The unequivoval answer is yes. HIV prevention programs are doomed to failure if they are expected to protect 100% of people from disease 100% of the tIme. No interventions aimed at changing behaviors to promote health have been or can be 100% successful. Driving deaths caused by drunk drivers declined from 57% in 1982 to 45% in 1992., and this was considered a major victory. In 1964, the Surgeon General first sounded an alarm about smoking; warning labels on cigarettes weren’t mandated until 1984, and now, 30 years later, stop smoking campaign are achieving some success even though smoking-related illness is the major cause of death for Americans.

In San Francisco, CA, new HIV infections reached a high of 8,000 in 1992, the estimated number of new HIV infection was 1,000. Comprehensive community-based HIV prevention programs targeted towards gay and bisexual men in the early to mid-1980s certainly contributed to this dramatic reduction in new HIV infections.

For prevention programs to work, cases of disease must be averted. As June Osborn, former Chair of the National Commission on AIDS said, “If we do preventive medicine and public health right, then nothing happens and it is very boring. We should all be praying for boredom.”

A thorough review of research evaluating HIV prevention programs found 20 studies that demonstrated long-term behavior change. Skepticism about the effectiveness of HIV prevention programs is not borne out by scientific evidence. The following are examples of scientifically evaluated prevention programs that have been proven effective.

What works for gay/bisexual men?

Small group counseling: Audio-viual presentations eroticizing safer sex, safe sex negotiation skills training, stress reduction training and intensive group counseling have been shown to be effective at changing behavior on a short-term basis. In Pittsburgh, PA, one study resulted in an increase in condom use from 36% to 80%.

Community interventions: AIDS education lef by peers on a community level is effective at reaching higher risk men who don’t often participate in small group counseling. In several medium-sized towns, the most populat people in social settings were trained to deliver AIDS risk-reduction messages to their friends and acquiaintances in gay bars. As a result, fewer gay men practiced unprotected sex. Another program found that using peers to support and encourage friends about safe sex was an effective approach to HIV prevention.

What works for injecting drug users?

Community outreach: In Chicago, peer-led street outreach targeting social groups of injecting drug users (IDUs) not in drug treatment found a substantial reduction in sharing needles from 100% to 14%. A four-year follow up of this program also found an impressive decrease in HIV seroconversion rates, from 5% to less than 1%. An HIV prevention media campaign aimed at a national audience was found effective at slowing HIV conversion among IDUs in Northern Italy.

Needle exchange programs: A comprehensive report prepared for the Centers for Disease Control and Prevention reported 10 studies of needle exchange programs that showed decreases in sharing needles, the main route of HIV transmission, as a result of the exchanges.

What works for adolescents?

Sex education: Although sex education for adolescents is still steeped in controversy, the preponderance of data has shown that age-appropriate school programs reduce risk behavior in the short term, and can actually decrease sexual activity for adolescents. An experimental sex education program helped students who were abstinent remain abstinent after a year and a half. Among those who did become sexually active, the program resulted in higher use of contraceptives.

Small group counseling and skills building: For hard-to-reach adolescents at high risk for HIV, intensive and repeated education, skills training and counseling sessions are effective. In New York, runaway youths in resiential shelters who received 15 or more sessions, reported an increase in consistent condom use from 33% to 63%, and a decrease in high-risk sexual behavior from 20% to zero. AS the number of intervention sessions increased, consistent condom use increased significantly and engaging in a high-risk sexual behavior decreased significantly.

Small group counseling. Patients in urban promary health care clinic receiving AIDS education, skills-training and peer support reported a 40% increase in condom use.

Couples counseling: Studies of discordant couples (i.e. whee one is HIV-infected and the other isn’t) have shown that when couples are counseled together about safe sex, condom use increases, and HIV seroconversion decreases. In one study, none of the couples who consistently used condoms seroconverted. In another study, discordant couples who received repeated HIV testing and post-test counseling showed increased condom use from 3% to 57%.

What kinds of progarms work best?

Many characteristics of siccesful HIV prevention programs hold true across populations.

1. Intense interventions that are sustained over time are more likely to produce long-term behavior change.
2. Improving access to devices necessary for safer practices, such as clean needles and condoms, is crucial.
3. Skills building and modifying community norms are essential program elements.
4. Timing of HIV prevention messages is important, as demonstrated with adolescent programs, where providing explicit prevention education before the time they are sexually active can have a greater impact than education after the initiation of sexual activity.
5. Programs addressing discordant couples are especially effective in groups with high prevalence of HIV infection.

A comprehensive HIV prevention strategy uses multiple elements to protect as many people at risk for HIV as possible. We should learn from and promote the effectiveness of HIV prevention programs already in place, as well as continue to evaluate these programs. The standard for measuring success of HIV prevention needs to be addressed; 100% effectiveness could never be achieved. Finally, fundingg for prevention programs and research into prevention science needs to be tied to effectiveness and public health importance. Now that we know that HIV prevention works, and what kinds of programs work, we need to put them into practice, sustain and refine them.

Link: www.epibiostat.ucsf.edu/capsweb/prevtext.html