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AIDS 2006 – time to deliver
Patient Education and Counseling 65 (2007) 1–2 www.elsevier.com/locate/pateducou
Editorial
AIDS 2006 – time to deliver The XVI International AIDS Conference in Toronto, Canada, had more participants than ever (24,000), and it was perhaps more political than ever. Information about the conference is still available at www.aids2006.org, including all abstracts. What were the major topics from a behavioral science point of view?
1. The pandemic Aids is still an ongoing pandemic and is hitting on vulnerable populations: women, children, ethnic minorities, men having sex with men (MSM), sex workers, and drug users. In Africa and Asia primarily by heterosexual transmission; in Eastern Europe and parts of Asia, drug users are at higher risk for HIV exposure. The epidemic among MSM is not limited to industrialized countries: also in LatinAmerica, Africa and Asia the HIV-prevalence among MSM is high, as it is among African-Americans. It is perhaps not as bad as it could have been, but Aids will be with us for the coming time. Prevention remains an important response to Aids, but the vulnerable populations themselves are often not allowed to participate which is a prerequisite for effective prevention. A response to Aids includes striving for human rights.
2. Pre-exposure prophylaxis Does it help to take pre-exposure prophylaxis? Actually, we do not know yet. At present many studies focus on preexposure prophylaxis, and preliminary results are promising for HIV-prevention and do not show side effects. If preexposure prophylaxis really works, this would be great news, especially since it may enable women to protect themselves better. At the same time, we may question if pre-exposure prophylaxis is going to be available in low and middleincome countries. It is promising that current HIV treatments have become increasingly available, and that some studies show very high rates of compliance. Still, not enough people have access neither to treatment nor to effective prevention. We need more money than ever. 0738-3991/$ – see front matter # 2006 Published by Elsevier Ireland Ltd. doi:10.1016/j.pec.2006.10.014
3. Gay men Among gay men, the Internet has become more and more important as a dating instrument. The question is whether especially risk-takers use the Internet for dating, or whether the Internet causes sexual risk-taking? We do not know yet, but at least we see some promising Internet prevention programs. Drug use among gay men is quite common, especially among those being HIV+. Does drug use make unsafe sex more likely? Again, we do not know, but there are some promising harm reduction programs. Are gay men and MSM the same? No they are not, and a more sexualculturally sensitive prevention is needed to reach gays, lesbians, bisexuals and the transgendered. Does negotiated safety work? It probably does, but in the heat of the moment promises may be broken. Then it is essential to educate men how to inform their partners.
4. Advanced technology, media and Internet The experiences with Internet research are divers. Some report very high response rates, others very low. Many studies struggle with attrition, but some recent studies have been successful in keeping attrition rates low. The Internet is obviously a means for HIV+ to find other HIV+ for serosorting. Being explicit about wanting safer sex, i.e. in one’s web profile, seems very effective in preventing unsafe sex. Clearly, the Internet gives new opportunities for applying advanced communication technology in sexual health promotion. There are also some promising examples of prevention programs using SMS.
5. Ethnic groups and migrants In many high-income countries, the epidemic among migrants does not receive enough attention. In specific groups the HIV-prevalence is very high and reflecting the prevalence in countries of origin. To date we hardly have an understanding of the risk behavior of these groups. Personal and external determinants of risk-taking are sometimes
2
Editorial / Patient Education and Counseling 65 (2007) 1–2
different. Moreover, there risk behavior seems related to SES and problems with integration. Fortunately, we see a number of successful demonstration projects. Refugees are a special group – a group that needs not only tailored prevention but also psychosocial help because of their oftentraumatic experiences. For this group, we still have not much to offer in terms of evidence-based prevention.
6. HIV-testing There are many reasons to find out one’s HIV-status as soon as possible. Early detection facilitates treatment decision-making and reduces risk behavior. That is why some countries go for an opting-out system. Other countries work on linking HIV-testing to all kinds of other visits to the health care system, or to wherever you may find key populations at higher risk (Emergency Departments; saunas). In the USA, oral fluid testing is introduced; unfortunately oral fluid testing has the side effect that people do not go for other STD-tests any more. First experiences with quick-tests are positive, although the organization of the counseling part seems rather difficult. In any case, follow-up counseling at testing sites is crucial.
7. People living with HIV and AIDS HIV+ gay men have relatively less unsafe sex after the test, but still relatively more unsafe sex than HIV men or men with an unknown HIV status, even when corrected for sero-sorting. Although disclosure is not very popular among HIV+ gay men, it certainly promotes safer sex and should be stimulated. Having an STD is a significant risk factor for HIV infection. So, HIV prevention includes STD prevention. PLHIV experience problems with their disease, but also with sexual health in general and the ambiguity of responsibility for protecting others. PLHIV do receive support from their religion, from social support groups, and from experiences of other HIV+, i.e. on www.dipex.org.
