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When Will We Wake Up to AIDS? : Every Sexually Active Person Must Choose Safe Behavior

May 10, 1987|NEIL R. SCHRAM | Neil R. Schram, an internist, was chairman of the Los Angeles City/County AIDS Task Force.

As the AIDS epidemic enters its seventh year, a grim reality must be faced: The AIDS virus is winning in our country.

In the absence of a medical solution--a vaccine or a medication that makes people non-infectious--our only hope to slow the spread of the virus lies in changing people's behavior. To attempt that, an education effort is needed, one far beyond the scope of anything that has been proposed to date.

Changing people's behavior is extremely difficult, as we've seen in the anti-smoking campaign; changing how tens of millions of people behave in every sexual encounter seems like an impossible goal. But we must do it. And we must begin now. As Surgeon Gen. C. Everett Koop recently said, "While we can aim for the year 2000 for a smoke-free society, we cannot wait for AIDS education."

Recent information confirms the difficulty of changing sexual behavior. In a UCLA study, "The Natural History of AIDS," more than half of the 1,200 male homosexual participants said that they no longer engage in anal intercourse, the highest risk factor for AIDS infection for gay men. However, of those who still do, and who are not in a monogamous relationship, half do not consistently use condoms.

Indications are that heterosexuals are equally resistant to behavioral change. In a study of 32 couples where one partner had AIDS and the other was healthy, despite counseling 14 couples did not use condoms and 12 partners became infected. Ten of the couples consistently used condoms and one partner became infected. The remaining eight chose to be sexually inactive.

A survey in People magazine last month provided another alarm: More than 95% of sexually active high school and college students polled knew that AIDS can be spread heterosexually; nevertheless, only 26% of high school students and 15% of college students surveyed had changed their sexual behavior.

There are only two sexual behavior choices for protecting against AIDS: One is abstinence or practices that do not risk the introduction of the virus into the partner's body through blood or semen. The other choice, vaginal or anal intercourse with a condom, significantly reduces but does not eliminate the risk. People must be educated to choose one or the other--the only unacceptable choice is neither.

Changing sexual behavior is a three-step process. People must understand that there is a risk, then believe that they can do something to lower that risk, and finally choose to practice the low-risk behavior. Most heterosexuals are at the first step. Most homosexually active blacks and Latinos are probably at the first stage also, because the educational message has not reached them as well as it has gay white men, who are at the second or third stage.

To reach heterosexual adults and homosexually or heterosexually active teen-agers, we must learn from the experience with gay and bisexual men. In San Francisco, knowing someone with AIDS was the biggest motivator to reduce risk. It would be an incredible tragedy if that becomes necessary for heterosexuals.

Individual counseling and small-group discussion to focus on low-risk behavior have been quite successful among gay men. That is the best model to follow. But applying this model to the entire sexually active American population would require organization and funding on a scale that we're unlikely to achieve in the foreseeable future. Tragically, our political leaders remain unwilling or unable to spend large sums on education about sexual practices or drug use. (Sharing needles or other drug equipment is the prime risk factor for the spread of AIDS among drug users.) Consequently, we must mobilize existing resources for an education effort of sufficient scope to convince all sexually active people that there is a problem, and then to convert them to least-risk practices.

Every business should be establishing AIDS education programs, both for humane and cost-saving reasons. Every community group and church group should educate its members about AIDS. Any establishment where single people meet to socialize, whether gay or non-gay, should provide information about AIDS, condoms and low-risk sex, and make condoms available for their customers.

The media must join in the effort--not only allowing condom ads but also encouraging and producing public-service announcements that deal with AIDS, condoms, low-risk sex and abstinence. Television in particular must get over its reluctance to present such information in prime time where it has the most educational value. It is precisely because people in many communities don't want to hear about AIDS and condoms that the message is so important.

Primary-care physicians are uniquely able to determine if their patients are at risk for AIDS and to counsel individually on low-risk behavior. They must learn the skills and use them. It is a tragic under-utilization of a major resource that this is not standard medical practice today.

Finally, and probably most importantly, schools must recognize the challenge posed by their role and responsibility. An annual seminar or a week's worth of health-class study on AIDS is not sufficient to make a lasting impression on young people, especially those who have little or no exposure to sexual activity or drug use at the time of the lecture. What's needed is frequent counseling, perhaps monthly, preferably on a one-to-one basis to encourage frankness and confidentiality.

It's easy for society to dismiss these ideas as impractical or too expensive. It's easy because most Americans and most political leaders have yet to see AIDS strike close to home. If personal experience, rather than the testimony of medical leaders, is what it takes, we're headed for a catastrophe of unimaginable dimensions.

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