By Peter Freiberg

With different groups and in different places, AIDS-prevention researchers are stepping up their efforts to find out what works?and what doesn?t?in encouraging safer sexual behavior.

?Prevention has really come into its own,? says psychologist Thomas Coates, PhD, director of the new AIDS Research Institute at the University of California?San Francisco, ?and it is recognized as a legitimate scientific enterprise in its own right.?

Psychologists have taken the lead in the prevention effort, which is viewed by researchers as increasingly important in view of the rising number of HIV infections worldwide (see story on page 32). As four recent studies show, psychologists? work in the area of AIDS prevention research has been varied:

? In four small U.S. cities, popular gay men were trained to advocate the benefits of practicing safer sex to men who frequent gay bars.

? In San Francisco, a group of African-American gay and bisexual men delved into issues of self-pride and the stigma many felt over their dual black and gay identities.

? In Akron, Ohio, inner-city women were issued ?condom credit cards? allowing them to get free condoms at three pharmacies during and after their participation in a study.

? And in Puerto Rico, a prevention research project called ?Nuestras Voces ante el VIH/SIDA? (?Our Voices Against HIV/AIDS?) will soon have women joining in a ?theatro foro??theatrical forum?in which they role play to learn how to negotiate safer sex with men. Many psychologists are finding that effective ways of cutting down HIV infection do not have to be based on ?high tech intervention [or] a lot of fancy anything,? says Jeffrey Kelly, PhD, director of the Center for AIDS Intervention Research at the Medical College of Wisconsin.

Instead, interpersonal communication is often the key.

Finding community leaders
Kelly led the study in which gay men were trained to advocate the benefits of practicing safer sex to men who frequent gay bars, reported in the Nov. 22 issue of The Lancet. In the study, Kelly sought to get well-liked community people to help bring about a lessening of risk behavior.

Bartenders in four small cities in Wisconsin, New York, West Virginia and Washington state were asked to identify their most popular patrons. People on more than one bartender?s list were judged ?opinion leaders? and recruited for training. In five two-hour workshops, opinion leaders were taught how to communicate effectively to their friends about the benefits of risk-behavior changes?carrying condoms at all times, discussing precautions with partners before sex, avoiding sex when drunk and refusing unwanted sexual coercions.

After each workshop, opinion leaders agreed to speak with four to 10 people before the next session. In a control group, bars in four other cities were given HIV posters, graphics and brochures to display. Based on survey questionnaires before and one year after the intervention, researchers found significant reductions in the number of occasions of unprotected anal intercourse in cities where opinion leaders were recruited compared with cities that only received educational materials.

Kelly believes similar methods could be useful with other HIV-vulnerable groups, including injecting drug users, teen-agers or populations in developing countries where condom use is not an accepted norm.

Culturally relevant messages
Most of the gay men in the bar study were white, as has often been the case. But in a study led by John Peterson, PhD, a psychology professor at Georgia State University, a culturally specific intervention was developed that reduced unsafe sex among African-American gay and bisexual men.

In the study, researchers put 318 San Francisco?area participants into a single- or triple-session experimental group or a control group. Facilitators for both single-session and triple-session experimental groups sought to promote a feeling of pride in participants? ?dual-minority status? and to help them understand how low self-esteem can promote riskier sexual behavior. The workshops also offered assertiveness training, taught negotiation skills and included game-playing to improve knowledge of safer sex and effective condom use.

Researchers reported that participants in the triple-session interventions greatly reduced their frequency of unprotected anal intercourse?from 46 percent to 20 percent?at the 12-month follow-up evaluation. Levels of risky behavior for the single session intervention decreased only slightly, and levels for the control group remained constant.

The study, Peterson said, demonstrated that African-American gay and bisexual men can reduce risky behavior if they are exposed to culturally relevant prevention messages. Researchers are not sure why the triple session was more effective than the single session, but suggested one possible reason: The multiple session allowed participants to observe successful behavior change in others before the sessions ended.

