Even the poorest and least educated members of society can be taught to eliminate or reduce the behaviors that lead to the spread of HIV, according to the first large examination of such efforts in the United States.
The federally sponsored team studied 3,706 men and women clients of 37 sexually transmitted disease clinics, including several in Los Angeles, Orange and San Bernardino counties. They found that behavioral intervention reduced the incidence of gonorrhea--a useful indicator of unprotected sexual behavior--by half, doubled the use of condoms and greatly reduced the rate of other high-risk sexual behaviors.
Results of the study are reported today in the journal Science.
"Reducing high-risk behaviors is still the best way to prevent HIV infections," said Dr. Steven E. Hyman, director of the National Institute of Mental Health, which sponsored the study. "There has been a stigma . . . about the ability to reach this disadvantaged population. We have identified an effective strategy that could be adopted by public health and community organizations all across America."
"There have been a number of small studies that have shown positive outcomes from behavioral interventions," said behavioral scientist Mary Jane Rotheram-Borus of the UCLA School of Medicine, who headed the study in Los Angeles County. "This is definitive. Every site got the same results."
The highest rates of HIV infection in the United States are found among ethnic and racial minorities living in low-income urban areas. They account for more than half of all new AIDS cases in this country.
AIDS is the leading cause of death among African Americans and Latinos between the ages of 25 and 44. It was this group that was the target of the study.
The study's participants were recruited in inner-city clinics in five cities: metropolitan New York, Baltimore, Milwaukee, Atlanta and metropolitan Los Angeles. Nearly three-quarters of the subjects were African American and one-quarter Latino; 42% were male. Most were single and unemployed.
To be eligible for the study, subjects had to have had unprotected sex during the previous 90 days, in addition to falling into one of the following categories: sex with multiple and new partners; infection with a sexually transmitted disease; sex with a partner known to have multiple partners; sex with an injection drug user, or sex with an HIV-positive partner.
People in these groups are the most likely to become infected with HIV, said psychologist Ann O'Leary of Rutgers University.
The participants were randomly assigned to either a control group or the intervention group. Those in the control group attended a one-hour AIDS education session that included a videotape and a question-and-answer session.
Those in the intervention group attended seven 90- to 120-minute sessions over four weeks. Each session, with 10 to 15 male or female participants, was led by a man-and-woman team. All of the teams were trained at UCLA.
Each session included short snippets of videotape, question-and-answer periods and other activities, such as role-playing games. One week might be focused on how to tell your partner that you don't want to have unprotected sex, Rotheram-Borus said. Others might focus on how to give advice to friends that they would heed, or how to reject a date who demanded sex.
On average, subjects attended 5.2 sessions, and more than half attended at least six.
"My impression is that people came once to see what it was and then came back because it was useful," said psychologist Jeffrey Kelly of the Medical College of Wisconsin.
Participants in both groups were then interviewed three, six and 12 months after enrollment.
Subjects in the intervention group reported that they had reduced their frequency of unprotected intercourse significantly more than did those in the control group. They also used condoms significantly more often. Men in the intervention group had only half as many cases of sexually transmitted diseases, as confirmed by their clinical records.
Ellen Stover, a division director at NIMH, estimated that the cost of the program was about $278 per person. That "is the cost of one week of treatment with protease inhibitors," the most powerful AIDS drugs, Hyman said.
"That is very cost-effective," said Dr. Eric Goosby, director of the HIV/AIDS Policy Office of the Department of Health and Human Services. "We are very excited about these developments."
AIDS Action, a national AIDS group, praised the report, but criticized the government's failure to provide funds for further implementation of behavioral intervention. "If we had a medical vaccine, forces would be mobilized to deploy it," said the organization's executive director, Daniel Zingale. "Today, we have a virtual vaccine--prevention--and those forces are paralyzed."