Effective targeted and community HIV/STD prevention programs - Statistical Data Included

Journal of Sex Research, Feb, 2002 by Michael W. Ross, Mark L. Williams

Targeting interventions to change sexual behaviors which cause sexually transmissible diseases (STDs) at individuals in large numbers usually involves community-level interventions, and such community-level interventions utilize both individual-level and community-level theoretical approaches. Renewed interest in the development of community interventions in the United States and Western Europe has occurred since the spread of the Human Immunodeficiency Virus (HIV), the causative organism of Acquired Immunodeficiency Syndrome (AIDS). In contrast to face-to-face programs that involve work with individuals, community-level HIV approaches attempt to bring about reductions in the level of risk behavior within entire populations or particular population subsets. To achieve their objective of promoting population-level risk behavior reduction, community interventions frequently attempt to bring about changes in safer sex knowledge, attitudes, intentions, and peer norms among members of the entire target population. The definition of community, however, whether defined geographically or subculturally, and definitions of peers need to be clarified, since often these terms are used without clear definition.

COMMUNITY INTERVENTIONS.

There are several major community interventions intended to reduce STDs and increase contraception. Arnold and Cogswell (1971) distributed condoms in an eastern United States city in 1970 to young men between the ages of 12 and 24 over a period of 3 months. The investigators chose nine sites for free distribution of condoms, including five barber-shops, two grocery stores, a pool hall, and a restaurant. Measures, based on a random time sample and a brief questionnaire handed out to condom recipients at randomly chosen distribution sites included the numbers of men who had used a condom in the past week, and the numbers who had never used a condom. After 4 weeks, 60% of recipients said they had used a condom in the past week (< 20% at baseline). No recipients had not used a condom by weeks 12 and 13. Eighty percent of condom recipients lived within six blocks, and half within three blocks, of the distribution sites, and about one quarter said that their choice to use condoms was influenced by other boys, or by girls. While there is some question whether this program instigated condom use or prompted users to shift from commercial sources, the rise in those reporting that they had used a condom previously (from 62% to 100%) is highly significant. In the test period, over 18,000 condoms were distributed from the nine sites, and those who had used a condom on their last sexual intercourse increased from 20% to 91%. Of particular importance is the fact that the consumer acceptability of the distributors (small local businesses) and the enthusiasm of the shopkeepers provided a community control component which Arnold and Cogswell believe enhanced the overall effectiveness and efficiency of the service. These data indicate both that condoms are acceptable to adolescents in a magnitude not previously appreciated and lead to an impressive increase in protected sex, and that small neighborhood commercial outlets have a potentially important role in contraception/STD prevention.

In France, however, a randomized trial to reduce genital discharge in matched counties with an average size of nearly 1 million population in both women and men showed no significant results after 5 months. Genital discharge is usually caused by sexually transmissible infections (STIs) such as chlamydia and gonorrhea. The prevention campaign (Job-Spira, Meyer, Bouvet, Janaud, & Spria, 1988; Meyer, Job-Spira, Bouyer, Bouvet, & Spira, 1991) consisted of installation of automatic condom vending machines and free condom distribution by health centers, university medical centers, and youth clubs. Public information messages were developed specifically for the study: advertisements on local radio and in newspapers; debates; a free hotline with recorded message; posters in medical offices and public areas; a videotape used to introduce debates; a 2-minute cartoon shown during advertisements in local cinemas; a pamphlet distributed through family physicians, pharmacists, family planning centers, and school health services; and three different strip cartoon books distributed through youth clubs, schools, and cinemas. Health professionals' education consisted of a pamphlet and a technical guide widely circulated in the experimental areas, along with an audio cassette specifically developed for family physicians. Finally, conference debates bringing together family physicians, pharmacists, and other health professionals were organized. The main message focused on chlamydia and the need for treatment of all the partners of infected patients.

Before the study, 100 family physicians per area were randomly drawn and invited to participate. Participation rates were similar across the six areas. Each physician had to fill out an anonymous questionnaire for all women with genital discharge and all men with urethral discharge. While the data showed some decrease in cases of genital discharge, this was not significant between the two areas of each pair. Each family physician saw an average of 2.6 cases of discharge in the 4 weeks of the post-intervention evaluation. In women, those presenting following the campaign were younger and presented earlier: There were no changes among men. While this community campaign over 5 months did not achieve significant results, this may have been due both to the dependent variable (genital discharge) and its low incidence, and to differences between the areas selected. Further, the focus on health practitioners and treatment for symptomatic disease in conjunction with population prevention may have undermined the prevention message. Nevertheless, younger women did respond to symptoms earlier.