8. Professionals Some Internet sites are targeting professionals (see i.e. www.aetcnec.org/vignette for an online training for nurses). Of course, the exchange of evidence-based practices combined with skills training for professionals is an excellent idea and the Internet provides great possibilities. One remark however; HIV prevention activities need to be culturally sensitive and individually tailored. Web-based programs need to be adapted, and frequently substantial
changes are needed. Other contributions directed at professionals focus on environmental changes: mandatory minimum conditions for sex facilities, i.e. free condoms and lube, education, and trained personnel.
9. What have we learned? The World Aids Conference is an important arena to set the political agenda. Politics however are not the only response to HIV. The exchange of information about what programs are working in what circumstances is very important as presented by Albarracı´n et al. [1]. Evidencebased health promotion and prevention is in the view of Bartholomew et al. [2] essential for HIV prevention, HIV-testing and care for PLWHA: no KAP studies and no fear arousing strategies anymore! Researchers can contribute to the quality of programs with up-to-date theory and research: the actual content may vary, but the determinants of behavior and the processes of change are basically the same. Fortunately we see many successful projects and programs, as presented in the paper of Van Kesteren et al. [3] in this issue of Patient Education and Counseling. Fortunately we see many high quality programs. Never enough and never good enough, but contributions that increase the evidence-base for future programs, do make a difference.
References [1] Albarracı´n D, Durantini MR, Earl A. Empirical and theoretical conclusions of an analysis of outcomes of HIV-prevention interventions. Curr Directions Psychol Sci 2006;15:73–8. [2] Bartholomew LK, Parcel GS, Kok G, Gottlieb NH. Planning health promotion programs; an Intervention Mapping approach. San Francisco, CA: Jossey-Bass; 2006. [3] Van Kesteren N, Hospers MPH, Kok G. Sexual behavior among HIVpositive men who have sex with men: a literature review. Patient Educ Couns 2007;65:5–20.
Gerjo Kok,* Herman Schaalma Maastricht University, Department Applied and Social Psychology, Maastricht, The Netherlands Onno de Zwart Municipal Public Health Service Rotterdam, The Netherlands *Corresponding author E-mail address: [email protected] (G. Kok)
Editorial
AIDS 2006 – time to deliver The XVI International AIDS Conference in Toronto, Canada, had more participants than ever (24,000), and it was perhaps more political than ever. Information about the conference is still available at www.aids2006.org, including all abstracts. What were the major topics from a behavioral science point of view?
1. The pandemic Aids is still an ongoing pandemic and is hitting on vulnerable populations: women, children, ethnic minorities, men having sex with men (MSM), sex workers, and drug users. In Africa and Asia primarily by heterosexual transmission; in Eastern Europe and parts of Asia, drug users are at higher risk for HIV exposure. The epidemic among MSM is not limited to industrialized countries: also in LatinAmerica, Africa and Asia the HIV-prevalence among MSM is high, as it is among African-Americans. It is perhaps not as bad as it could have been, but Aids will be with us for the coming time. Prevention remains an important response to Aids, but the vulnerable populations themselves are often not allowed to participate which is a prerequisite for effective prevention. A response to Aids includes striving for human rights.
2. Pre-exposure prophylaxis Does it help to take pre-exposure prophylaxis? Actually, we do not know yet. At present many studies focus on preexposure prophylaxis, and preliminary results are promising for HIV-prevention and do not show side effects. If preexposure prophylaxis really works, this would be great news, especially since it may enable women to protect themselves better. At the same time, we may question if pre-exposure prophylaxis is going to be available in low and middleincome countries. It is promising that current HIV treatments have become increasingly available, and that some studies show very high rates of compliance. Still, not enough people have access neither to treatment nor to effective prevention. We need more money than ever. 0738-3991/$ – see front matter # 2006 Published by Elsevier Ireland Ltd. doi:10.1016/j.pec.2006.10.014
3. Gay men Among gay men, the Internet has become more and more important as a dating instrument. The question is whether especially risk-takers use the Internet for dating, or whether the Internet causes sexual risk-taking? We do not know yet, but at least we see some promising Internet prevention programs. Drug use among gay men is quite common, especially among those being HIV+. Does drug use make unsafe sex more likely? Again, we do not know, but there are some promising harm reduction programs. Are gay men and MSM the same? No they are not, and a more sexualculturally sensitive prevention is needed to reach gays, lesbians, bisexuals and the transgendered. Does negotiated safety work? It probably does, but in the heat of the moment promises may be broken. Then it is essential to educate men how to inform their partners.