Designing for women
AIDS prevention efforts also have to be targeted specifically for women, says Anke Ehrhardt, PhD, director of the HIV Center for Clinical and Behavioral Studies at the New York State Psychiatric Institute.

?You have to teach women negotiating skills and to understand the risks and barriers that have to do with their relationships with men,? she says.

A study in Akron, Ohio, led by psychologist Steven Hobfoll of Kent State University, underscores this belief. In the intervention, reported in Health Psychology (1994, Vol. 13, No. 5), 206 single, pregnant inner-city women?57 percent African-American, 40 percent white, 3 percent other?were assigned to either an AIDS-prevention group or one of two control groups?a general health- promotion group or a no-intervention group.

By providing knowledge and skills, the AIDS-prevention group sought to help the women develop a health plan to curb their risk for HIV infection; the other group focused more broadly on improving the participants? general health. Women practiced assertiveness and negotiation skills with their partners and ?cognitive rehearsal??imagining how they would solve a problem. All participants were issued condom credit cards, allowing them to buy free condoms from the time the study began until 12 months after the intervention.

As researchers predicted, focusing on AIDS-related knowledge, attitudes and skills had greater impact on AIDS-related behavior. Results indicated significantly greater condom acquisition for the AIDS-prevention group than for the no-intervention group; the health-promotion group obtained more condoms than the no-intervention group but fewer than the AIDS group.

Participants in the AIDS-prevention group also reported moderate increases in knowledge and safer sex behaviors in comparison with either the general health-promotion or no-intervention group. ?Even though the average change was only moderate,? the researchers concluded, ?this may translate to potentially major impact on a public health scale.?

A program of support
An AIDS-prevention project in Puerto Rico also seeks to provide women with the skills they need to change risky sexual behavior.

Psychologist Irma Serrano-Garcia, PhD, professor of psychology at the University of Puerto Rico, has undertaken a project with heterosexual women, one of the highest risk groups in the commonwealth. In preliminary surveys, Serrano-Garcia says she found most of the women possess basic knowledge about AIDS transmission and prevention. But she also found that much of the women?s sexual behavior is high-risk-vaginal or anal sex without a condom?and that ?they do not negotiate their sexual relationships.?

The ?Voces ante el VIH/SIDA? project, which will get under way full scale this year, includes workshops that will culminate in a ?theatro foro? in which women role-play negotiating with men over safer sex.

?The man has instructions not to yield, no matter what [the women] say,? says Serrano-Garcia. ?It has to come to the point where if?she is insistent on being protective, then it?s non-negotiable and she will just have to withdraw from having sex.? Subsequent support meetings, says Serrano-Garcia, will allow participants to report on what?s going on in their personal lives and to receive support and feedback from other women. Participants in a control group as well as the experimental group will be surveyed for evidence of behavior change, as measured by increased negotiation skills and having safer sex, says Serrano-Garcia.

CDC data show the benefits of prevention programs

The impact prevention programs are having in the United States was demonstrated last September when the Centers for Disease Control and Prevention (CDC) reported a 6 percent decline in the estimated number of people diagnosed with AIDS in 1996 compared with 1995?the first decline ever reported during the epidemic.

?This decline,? the CDC said, ?reflects the combined impact of successful prevention efforts, which have helped slow the epidemic in recent years, and the impact of new therapies in lengthening the healthy lifespan of people with HIV.?

The greatest decline occurred among white gay and bisexual men, where prevention efforts started earliest in the epidemic. Heterosexual incidence, however, has continued to increase?particularly among minority men and women.

Nevertheless, gay and bisexual men still account for almost half of those living with AIDS, says psychologist Jeffrey Kelly, PhD, director of the Center for AIDS Intervention Research at the Medical College of Wisconsin. He also notes that unsafe sex practices and HIV infections in these groups still remain high in many areas, with younger gay men at particular risk.

?Peter Freiberg