside the box’ rationale and an unwillingness to explore new avenues for progress. Combined with the bureaucratic and political pressure, there is an increased likelihood of interventions being built on top of earlier interventions with few modifications. While this may work for a certain period of time, it is important to acknowledge that interventions need to change with the changing times.

Implications for Future Interventions and Policy Decisions

In the light of the above mentioned factors, future interventions undertaken by NACO must therefore take into account socio-political factors. The crisis of AIDS can be successfully addressed only when all individuals who are at risk of contracting AIDS are targeted to receive the interventions. By excluding a particular group or ignoring important factors that may impact the prevalence of AIDS, the current interventions exhibit a lack of informed implementation. Despite being the largest democracy in the world, India still faces political hurdles that diminish the effectiveness and applicability of public health interventions. With the AIDS epidemic being a threat to the population of the country, more steps need to be taken to tackle the concerns at the grass root levels. While the current interventions have been shown to be marginally effective, it becomes more imperative to develop interventions that don’t just follow what has been done before but which incorporate the concerns of the diverse at-risk populations. Changes must originate at the grass roots level and must address individuals in the rural and urban areas. Changes need to be brought about at the societal and the judicial level for the gay community to feel accepted and acknowledged. Only when interventions addressing all populations and all concerns are developed will the battle on HIV/AIDS be successful.

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