4. Advanced technology, media and Internet The experiences with Internet research are divers. Some report very high response rates, others very low. Many studies struggle with attrition, but some recent studies have been successful in keeping attrition rates low. The Internet is obviously a means for HIV+ to find other HIV+ for serosorting. Being explicit about wanting safer sex, i.e. in one’s web profile, seems very effective in preventing unsafe sex. Clearly, the Internet gives new opportunities for applying advanced communication technology in sexual health promotion. There are also some promising examples of prevention programs using SMS.
5. Ethnic groups and migrants In many high-income countries, the epidemic among migrants does not receive enough attention. In specific groups the HIV-prevalence is very high and reflecting the prevalence in countries of origin. To date we hardly have an understanding of the risk behavior of these groups. Personal and external determinants of risk-taking are sometimes
2
Editorial / Patient Education and Counseling 65 (2007) 1–2
different. Moreover, there risk behavior seems related to SES and problems with integration. Fortunately, we see a number of successful demonstration projects. Refugees are a special group – a group that needs not only tailored prevention but also psychosocial help because of their oftentraumatic experiences. For this group, we still have not much to offer in terms of evidence-based prevention.
6. HIV-testing There are many reasons to find out one’s HIV-status as soon as possible. Early detection facilitates treatment decision-making and reduces risk behavior. That is why some countries go for an opting-out system. Other countries work on linking HIV-testing to all kinds of other visits to the health care system, or to wherever you may find key populations at higher risk (Emergency Departments; saunas). In the USA, oral fluid testing is introduced; unfortunately oral fluid testing has the side effect that people do not go for other STD-tests any more. First experiences with quick-tests are positive, although the organization of the counseling part seems rather difficult. In any case, follow-up counseling at testing sites is crucial.
7. People living with HIV and AIDS HIV+ gay men have relatively less unsafe sex after the test, but still relatively more unsafe sex than HIV men or men with an unknown HIV status, even when corrected for sero-sorting. Although disclosure is not very popular among HIV+ gay men, it certainly promotes safer sex and should be stimulated. Having an STD is a significant risk factor for HIV infection. So, HIV prevention includes STD prevention. PLHIV experience problems with their disease, but also with sexual health in general and the ambiguity of responsibility for protecting others. PLHIV do receive support from their religion, from social support groups, and from experiences of other HIV+, i.e. on www.dipex.org.
8. Professionals Some Internet sites are targeting professionals (see i.e. www.aetcnec.org/vignette for an online training for nurses). Of course, the exchange of evidence-based practices combined with skills training for professionals is an excellent idea and the Internet provides great possibilities. One remark however; HIV prevention activities need to be culturally sensitive and individually tailored. Web-based programs need to be adapted, and frequently substantial
changes are needed. Other contributions directed at professionals focus on environmental changes: mandatory minimum conditions for sex facilities, i.e. free condoms and lube, education, and trained personnel.
9. What have we learned? The World Aids Conference is an important arena to set the political agenda. Politics however are not the only response to HIV. The exchange of information about what programs are working in what circumstances is very important as presented by Albarracı´n et al. [1]. Evidencebased health promotion and prevention is in the view of Bartholomew et al. [2] essential for HIV prevention, HIV-testing and care for PLWHA: no KAP studies and no fear arousing strategies anymore! Researchers can contribute to the quality of programs with up-to-date theory and research: the actual content may vary, but the determinants of behavior and the processes of change are basically the same. Fortunately we see many successful projects and programs, as presented in the paper of Van Kesteren et al. [3] in this issue of Patient Education and Counseling. Fortunately we see many high quality programs. Never enough and never good enough, but contributions that increase the evidence-base for future programs, do make a difference.
References [1] Albarracı´n D, Durantini MR, Earl A. Empirical and theoretical conclusions of an analysis of outcomes of HIV-prevention interventions. Curr Directions Psychol Sci 2006;15:73–8. [2] Bartholomew LK, Parcel GS, Kok G, Gottlieb NH. Planning health promotion programs; an Intervention Mapping approach. San Francisco, CA: Jossey-Bass; 2006. [3] Van Kesteren N, Hospers MPH, Kok G. Sexual behavior among HIVpositive men who have sex with men: a literature review. Patient Educ Couns 2007;65:5–20.
Gerjo Kok,* Herman Schaalma Maastricht University, Department Applied and Social Psychology, Maastricht, The Netherlands Onno de Zwart Municipal Public Health Service Rotterdam, The Netherlands *Corresponding author E-mail address: [email protected] (G. Kok)